Muscles Affecting Pelvic Health: It’s Not Just The Pelvic Floor

In Pelvic Floor Physical Therapy by Shannon Pacella5 Comments

By: Shannon Pacella, DPT, PHRC Lexington

As you may know, us pelvic floor physical therapists tend to talk about the pelvic floor muscles quite a lot. However, we also assess and treat many other muscles surrounding the trunk, pelvis, hips, and thighs, that influence pelvic health and various pelvic floor muscle dysfunctions. If you’d like to learn about pelvic floor muscle anatomy, check out this previous blog post: Your pelvic floor: what is it good for?

I will also be mentioning myofascial trigger points; here’s a good blog post to read to get familiar with what these are: Pelvic pain trigger points explained

I am going to take you through some of the muscles I commonly find impairments with, and treat in conjunction to the pelvic floor muscles.

First, here’s a quick recap of pelvic bone anatomy, as I will be mentioning these different parts of the pelvis:

The pelvic girdle is comprised of:

  • Ilium: the largest pelvic bones – when you put your hands on your hips you are touching the ilium.
  • Ischium: the part of the pelvis that you sit on (aka sit bones).
  • Pubis: the front part of the pelvis that joins both sides together via the pubic symphysis.
  • Sacrum: the sacrum attaches to the ilium via the sacroiliac (SI) joint.
  • Coccyx: also known as the tailbone, and attaches to the lower part of the sacrum.

Netter FH. Atlas of human anatomy. 6th ed. Philadelphia, PA: Elsevier Inc.; 2014.

Hip Flexors (Iliopsoas): The psoas and iliacus muscles join together at the attachment on the femur.


Netter FH. Atlas of human anatomy. 6th ed. Philadelphia, PA: Elsevier Inc.; 2014.

  • Psoas (highlighted in the above photo)
    • Attachments: the lumbar vertebrae from T12-L5 to the femur.
    • Actions: hip flexion, balances trunk in sitting position, trunk flexion, trunk side-bend.
  • Iliacus
    • Attachments: the inside of the pelvis at the ilium and iliac fossa to the femur.
    • Actions: hip flexion, stabilizes hip joint.

If the iliopsoas muscles are tight or if there are myofascial trigger points in the iliopsoas muscles, this can lead to anterior pelvic tilting, abdominal/anterior hip/groin pain, and low back pain. The hip flexors are put into a shortened position when in a sitting position, and are used when walking, running, hiking, and going up stairs (to name a few activities).


Photo courtesy of Beth Ohara

Inner thighs:

  • Adductors (Brevis, Longus, and Magnus)
    • Attachments: the pubis to the femur.
    • Actions: hip adduction (brings thigh inward towards other thigh), partially used for hip flexion and extension.

Myofascial trigger points in the adductor muscles refers pain to the upper inner thigh area, and is a leading cause of groin pain. Adductor muscles are commonly contracted when people have urinary urgency and urinary incontinence to try to (ineffectively) prevent leakage and ‘hold in the pee.’ The adductor muscles also tend to contract when pelvic floor muscle weakness is present, as a way to compensate for the weakness.

Hip External Rotators:

  • Piriformis
    • Attachments: the sacrum and sacrotuberous ligament to the femur. This muscle is located deep in the buttocks (under the gluteals).
    • Actions: Externally/laterally rotates the thigh, abducts flexed thigh.

Tightness in the piriformis muscle can be linked to sciatica (nerve pain down the back of the thigh), due to the muscle’s proximity to the sciatic nerve. Myofascial trigger points in the piriformis muscle can lead to referred pain at the mid to upper buttock area and the pelvis.

  • Obturator Internus
    • Attachments: The pubis and ischium to the femur.
    • Actions: Externally/laterally rotates the thigh, abducts flexed thigh.

Tightness and/or myofascial trigger points at the obturator internus muscle can lead to referred pain into the coccyx/tailbone and deep pelvis.

*Take a look down at your legs when you are standing and walking, are your knees and/or toes turned outward? If so, you might have tight hip external rotators.

Hamstrings (biceps femoris, semimembranosus, and semitendinosus):

  • Biceps Femoris
    • Attachments: ischial tuberosity and femur to the fibula
    • Actions: hip extension, and knee flexion and external/lateral rotation
  • Semimembranosus
    • Attachments: ischial tuberosity to the tibia
    • Actions: knee flexion, and hip extension
  • Semitendinosus
    • Attachments:ischial tuberosity to the tibia
    • Actions: knee flexion, and hip extension

These three muscles together form what is known as the hamstrings. Hamstring tightness can lead to posterior pelvic tilting, and myofascial trigger points can lead to referred pain up into the buttocks, and down the leg behind the knee.

Here are the main points I want you to take away after learning all of this anatomy:

  • Low abdominal, pelvic, groin, buttock, and tailbone/coccyx pain may be from muscles surrounding the pelvis, and not the pelvic floor muscles themselves.
  • Even though we are called pelvic floor physical therapists, it is our job to assess and treat all aspects related to your pelvic health.
    • This may include manual therapy and trigger point release of muscles in the abdomen, hips, buttocks, and thighs.
    • It is also important to assess posture and pelvic alignment,and to evaluate whether your body is compensating for tight and/or weak muscles that can contribute to pelvic floor muscle dysfunction.


Are you unable to come see us in person? We offer virtual appointments!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $85.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.



  1. Netter FH. Atlas of human anatomy. 6th ed. Philadelphia, PA: Elsevier Inc.; 2014.
  2. Travell JG and Simons DG. Myofascial pain and dysfunction: the trigger point manual. Volume 2. Baltimore, MD: Williams & Wilkins; 1992.


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.


    1. Hi Russ,

      Yes, Shannon treats patients in our Lexington and Natick office. Please call to schedule an appointment.



  1. Very informative. Thank you so much. I’m not saying I understand it all but it might help explain some of my symptoms.

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