Sitting on painful fascia: connective tissue and pelvic pain

In Pelvic Floor Physical Therapy by pelv_admin6 Comments

 

 

By: Admin

 

If you’ve recently been to your physical therapist, massage therapist, personal trainer, or body worker and heard the words “fascia” and “manipulation” in the same sentence, you are not alone. Fascia has become quite the buzzword for treating everything from chronic neck pain, ACL repair surgery, plantar fasciitis, and yes—even pelvic floor dysfunction. But what is fascia and how does keeping it healthy help you decrease shoulder pain AND pain with intercourse? The truth is that fascia is literally the entire body—head to toe we are covered in layers of connective tissue that surround our internal organs, our muscles, nerves, and bones. These layers of connective tissue are separated by a ground substance that is fluid and mobile, allowing our layers to slide and glide on each other to allow healthy and balanced movement. The structure of these bodily layers can be likened to the layers and sections of an orange to illustrate how fascia is a 3-dimensional network that houses and protects our internal structures: The superficial layers are much like that fuzzy, spider web-like layer just beneath the skin, adhered lightly to the layers below; the deeper layers are like the thin white sheath that separates the juicy flesh of the fruit from the outer layer. Now imagine a dehydrated, super tough orange that you spent 10 frustrating minutes peeling…that’s unhealthy connective tissue!

 

The complex nervous system of a human being allows us movement and cognition–so unlike an orange, we suffer from our immobile connective tissue by receiving its faulty nerve signals into our central nervous system which registers discomfort and pain. Understanding the manifestation of pain is a science in and of itself, and could fill blog posts from here until the next millennia; nociception, or how our brain perceives possible dangerous sensations through free-nerve endings in the skin, which helps protect us from harm. But often time there is the experience of pain long after the injury has happened and tissue healing time is far past–this is when pain becomes chronic and begins to affect everything in our lives. To learn more about brain and chronic pain check out this short 5 minute video, and then look up Dr. Lorimer Moseley and Dr. David Butler’s world renowned book developed from their research Explain Pain. The question is: how does fascia contribute to pain?

 

Research has shown in animal models and in humans that this complex layered system has multiple functions. Superficial and deep fascia act as padding and covering for protection of delicate structures such as nerves, blood vessels, muscles and bones. The composure of a layered system allows for sliding mechanisms, as multiple sheaths made up collagen, fibrin, and reticular fibers, separated by a unique fluid primarily composed of hyaluronic acid; and it is also considered a part of our nervous system.1,2 The deeper layers of connective tissue between the superficial retinacula and the muscle help maintain the fluidity of our movements. When thickening, or densification, occurs at a particular point in the connective tissue of the shoulder, the calf muscle, or the groin, where vital layers of connective tissue must glide, a pain response is usually created as the tissue pulls and rubs irregularly. The fascia uses a sliding structure to enable smooth movement; the fluid-like substance between layers contains hyaluronic acid is found to be more viscous is denser points of fascia—it begins to act more like honey, with the layers sticking together, creating faulty movement and faulty messages back to the spinal cord and brain.3 Because we now know that fascia is innervated with both free nerve endings and mechanoreceptors that respond to pressure and friction, we can better understand pain syndromes based on faulty joint movements that arise in the myofascial system, and why they are not detected on modern imaging modalities such as a CT scan or MRI.4   

 

Deep fascia does not exist separately, but actually is strongly adherent to the muscles of the trunk. This means that approximately 30% of muscle fibers in the trunk are merged through the deep connective tissue and respond to the stretch and stress of your muscular contractions, which in turn stretch and activate fascial mechanoreceptors, igniting a neural feedback loop through the spinal cord to activate perfect movement.5 This “sense of space” and “recognition of tension” through the system is called “proprioception” and it allows us to perceive the depth and height of a set of stairs, have the ability to balance on one foot, catch a ball in mid-air, and regain our balance if we lose our footing. Antonio Stecco, MD, PhD, states that “fascia is the organ of proprioception,” which means that this previously unknown “organ” that encapsulates our entire being plays a lead role in knowing where your body is in space.6

 

You probably didn’t think you had another organ in your body, let alone an organ that literally is your entire body! It’s exciting to think that we are still discovering and exploring the intricate world of fascia and how it contributes to the nervous system. Dr. Jean Claude Guimberteau, a hand surgeon in France, conducted some of the first scientific studies on this “new” organ beneath our skin and created some of the most stunning video footage the world had even seen of what fascia actually looks like en vivo; check out this short clip to glimpse the complexity of our connective tissue.

 

How does this fascial system relate to my testicular or vulvar pain, burning and aching during sitting around the sit bones and tailbone, or my searing pain that I have every time I attempt intercourse?

