Getting over the hurdle: restoring power and function to the pelvic floor

Tighter is not better, and strengthening is not always the answer when muscles are stiff or sore. Sandra Hilton expounds on why this is as true for the pelvic floor as stiff backs, shoulders, or ankles.

Treating pelvic pain is a unique challenge because its the association with bowel, bladder, and sexual function. A common misconception is that incontinence is necessary to implicate the pelvic muscles as the cause of a deep ache or sharp pain in the female athlete’s pelvis. However, the pelvic floor is the foundation for power and endurance in sport and is susceptible to the same strain and injury as other muscles.

There isn’t a standardized metric for measuring pelvic muscle stiffness or tone. Thus, there exists a wide range of ‘normal’. An internal examination by a trained pelvic health therapist or a guided self-assessment by the athlete can determine if the pelvic muscles can relax as well as contract.

Screening for pelvic pain

Suspect the pelvic floor when athletes describe their pain as somewhere between the umbilicus and the mid-thigh, especially when they indicate the saddle area⁽¹⁾. Screening for the source of pelvic pain is especially challenging because the involved area is quite large. While there is no standardized screening, there are helpful questions to guide the assessment. Checking both sensory and motor function is important to address both ‘top down’ and ‘bottom up’ influences. Include the following in your assessment:

Abdominal:  A non-painful response to light touch and gentle pressure via a physical exam on the lower abdomen indicates normal sensation. Hot, hard, or tender areas could be related to ovulation, bowel, or bladder function and signify the need for referral to a qualified physician for further testing. Check tolerance to touch at the inguinal ligament and along the iliac crest. This area is the pathway for the anterior pelvic nerves (ilioinguinal and iliohypogastric) which provide sensory innervation to the labia and pubic area.

Spinal:  Perform a segmental mobility screen from T12 to L5. The nerves that provide sensory and motor function to the pelvis arise from these levels. Identify and correct any vertebral stiffness. Use spinal flexibility and comfort to help decrease the sensitivity around the dorsal nerve roots and improve tolerance to stresses through the trunk, pelvis, and lower extremities.

Pelvic Girdle:  It’s time clinicians stop talking about the sacrum ‘going out’ of alignment and being overly concerned about sacroiliac joint rotations. These explanations of pelvic pain are outdated and promote fear-avoidance behaviors among patients. Rather, emphasize to the athlete that the pelvis and sacrum are inherently stable. Avoid catastrophic wording and encourage confidence and a return to full function. Communicating an understanding of the pain process and crafting an individualized program to address joint laxity or core weakness is more helpful than outdated explanations of malalignment or instability⁽²⁾.

Bladder:  Pain just above or behind the pubic bone, or a sense of pain and pressure before urination can originate from the bladder or the surrounding structures. Intolerance to filling and emptying indicates a need for a referral to a pelvic therapist or urologist. Pain here isn’t necessarily accompanied by incontinence.

Bowel:  A healthy gut is vital for good sleep, tolerance to the strengthening needed for performance, and comfort through the abdomen and pelvis. Constipation creates a demand for the pelvic muscles to match the increased pressure, and the challenge of voiding hard stool can create a reflexive tightening of the pelvic muscles. Normal bowel function easily passes a well-formed stool anywhere from three times in one day to once every three days. For easy reference to ask about stool consistency, use the Bristol Stool Scale. (3)

Difficulty voiding is made worse if the pelvic muscles do not relax enough at the right time. This dysfunction can lead to complaints of pain in the rectum, often described as a ‘golf ball’ or sharp burning pain after voiding. Pelvic health therapists work on restoring normal muscle timing and coordination to ease voiding.  There must also be work concerning diet, fluid intake, and an appropriate rest/exercise ratio to restore normal gut health.

Sexual Function:  Intimacy and sexual intercourse should never hurt.  If the athlete reports pain with touch, movement, or orgasm, refer them to a gynecologist or pelvic health therapist to rule out infection, skin irritation, or pelvic muscle impairment.

Expectations:  Pain is an important motivator to address a problem and change behavior. When an athlete feels unable to play due to pain, it creates a negative cycle where expectations of pain create an enhanced pain response⁽⁴⁾. It’s essential to stack positive movement experiences to change expectations. Advise the athlete to use a journal to track positive sensations rather than the bad ones to flip the focus to finding the small successes and building upon them.

What to do with pelvic pain?

While there is evidence that strengthening the pelvic muscles improves continence, more strength isn’t always the answer for pelvic pain⁽⁵⁾. It isn’t usually weakness that causes the discomfort. Instead, muscle stiffness and dyscoordination contribute to pain in the pelvic area.

