Bridging the Gap Between Orthopedics and the Pelvic Floor: Why So Separate?

By Emily Schlaefer, PT, DPT

 

Earlier this year, Emily was going to spend her final clinical rotation of PT school with us here at the Pelvic Health and Rehabilitation Center. Unfortunately, COVID hit and after only one day Emily sadly had to leave the rotation. She shared this blog post regardless about her experience as a PT student observing the separation between orthopedic and pelvic floor physical therapy. Check it out!

Growing up in a passionate and open Italian family, it was normal to joke about peeing and pooping at the dinner table. However, as I got older, my friends and family started to notice how often I ran to the bathroom. Sometimes it was every hour on the hour, and sometimes it was as close as 20 minutes apart. At the time, I had no idea what pelvic floor dysfunction was. I brushed off their comments by saying that I just had a really tiny bladder! Little did I know that I could actually do something about it. 

When entering Physical Therapy (PT) school at Columbia University, I finally learned that Women’s Health PT existed. I was thrilled to learn more about myself and find a way to help others with pelvic pain, incontinence, and more. However, I quickly discovered that these topics were uncomfortable and scary to talk about for some individuals. In school, the pelvic floor was mentioned…well, I can probably count how many times it was mentioned on one hand. All I kept thinking was, “How is this possible? There are 14 muscles in the pelvic floor, they hold up all of our abdominal organs and they are constantly working! Why is this not mentioned more?” Thankfully, I found someone who was entirely on the same page. 

My good friend and classmate, Rachel Gofman, shared this passion with me and has known she wants to work as a Women’s Health PT for years. She is a huge role model to me and I always learn something new from her. We decided to pair up for our final and largest project of PT school in the fall of 2019: Masterclass presentations for our Advanced Seminar in Orthopedics class. However, we were soon faced with a massive challenge. We were presenting about the pelvic floor to a majority of people who were not planning to pursue Women’s Health, let alone perform internal work on patients. So how do we bridge the gap between Orthopedics and Women’s Health? Why did they become so separate in the first place?

Our main goal was to inform these future Outpatient (OP) Orthopedics PTs that the pelvic floor is integral to all whole-body movement, and that you do not have to be a “Pelvic Floor PT” to work on the pelvic floor. Additionally, we wanted to provide some techniques to use in an OP clinic to address pelvic floor dysfunction. To start off the presentation, we asked our classmates to perform three activities while paying attention to their respective pelvic floors: blowing your nose into a tissue, laughing, and coughing into their elbow (stay safe please!). We then asked what they felt. Some said they felt their pelvic floors contract up and in, others said it bulged out, and a few said they honestly had no idea. So what should happen when you do these activities? 

Following this exercise, we explained what your pelvic floor should be doing. When you cough, laugh, or blow your nose, this increases pressure in your abdominal cavity. Your pelvic floor is key in helping to control that pressure. It should be contracting up and in to maintain that support for your organs. The pelvic floor is the only transverse load bearing muscle group in the entire body, and it works along with the diaphragm to maintain intra-abdominal pressure. It is constantly active, even during quiet breathing. In our presentation, we referenced an article written in 2004 by Ruth Sapsford, which showed the difference in pressure control between a normal pelvic floor and a dysfunctional pelvic floor of someone with stress urinary incontinence (SUI). In a healthy situation, the pelvic floor should rise up as shown in the “Normal Cough” picture in Figure 1. In SUI, the pelvic floor goes down, opposite as the diaphragm, indicating that it is bulging out and not maintaining pressure control. 

Figure 1: (Left) Part A shows quiet breathing. The arrows pointing down indicate the diaphragm, and the arrow pointing to the left shows the activity of the abdominals. In Part B, it shows what the diaphragm, abdominals, and the pelvic floor are doing to maintain pressure control. (Right) Part A shows quiet breathing again. Part B shows how the pelvic floor is dysfunctional during SUI by going down rather than up.

Next, we described the difference between a hyper (tight) and hypotonic (weak) pelvic floor and the effect of posture and positioning on the pelvic floor. Just like any other muscle in the body, if it is too weak, it is not strong enough to carry the load or stress put on it. If it is too tight, the muscles may have a difficult time relaxing and can cause pain. After giving a brief overview of the pelvic floor and other muscles that attach to the pelvis, we went into describing that the muscles can be separated into two triangles—the Urogenital and the Anal Triangles—and how the position of your pelvis can have an effect on these two areas. Take a look at Figure 2 below to see how an anterior and posterior pelvic tilt can help with urinating and performing a bowel movement. 

Figure 2: Diagrams to show how an anterior or posterior pelvic tilt can slacken the Urogenital Triangle and Anal Triangle respectively to help with urination and bowel movements.

With an anterior tilt, or the “booty pop” position as some like to call it, this puts the Urogenital Triangle on slack. On the contrary, a posterior tilt, or tucking your pelvis in, can put the Anal Triangle on slack. 

