By Kim Buonomo, DPT, PHRC Lexington
Ally is a lovely 64 year old woman that I’ve been working with at PHRC Lexington since April 2019. During the course of her treatment, she read my previous success story and told me how it inspired her and that she believed she would find the same success some day. I’m so happy she has allowed me to share her story.
Ally had a bike accident in May 2018. Someone crashed into her front bike tire while she was riding, causing her to fall. A week after the accident, she started having right vulvar/labial pain. In the year since her accident, her pain has limited her from sitting and riding her bike. She is afraid to have sex because of the pain, and can no longer tolerate wearing jeans due to discomfort. She has noticed posture changes that are uncomfortable, such as standing with her weight through the balls of her feet, causing soreness in her feet and legs. She reports that engaging her core to lift heavy objects hurts the spot in her labia. She saw a chiropractor a week before seeing me for the first time, and noted that it seemed to help her pain.
- Impaired pelvic floor strength ⅕ on testing
- Impaired pelvic floor coordination, with minimal bulge and difficulty with pelvic floor relaxation
- Moderate to moderate + pelvic floor hypertonus of piriformis, obturator internus, and the urogenital triangle (right side more restricted than left)
- Trigger point internally at L obturator internus
- Moderate to severe connective tissue restrictions of the suprapubic region, bony pelvis, medial thigh, posterior thigh, glutes and low back (right side more restricted than left)
- Postural deviations including left shoulder elevation, right anterior rotated innominate in standing
Assessment: Ally found me in April 2019 because she felt that she was reaching a plateau with her current PT. She saw an article on the PHRC Blog about connective tissue, and specifically wondered if connective tissue restrictions could be contributing to her symptoms, which was a component that was not being addressed under her current program.
Her connective tissue restrictions were certainly a contributing factor here, but given the fact that core exercises and back stretches seemed to make Ally’s pain worse, spinal adjustment with a chiropractor made things better, and considering her mechanism of injury, I believed that her issues were also coming from the nerves in her spine and that her connective tissue restrictions were a consequence of this dysfunction. Identifying the peripheral nerve that is causing pain in the vulvar region can be tricky, as there are many nerves that have overlapping innervation through the pelvis, as you can see below.
Peripheral innervation through the pelvic floor
After getting more information about how Ally fell off her bike, I learned that the way she fell pulled on her right leg in a way that would be very likely to irritate the genital branch of the genitofemoral nerve, so that was one of the nerves I was considering as a source of pain, but there were several other nerves that could also be involved.
Another big contributor to her presentation was her posture. With any injury, the body compensates to avoid pain. Ally had not been moving comfortably for a year prior to seeing me. Every time she sat in an awkward position it would contribute to her postural and connective tissue restrictions, and those restrictions would further irritate her nerves, causing a cycle of pain and dysfunction. Now that her pain had become chronic, one big question was, which came first: the chicken or the egg? But in this case, the question was which came first: the nerve irritation or the connective tissue dysfunction? Either way, we know that improving one will help the other, so we worked on her connective tissue restrictions and considered pain management to address the nerve pain (more on that later). I also believed that her pelvic floor was involved in the pain cycle because of her pain with lifting. With ineffective use of her pelvic floor muscles during lifting, her pelvic floor became restricted and limited her ability to contract and relax effectively. This led to motor control deficits, meaning that her pelvic floor muscles weren’t able to support her while lifting, weren’t able to relax at rest, and appeared weak on examination.
My goals for her included:
Short Term Goals:
1: Will be independent with pelvic floor drops
2: Will demonstrate decreasing connective tissue restriction by 30%
Long Term Goals:
1: Will demonstrate no greater than minimal hypertonus of the pelvic floor
2: Will demonstrate no greater than minimal connective tissue restrictions of the posterior chain (bony pelvis, glutes, low back, posterior thighs)
3: Will return to sexual activity with minimal pain
4: Will tolerate sitting up to an hour on soft surfaces without pain
I started seeing Ally weekly. We focused on the connective tissue restrictions on the right side of her body, especially the labia, suprapubic region, bony pelvis, and posterior chain. We also did internal manual therapy focusing on the restrictions of the urogenital triangle and improved her ability to contract and relax her pelvic floor muscles. For homework, I had her use the Stick to further address her myofascial restrictions and had her working on pelvic floor drops to improve her motor control. The goal of all of this was to improve the quality of her tissues, decrease nerve irritation, and decrease pain.
I recommended that Ally see a pain management provider. I did this because she had been in pain that had not been well controlled. Pain management providers are professionals who (you guessed it!) manage pain. This could provide her with some short term relief and get her back to sitting and doing the things she wanted to do more quickly, with better posture, and with less pain while we continued to work on things at PT.
We talked about how I wasn’t sure which factor was driving her continued symptoms. It could be her nerve pain or connective tissue dysfunction or the combination of both. Although PT can definitely calm down the nervous system, I thought adding a different approach through nerve pain management techniques in addition to addressing the myofascial restrictions with PT would help us more comprehensively address both sides of the problem. Ally really thought the connective tissue was the culprit and didn’t like the idea of another doctor and potentially a procedure, so she decided to continue with PT with the knowledge that we could always revisit the idea of pain management later. We planned to see her weekly to focus on the myofascial findings and to check in on a regular basis to make sure we were still making progress.