 

Just as the muscle fibers are continuous with the deep fascia in the trunk, so are the layers connected to each other through central points of the body where increased force, movement, or friction may occur. As I mentioned earlier, we need the layers of connective tissue to slide and glide appropriately on each other with ease, and for this we need a healthy intracellular matrix that is fluid, i.e. less sticky, less dense and adhered. Once these layers build increased density—mostly to protect us from pain and unhealthy movement– and adhere to each other, we find decreased blood flow to the area, and decreased cellular exchange. This results in increased movement compensation, pressure, and pull on an already taxed system—like sitting on tight fascia around the delicate structures of the pelvic floor for 8-10 hours per day.  At PHRC we treat both the superficial and deep fascia. See Stephanie Prendergast’s previous blog post on loose connective tissue and how pelvic floor physical therapists treat superficial layers of fascia with skin rolling. PTs also treat the deeper layers of connective tissue where they interact with the muscle fibers—particularly muscles that connect to the pelvis bones, as well as the protective fascia housing the pudendal nerve and vital blood structures that reside near your sit bones. See Stephanie’s blog on how trigger point release helps regain normal muscle function and treat fascial pain.

 

So how can I get my fascia healthier? Once it’s stuck, can it get un-stuck?

 

Lucky for all of us the research on treatment for dysfunctional fascia is rich with new discoveries. Numerous un-embalmed cadaver dissections and scientific journal studies have helped to create the Stecco Method of Fascial Manipulation based on decades of clinical work by Italian physiotherapist, Luigi Stecco. This research is not the first to recognize the connective tissue matrix beneath the skin.In fact, early physicians throughout history have written in depth about the importance of this spidery substance—but it is not until now that the science has reached randomized control trials in the US to help show exactly how the fascial layers work as a system—creating “lines and planes” of movement that can be therapeutically treated as such. Essentially, Fascial Manipulation has discovered a series of specific points where the deep fascial layers coalesce to connect body segments to each other—much like acupuncture points that form meridian lines. These points, called Centers of Coordination, or “CCs,” are points that are replicable on each human body, laid out systematically in multiple movement planes, in order to treat the poor-gliding dysfunctions that occur in the connective tissue. When a practitioner palpates these specific places (sagittal, horizontal, or frontal) that elicit pain from the patient and reveal palpable restrictions, the treatment that occurs is deep pressure coupled with friction to the specific center of coordination (CC) until the pain decreases by greater than 50%.  The treatment is performed only in a single plane of movement at one time (think forward-backward motions or lateral motions being separate treatments), and should trigger a deep ache that resolves into a low-level ache or soreness for a day or two afterward. The friction, causing heat, and the pressure, triggering mechanoreceptors in the tissue, ignites a cellular cascade that breaks down the coagulated hyaluronic acid—that “sticky” stuff I mentioned earlier—and leaves the patient with pain free movement. See Fascial Manipulation link here to learn more.

 

What’s up with those crazy scraping tools that leave me black and blue?

 

Other connective tissue treatments, such as IASTYM (Instrument Assisted Soft Tissue Mobilization), better known by the popular manual treatment devices Graston, leave the patient with visible skin discolorations and often deep bruising. IASTYM originates in Asia and is often called “Gua Sha,” translating to “rub” or “friction.” This scraping technique is believed to created fluid exchange, increased “ion flow,” and even “neutralize acidic conditions.”Although most of these claims have yet to be shown in scientific literature, it seems that fluid exchange within the extracellular matrix, may be a closer to the reality than previously thought.

 

…And those weird suction devices that leave purple dots on the skin—is that treating fascia?

If you watched the Summer Olympics you’ll see that sporting purple spots are en vogue!  Those purple bruises are the signs of Myofascial Decompression which is a treatment applied to the layers of fascia using tools traditionally found in Acupuncture cupping techniques. Myofascial Decompression@, or MFD, is applied through a pumping action to create negative pressure and “suck” the fascia upward away from the deeper structures. MFD treats the dense connective tissue decreased mobility by drawing the tissue up into the cup and increasing tension on the surrounding tissue. The key difference between MFD and Acupuncture related cupping is that the patient is instructed to actively move the limb or trunk to stretch the fascia underneath the cups. When the MFD cup is released, a dark purple or red spot where it has been indicates an area that has been treated, leaving newly mobile and blood-flushed tissue in its place. In treating pelvic pain and scar tissue, physical therapists will utilize MFD to help mobilize densified connective tissue around the bony pelvis to help relieve referred pain and increase healthy blood flow to the internal pelvic floor musculature.7

 

All of this sounds great, but pretty expensive…what tools can I use at home to treat my connective tissue?

