Have a pain in the a** while sitting on your bike saddle? Optimize your saddle using pressure mapping!

In Pelvic Floor Physical Therapy by pelv_admin2 Comments

Guest post by Justin Lucke and Morgan Conner, DPT, PHRC Los Gatos

In bike fit, oftentimes small changes can lead to profound improvements, but in practice it can be hard to quantify the impact. In this blog post Morgan talked about her quest to find a better seat and how using trial and error found something that worked a lot better. And it is true that trying out multiple seats is super helpful in solving the saddle pressure dilemma. A poorly fitted saddle or bike fit can contribute to or exacerbate already existing pelvic floor pain. 

In fact, one cause of pelvic floor pain, pudendal neuralgia, was long considered to be a problem that only happened to male cyclists! The pudendal nerve arises from sacrum, taveling through alcocks canal with the pudendal artery and vein to innervate the pelvic floor. It is the only nerve in the body that has both sensory and motor functions as well as autonomic functions. This means that it is involved in controlling the contraction and relaxation of pelvic floor muscles (motor function), transmitting sensation information (such as pain, pressure, or touch) to the brain (sensory function) and regulating urinary, bowel and sexual function (autonomic function). Getting back to anatomy, the pudendal nerve has a tortuous course through the pelvic floor and can be compressed when cycling leading to pain, numbness or tingling in the genitals or pelvic floor muscle dysfunction. The good news is that it does not have to! We teamed up with Curtis Cramblett and Justin Lucke at Revolutions in Fitness to talk about one way to help improve your bike saddle fit and comfort. 

But in addition to trying new saddles, Revolutions in Fitness uses pressure mapping to measure an extra dimension that helps isolate cause and effect from small changes. While the broad approach might be to start switching saddles and look for subjective feedback on the saddle to improve, along with objective markers like visual stability, pressure mapping provides a more focused assessment to help choose the right saddle and then optimize the position. 

In this case, pressure mapping showed that the saddle was broadly appropriate (no pressure in the center on nerves and blood vessels; pressure on the outside focused on bony structures). Even so, at the start, saddle pressure was still pretty awful, with pressure creeping over 1000 milibars there was room for improvement:

The current setup was based around a 100mm long stem (attaches the handlebar to the bike) with +17 degrees of offset (offset is the angle of the stem relative to the bike’s steering, where positive means the stem is pointing up while negative is pointing down). Typically, a rider would use a stem with more positive offset to help raise the bars and take pressure off of the neck and back and help open up the hips. The flip side of higher bars, however, can be a reduction handling and stability and less ability to powerfully recruit the glutes. In this case, the rider had improved mobility, so strain on the neck, back and hips was less of an issue, and wanted to improve handling and performance. So we were lowering the bars to help achieve this goal.  

Using an adjustable fit stem, we were able to move between several different setups and benchmark using pressure mapping. Starting with a switch to a +8 degree offset, pressure was better — more stable (shown by the red line being shorter, flatter and more centered), lower and better balanced left to right:

But the benefits of using pressure mapping start to really appear when we overshot the likely best option.  Moving from a +8 offset to a zero offset saw pressure go back up:

Clearly something is going on here that subjective experience — how does that feel? — might not capture.  Making the next step, from zero offset to -8 offset really shows the trend:

Pressure goes up once again so going lower is not the right path in this case. Re-setting the stem to +8 offset validates the original observation that a little lower, and a little longer, has a big impact and is the right move at this point for the rider:

The takeaway is that pressure mapping allows us to benchmark the starting point, document the changes and establish one way to define improvement. In this case, pressure mapping allowed us to move towards the rider’s goal — performance improvement — while increasing comfort.

You might find that the right bike saddle fit clears up your symptoms while riding but if not you may want to consider seeing a pelvic floor physical therapist to see if there are any muscular or connective tissue contributions that may need to be addressed. If you are wondering what a pelvic floor physical therapy evaluation is like check out this blog post.

To schedule a bike fitting with Curtis or Justin you can find information at the Revolutions in Fitness website: Revolutionsinfitness.com, email [email protected] or call their office at (650) 260-4743. 

To schedule an in person appointment for a pelvic floor physical therapy evaluation with a physical therapist at PHRC you can contact us here or if you are interested in a digital health appointment you can schedule one here.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

Comments

  1. Excellent post on this subject! I’ve been plagued with this problem for several years and this helps make sense of it all. Great research!

    1. So glad we can help make sense of it all and provide you with some clarity!

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