A month after we started working together, Ally’s restrictions were starting to improve. She felt great for two days after a session, and was able to sit at her kitchen table for 10 minutes! At our eight week visit, she was able to sit at her kitchen table for 40 minutes and had returned to wearing her typical underwear without pain. Her pain felt less “tingly” and more “tight and achy” which indicated to me that the nerves were starting to calm down. Her symptoms felt like they were shrinking to a smaller area (another good sign). She felt overall 40-50% better since starting PT and was almost ready to attempt sex again. The next week, she told me that for the first time in a long time, she had an entire day without pain and was able to sit through a movie!
But as we know, success is rarely a straight line. Almost three months into treatment, she wore sandals for a few days which caused a major setback. I believe wearing unsupportive shoes while her core muscles were still so weak contributed to postural impairments and flared up the nerves. I knew some of the stretches she was doing (specifically the hamstrings and piriformis muscle) can often make those symptoms worse, so I advised her to stop those. Now that her typical labial/vulvar pain was improving and she was doing a great job controlling her pelvic floor, we started adding some gentle core exercises to improve her stability and to further address her posture and the newer pain in the back of her leg. This flare lasted over a month, while we tried different strategies to calm things down. Ally vowed to never wear sandals again.
When things calmed down from that setback, Ally had made significant improvements with her objective findings. Her pelvic floor had great motor control, and the tone had mostly normalized, with only minimal restrictions. The tingling in her leg was now gone, but she still felt some pulling in the labia and was having issues maintaining good hip and pelvic alignment. A lot of this came down to stability. We decided to add an orthopedic PT closer to Ally’s home to work on stabilizing her core, glutes, and hips, and we decreased the frequency of her visits so that she was seeing me every other week as she focused on her strengthening program. With the addition of the ortho PT, Ally felt that everything was falling into place. She felt less pulling through the labia and was engaging her glutes more effectively.
After two months of this new phase, Ally followed up with me. She had developed some tightness and trigger points of the glutes and the adductors. As she was exercising more, these muscles were working hard to keep her stable and were tightening as a result. We decided to try dry needling the glutes and adductors to help manage that tightness and keep her muscles and pelvis in optimal alignment so that they would continue to support her effectively while she was building strength. After our first needling session, Ally noticed a big difference in her symptoms. She was able to stretch with less pulling and her pain was continuing to decrease. A month after we started needling, Ally started going to Pilates. When I asked about her symptoms and her progress, she told me she was “so close [to being totally better] that she could taste it” and the next week was the best she had felt in over a year.
We continued needling every other week for the next two months while she was continuing to build strength, and then took some time off for the holidays. When we checked in during January 2020, nine months after her evaluation, she was doing great. She had no more trigger points, her pelvic floor tone and motor control was within normal limits, she was much stronger and her connective tissue restrictions had significantly improved. She was able to sit to go to plays and to drive to see her family. She was consistent with Pilates and getting stronger and more functional every day. She did have a little tightness in the back of her legs, but this was much better managed. At that point, Ally and I decided to take some time away from PT while she continued to focus on her strengthening.
I emailed her at the beginning of May and she said “I finally have a strong core and glutes! Had been to my original PT a few times… She found a big part of what I’ve had is lack of hip mobility and thoracic rotation (all connected I guess). My pelvic floor is fine- just still that stubborn upper adductor/hamstring that is slowly releasing, which then helps that last little area. I still stretch, roll, etc.-have plenty of time to do it!! The rest of my body is finally feeling better. You helped a lot- now Pilates is really helping!”
I wish Ally the best as she continues her strengthening journey, and am so grateful that she is no longer having labial pain and is continuing to make progress toward achieving her other goals. I’m glad that she has the tools to make sure she keeps improving!
My Take Home Points:
- Don’t give up. Physical therapy is very rarely a quick fix, especially in a case like this, where she had been having symptoms for a year prior to seeing me. As long as things are continuing to progress, your PT should help you keep looking for next steps to keep making progress. In this case, her ortho PT and Pilates instructor ended up being very important pieces to the puzzle.
- The patient’s goals and wishes for treatment are critical. The patient is always in charge of what happens to their body. Ally did not want to see a pain management provider, so we didn’t go down that road. Of course, I took the time to explain to her my rationale behind my recommendation, but we needed to find a treatment option that we both were comfortable with, and we were able to be very effective even without pain management.
- Roll with it. Sometimes things don’t go as expected. People have flares in pain that we can’t always predict. At the time, I never would have thought to advise Ally against wearing sandals, but we were able to work through the setback and it ultimately helped us get to the next step in her stability training. It was a very long road, but ultimately through her hard work and dedication, her pain is almost gone and she is feeling stronger than she’s ever been!
Are you unable to come see us in person? We offer virtual physical therapy appointments too!
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.
PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836
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