 

Bust out that foam roller you’ve been hiding under your bed since you discovered your IT band just isn’t ever going to get less painful: that’s your fascial self-treatment tool!  Foam rollers of all shades and densities have flooded the market, but regardless of how much of a glutton for pain you have become, I still am partial to the soft foam roller that Sue Hitzmann created during her launch of The MELT Method. Sue Hitzmann uses accessible language to introduce physiologically complex functions of the human body, and describes how fascia plays a vital role in maintaining a healthy nervous system. Similar to the Stecco Method, where there are key points of fascial treatment that relate to movement dysfunction, she describes specific movements performed on her soft foam roller and hand-foot treatment balls as ways to apply pressure, friction, and rinsing motions activate “the 5 R’s” of MELT: Reconnect, Rebalance, Rehydrate, Release, and Reintegrate to heal traumatized and painful fascia and the proprioceptive “body sense” within it. Her movements are applied in a system, linking them together in what she calls “body maps” for various pain syndromes, and always beginning and ending with a body scan linking the breath to the “neurocore”—a term she coined to explain how integral the diaphragmatic breath is to reintegrating healthy, pain-free movement back into the body.8 See Sue’s MELT Method page here.
The bottom line on fascia is that it encompasses your entire being,so embrace this previously esoteric substance that helps your movement be spot on and less painful when you finish your day. An important note is that we can actively or passively treat the fascia all day long, but healthy habits are still the key: Less time sitting on the back-line of connective tissue that travels from the back of your skull down past your pelvic floor, all the way to your toes; take walks, drink water, and explore how fascia can enhance your mobility and free you up for more delightful activities…and who knows, maybe a little hanky-panky with your partner won’t seem so daunting after all!9

 

 

References:

 

  1. Cowman M., et al. Viscoelastic Properties of Hyauronan in Physicological Conditions. F1000 Research. 2015, 4;622.
  2. Branchini M., et al.  Fascial Manipulation for chronic aspecific low back pain: a single blinded randomized controlled trial. F1000 Research. 2015; 4:1208.
  3. Stecco A., MD, PhD. The Fascial Manipulation, Stecco Method. Level 1, lecture and lab. University of California, San Francisco. January 6-8, 2017.
  4. Stecco C, Gagey O, Belloni A, et al. Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie. 2007;91:292:38-43.
  5. Stecco C, Gagey O, Belloni A, et al. Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie. 2007;91:292:38-43.
  6. Stecco A., MD, PhD. The Fascial Manipulation, Stecco Method. Level 1, lecture and lab. University of California, San Francisco. January 6-8, 2017.
  7. DaPrato C, Kennedy C. Myofascial Decompression Techniques (MFD): A Movement Based Myofascial Course. Level 1 Course. University of California, San Francisco. March 14-15, 2016.
  8. Hitzmann, S. The MELT Method, First Edition. New York, Harper Collins; 2013.
  9. Raghavan P, Ying L, Mirchandani M, Stecco A. Human Hyaluronidase Injections For Upper Limb Muscle Stiffness in Individuals With Cerebral Injury: A Case Series. EBioMedicine. 2016;9:306-313.

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. Thank you! This stuff can’t be explained too many times! I think I’m getting it!

  2. Question: I have been seeing physical therapist for months now and they have still not addressed my severe muscle tightness in both legs but particularly more in the right leg in my hamstring and calves and tightening into my heel causing severe pain. They don’t seem to have an answer. It can be rather painful at times. Can my pelvic be causing my problem? I have previously been diagnosed as having pelvic tilt forward. I am trying to stretch out the muscles with lacrosse ball but that is a temporary solution. Even on extended walks my hamstrings/calves will tight up or could it be more hip related?

    Thanks

    1. Author Ciel Yogis says:

      Dear Michael,
      Thanks for your question! Your pelvis is the integral connection between your torso and your lower extremities, so it is very likely that a muscular or skeletal imbalance can contribute to your muscle tightness that you are describing. The pelvis typically tilts anterior or posterior due to how we stand and sit–and our hamstrings, quadriceps, gluteals and abdominals are main actors on the pelvis to maintain posture. Postural dysfunction can be a major source of pain, as well. Based on the information you provided it is difficult to say whether your discomfort is being driven by a structural issue or a muscular one–or both. Ask your PT and see if he or she may delve into a bit more with you! Good luck!

  3. Thanks for this article, when I first found out about fascia and the role it plays in my health, I was amazed that it isn’t more known. I found Block Therapy and the changes that were made have been amazing.

    1. Hi Helen! We are so glad that you found this article as well & that you are seeing improvement in your health!

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