Keeping the pelvic muscles strong is critical for pelvic health and necessary for sport, childbirth, and pleasurable sex⁽⁶⁾. However, an inability to relax the muscles or an overly sensitized nervous system may be the source of persistent pain. Both of those scenarios are treatable. Teaching the athlete to self-administer the interventions allows them to participate in their recovery and more quickly resolves the issue. Work on ‘top down’ influences of autonomic regulation and sensory integration techniques and ‘bottom up’ components of tissue tolerance to expected loads and movement.

Top Down:  Autonomic regulation is necessary for function. Though not under conscious control, there are ways to intentionally influence autonomic regulation, such as relaxed breathing, conscious selective relaxation of tense muscles, and a sense of self-efficacy that these tools are available. Emotional distress, lack of sleep, fear, agitation, and gut dysregulation – including constipation – contribute negatively to the upregulation of muscle and organ function.

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Tips for calming autonomic regulation

Box Breathing:  Inhale 4 seconds, pause for 4 seconds, exhale 4 seconds, pause 4 seconds. Repeat for 5 minutes or perform throughout the day.

Pleasure Snacks:  Purposefully engage in things that feel good.  Dive into the sensory experience of pleasurable sight, smell, sound, touch, or taste for three to five minutes, six times per day.

Sleep:  Seven to eight hours a night is needed for optimal function.

Engagement: Virtual reality games or anything that encourages a full embodiment in the activity can create an internal environment focused beyond the pain experience and work to normalize the response to nociceptive (unpleasant) input.

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Relieving pain is more than just pleasurable engagement and breathing techniques. The athlete needs to know what to expect and be confident she can take measures to address the painful areas. Education in the treatment techniques aimed at the irritated muscles are an essential part of a therapeutic intervention.

Bottom Up: Work directly on the area of pain through pleasurable manual therapy techniques, just as you would a sore or overworked muscle in another part of the body. There is no evidence that painful techniques like skin rolling or connective tissue manipulation are more effective than non-nociceptive techniques such as a slow sustained hold. Why aggravate an upregulated system when pleasurable or neutral touch is as effective?

Independently administered techniques are best. Self-treatment allows the athlete to take charge (which also helps lessen the top-down influences). The athlete will know it is helping because they feel better.  If they are doing self-treatment, they are on the right track if what they are doing feels good. They don’t have to hold their breath, brace their muscles, or anticipate pain to feel better.

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Tips for Direct Tissue Techniques

The short answer to this approach is to do what feels best in the painful area.

Small balls:  Use a three to four-inch ball and follow the Goldilocks principle of self-care – experimenting until the athlete finds the area and pressure that feels just right. Some patients prefer to use the ball like a fulcrum to relax over and let gravity help the tissues return to normal. Others enjoy moving over the ball. The right answer is doing what feels best.

Large balls:  Sitting with a broad base of support on a large therapy ball supports the pelvic muscles and lumbosacral girdle to allows movement without guarding.

Wands:  A variety of pelvic wands and dilators exist to work on stiff muscles directly. Use sensory tolerance to pressure, touch, and movement as the indication that the pressure is helpful.

Sex/Orgasms:  Orgasm is an indicator of pelvic muscle coordination, circulation, tissue mobility, and sensory tolerance to touch, pressure, and shearing forces. Reassure athletes that pleasurable intimacy and orgasms are healthy for the pelvic muscles.

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Conclusion

Screen athletes with pain anywhere within the lower trunk or pelvic region for signs of pelvic dysfunction. Autonomic factors influence the performance of the pelvic floor. Athletes under high levels of stress or with increased anxiety may experience tightness and spasm in the area. Symptoms of pain without the hallmark incontinence are common.

Educate the athlete in autonomic relaxation techniques and direct tissue treatment so that they can feel in control over their pain. Avoid catastrophizing language and reassure them that improvement is possible. Emphasize the importance of good bowel and bladder habits and sleep in keeping the pelvic floor optimized. Lastly, encourage the athlete to use their sensory system to engage in pleasurable experiences. Athletes are susceptible to viewing their bodies as machines and forgetting that they are made for pleasure too.

References

1. Pain Physician. Mar-Apr 2014;17(2):E141-7.
2. Phys Ther. 2019 Nov 25;99(11):1511-1519.doi: 10.1093/ptj/pzz108.
3. Continence Foundation of Australia. 2021. Bristol stool chart | Continence Foundation of Australia. [online] Available at: <www.continence.org.au/bristol-stool-chart> [Accessed 29 April 2021].
4. Clark, A., 2019. Surfing uncertainty. New York: Oxford University Press.
5. World Journal of Urology. 2011;30(4):437-443.
6. Sports Injury Bulletin. 2021. The Athlete’s Pelvic Floor. [online] Available at: <www.sportsinjurybulletin.com/the-athletes-pelvic-floor/> [Accessed 29 April 2021].