Looking at someone’s posture is important for any type of patient–including one with pelvic floor dysfunction. If a patient discloses that they are having trouble with urinating or performing a bowel movement, the PT can provide patient education on either anteriorly or posteriorly tilting your pelvis to help with using the restroom.  By sitting on the toilet with an anterior pelvic tilt, this slackens the muscles in the Urogenital triangle, which helps to relax the pelvic floor and creates a better alignment for your bladder and urethra to empty. On the contrary, a posterior tilt (with the knees elevated above the hips) helps to create a better alignment for your rectum and slackens the muscles in the Anal Triangle to help perform a bowel movement. Otherwise, the puborectalis muscle in the pelvic floor can constrict the rectum, making it harder to evacuate stool. These are two small, but effective tips that an OP Orthopedics PT can use to help their patients.

 

To conclude the didactic portion of our presentation, we discussed how the positions of other joints in the body can affect the pelvic floor. Let’s not forget how much the body is connected—dysfunction at the hip can affect the shoulder, the knee, the spine, you name it! So how does the ankle affect the pelvic floor? We had our classmates stand up, hold onto the table in front of them, and perform three different ankle positions while paying attention to what their pelvis does: standing with feet flat (neutral), standing on tip-toes (plantarflexion), and standing on their heels (dorsiflexion). It is expected that with plantarflexion, the pelvis tilts posteriorly, and anteriorly with dorsiflexion. In an article by Kannan et al. in 2018, a meta-analysis was conducted that looked at how ankle positions affected pelvic floor muscles in women. Additionally, they hoped to find which ankle position could be best for pelvic floor muscle training for women with SUI. This article found that there is significantly greater resting pelvic floor muscle activity and greater contraction of the pelvic floor in 15 degrees of ankle dorsiflexion compared to 15 degrees of ankle plantarflexion. However, there was no difference between pelvic floor muscle activity between ankle neutral and ankle dorsiflexion. Ankle dorsiflexion induces changes at the pelvis, sacrum, and coccyx, which causes the attachments of the pubococcygeus muscle to move closer, creating a shortening of the muscle fibers. This is thought to increase the contractility of the pelvic floor muscles. But what does all of this mean?

Figure 4: Plantarflexion and Dorsiflexion
Photo courtesy of TeachMe Anatomy

If a patient comes to an OP clinic and discloses that she has SUI, a PT can provide some tips for proper ankle positioning. This includes choosing what type of shoe to wear! As much as I love high heels, they plantarflex your feet, which creates a posterior pelvic tilt, ultimately decreasing the activity of the pelvic floor. This can cause more leakage during exertion in a standing position for women with SUI. It could be beneficial to swap those heels for some cute flats to help manage SUI.

We concluded our presentation by teaching an external coccyx mobilization as we wanted to give our classmates a tool to use that did not require an internal exam or treatment. This mobilization could help with a double limb squat and hip external rotation strength. We instructed the class on how to identify the coccyx through clothing, and to see if it was rotated a certain way by using our manual palpation skills. I then demonstrated a double limb squat, and Rachel was able to test my strength for hip external rotation (ER) on both legs. She found that my coccyx was rotated, and felt that the right side of the coccyx was more prominent. Additionally, my right leg collapsed inward during the squat, and my left hip ER strength needed some improvement (MMT = 4-/5). We instructed the class on how to perform a few different Muscle Energy Techniques to improve my left hip ER strength while applying anterior to posterior pressure on the right side of the coccyx. Rachel then retested me after the techniques. My coccyx was no longer rotated, my right leg did not collapse inward during the double limb squat, and my left hip ER strength improved. Please refer to the attached lab manual to see pictures and explanations of all the manual techniques. 

Of course, these techniques may not solve a patient’s pelvic floor dysfunction. One takeaway that we wanted to drive home for future OP Orthopedics PTs was to use your best clinical judgment when treating someone with pelvic floor dysfunction. It is important to know when to refer the patient to a pelvic floor specialist in order for the patient to get the proper treatment they need. At the end of our presentation, we were able to walk around the classroom and observe our classmates practicing the techniques we taught them. Our peers stated that these techniques were comfortable to perform and that our presentation helped to ease the fears and uncertainties about the pelvic floor. Additionally, I have had students contact me in the last few months saying these techniques were useful in their OP Orthopedics affiliations. Orthopedics and Women’s Health PT are far from separate. We were happy to hear that the consensus was that the pelvic floor is not so scary after all!

Figure 6: Rachel (right) and I after completing our 70-minute Masterclass presentation that consisted of a 30-minute lecture, a 15-minute small group discussion, and a 25-minute lab demonstration.

*Special thanks to Dr. Christopher Kevin Wong and Dr. Evan Johnson from Columbia University for their guidance on this project!

 

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