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6 Key Strategies for Diagnosing Musculoskeletal Causes of Pelvic Pain

October is National Physical Therapy Month, a time to raise awareness about the benefits of physical therapy in improving the quality of life and overall health of our society. Musculoskeletal dysfunction is a common but often overlooked contributor to chronic pelvic pain (CPP), and physical therapists (PTs) play a crucial role in diagnosing and treating these issues.

Given the complex relationship between the pelvic floor, hips, lower back, and abdominal muscles, effective diagnosis and therapy can significantly impact pain. This guide provides practical diagnostic tools and highlights physical therapy's vital role in addressing musculoskeletal contributors to pelvic pain.

#1 Recognizing Pelvic Floor Tension Myalgia

Pelvic floor tension myalgia is a significant cause of chronic pelvic pain (CPP). It is a disorder of increased tone in pelvic floor muscle (PFM) tension myalgia (global) and pelvic floor myofascial pain syndrome (local), with 73.7% to 82% of patients with CPP exhibiting tender pelvic floor muscles and decreased relaxation ability. This chronic contraction and tension in the pelvic floor are often underdiagnosed, making recognition of these symptoms critical.

Symptoms:

  • Dyspareunia (painful intercourse)

  • Urinary urgency and frequency without evidence of UTI

  • Perineal pain, often described as "sitting on a ball".

  • Lower abdominal pain without other organ-specific symptoms

  • Sensation of incomplete bladder emptying despite normal post-void residual volume

Clinical Diagnostic Tips: A 3-point firmness scale is recommended during a manual pelvic exam to assess PFM tone. Clinicians can compare the muscle tone of the pelvic floor to the thenar eminence (muscle of the thumb) to determine if there is abnormal tension. The firmness of the pelvic floor can range from normal to severe high tone, guiding treatment strategies like muscle downtraining.

Case Example: A typical case involves a 32-year-old female with no prior surgical history, experiencing pelvic pressure, dyspareunia, and urinary urgency/frequency after prolonged periods of desk work. The stress and prolonged sitting led to increased PFM tension, which can be alleviated through pelvic floor relaxation therapy and myofascial release.

#2 Identifying Lower Back and Pelvic Girdle Dysfunction

Lower back and pelvic girdle dysfunction, often due to conditions like sacroiliac joint dysfunction or pubic symphysis dysfunction, can refer pain to the pelvic area, frequently complicating the diagnosis of chronic pelvic pain. This connection between lower back and pelvic dysfunction is important to recognize as part of a comprehensive musculoskeletal assessment.

Symptoms:

  • Pain around the coccyx (tailbone), often worsened by sitting or transitioning from sitting to standing.

  • Pelvic girdle pain, particularly stiffness and spasms in the lower back, hips, or pelvis, worsened by prolonged sitting or poor posture

  • Low back pain and gluteal spasms, which can extend into the pelvic region

Clinical Insight: Ergonomic interventions are vital, especially for patients who spend long hours sitting. Sacroiliac joint dysfunction and coccygeal pain (coccydynia) can often be traced to poor posture or trauma (e.g., falls), and patients can benefit from adjustments to their seating arrangements, including the use of ergonomic chairs or cushions.

Case Example: Patients with a history of coccygeal pain may report discomfort when sitting on hard surfaces or transitioning from sitting to standing. Physical therapy and ergonomics can address underlying sacroiliac or pelvic girdle dysfunctions, significantly improving symptoms.

#3 Evaluating Hip Pathology as a Pain Source

Hip pathology is frequently overlooked in patients with pelvic pain, yet conditions like femoroacetabular impingement (FAI), labral tears, and trochanteric bursitis can refer pain to the pelvic region. A thorough evaluation of the hip joint is essential for accurate diagnosis.

Symptoms:

  • Anterior groin pain often associated with femoroacetabular impingement, exacerbated by physical activity

  • Lateral hip pain, typically due to trochanteric bursitis or gluteal muscle dysfunction

  • Reduced hip range of motion, particularly internal rotation, which may indicate labral tears or capsular laxity

Diagnostic Tip: The FABER test (Flexion, Abduction, and External Rotation) is a simple yet effective tool to differentiate between hip-related and lower-back pain. When this test reproduces groin pain, it may suggest hip pathology like FAI or labral tears, while the absence of pain points to other pelvic or lumbar causes.

Case Example: A patient with hip pathology might present with pain radiating down the inner thigh or lateral hip pain. Assessing hip range of motion and performing specific tests such as FABER can help isolate the hip as a potential source of pelvic pain.

#4 Simple Self-Help Tools for Musculoskeletal Pelvic Pain

Self-management strategies are crucial in empowering patients to manage their musculoskeletal pelvic pain. Several low-risk, effective interventions can be taught to patients for daily use, improving pain management and reducing flare-ups.

Interventions:

  • Gentle yoga targeting the pelvic floor and lower back to increase flexibility and reduce muscle tension

  • Diaphragmatic breathing exercises to help relax both abdominal and pelvic floor muscles, which can be overactive in patients with chronic pelvic pain

  • Heat therapy applied to the lower abdomen or back, helping to reduce muscle spasms and discomfort.

Practical Tip: Encouraging patients to incorporate these tools into their daily routines can improve their quality of life by reducing pain frequency and intensity. For instance, patients with pelvic floor tension myalgia may benefit greatly from diaphragmatic breathing to downtrain overactive muscles.

#5 When to Refer to Pelvic Physical Therapy (PT)

For patients with persistent or complex musculoskeletal pelvic pain, referring them to a pelvic physical therapist is essential. Pelvic PTs are trained to assess and treat conditions such as pelvic floor dysfunction, pelvic girdle pain, and abdominal wall dysfunction.

Pelvic PT Expertise:

  • Biofeedback to help patients learn to relax their pelvic floor muscles

  • Myofascial release and connective tissue mobilization to relieve tension and pain in the muscles and fascia

  • Posture correction and ergonomic advice for patients with desk jobs or poor sitting habits

  • Therapeutic exercise programs designed to strengthen the core, pelvic girdle, and lower back muscles, improving stability and reducing pain

Case Example: In cases where self-help tools have been ineffective, specialized pelvic PT interventions, such as biofeedback and targeted exercises, can help resolve the underlying muscular and fascial dysfunctions contributing to chronic pelvic pain.

#6 Pelvic PT Interventions

Pelvic physical therapy offers a range of interventions tailored to patients with chronic pelvic pain. These therapies are specifically designed to target the musculoskeletal contributors to pelvic pain.

Interventions:

  • Biofeedback and myofascial release techniques to alleviate overactive pelvic muscles

  • Therapeutic exercise programs focused on strengthening the pelvic girdle, improving core stability, and reducing pain

  • Transcutaneous electrical nerve stimulation (TENS) applied over the lower abdominal wall to manage pain and promote muscle relaxation.

Working with a pelvic PT can significantly improve pain and function for many patients.

Next Steps

Musculoskeletal causes of pelvic pain are often overlooked, but physical therapists have the expertise to diagnose and treat these issues effectively. This National Physical Therapy Month let’s acknowledge physical therapists' vital role in helping patients find relief and improve their quality of life.

For further learning and support, explore these resources:

These resources can enhance your knowledge, empower your patient care, and advocate for the critical role of physical therapy in managing chronic pelvic pain.

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