By Stephanie Prendergast, PHRC West Los Angeles
You say “skin rolling.” I say “connective tissue manipulation.” Tomato…tomahto; semantics aside, let’s talk about what it is and what it has to do with pelvic pain.
“Skin rolling” or “connective tissue manipulation” as I’ll be referring to it throughout this post, is a major component of our pelvic pain treatment technique here at PHRC. That’s because in our experience treating pelvic pain patients—both male and female—more often than not, when there is pelvic pain, there will be some level of connective tissue restriction.
Before we delve into the connection (wink) between connective tissue restriction and pelvic pain, let’s first explore exactly what “connective tissue” is.
Connective tissue is one of the four general classes of biological tissues—the others being epithelial, muscular, and nervous tissues. The job of connective tissue is to support, connect, or separate different types of tissue and organs.
Bones, ligaments, tendons, and cartilage are all considered connective tissue. However, the type of connective tissue that we’re interested in in the context of pelvic pain is known as “loose connective tissue.”
Loose connective tissue is aptly named because its fibers are randomly arranged and there’s lots of space between the cells, which makes it THE ideal tissue for cushioning and protecting. Besides surrounding blood vessels and nerves, one of the biggest jobs of loose connective tissue in the body is to attach the skin to the muscles.
(For the sake of brevity, even though I’m referring specifically to “loose connective tissue,” going forward I’m going to use the term “connective tissue.”)
Connective tissue can become restricted as a result of dysfunction in underlying muscle, nerves, joints and organs. Reflexively, once connective tissue restrictions have developed there will be dysfunction in the area (locally) and in distant locations if not properly addressed by manual treatment.
When the connective tissue that attaches the skin to the muscle becomes restricted (think thickened or dense) it can and does cause pain. One reason is that restricted connective tissue impedes healthy blood flow to the area. Plus, research shows that connective tissue restrictions lead to local pain via the peripheral nervous system.
In addition, a strong association between active trigger points and connective tissue restriction exists. As a result, treating the connective tissue restriction can relieve trigger points activity and/or make trigger points more responsive to treatment. (How cool is that?!) On top of all of that, it’s hypothesized that restricted connective tissue can cause referred pain—including pain to organs (think bladder in the case of pelvic pain)— via the central nervous system.
For all of the above reasons, it’s important for pelvic floor PTs to treat connective tissue restrictions as part of a comprehensive treatment plan.
The manual test that’s used to determine if a patient has connective tissue restriction (a.k.a. “subcutaneous panniculosis”) is the “pinch-roll test.” When a PT carries out a pinch-roll test he or she will roll a fold of skin between his or her fingers, and note whether the tissue is thickened. This is painful to the patient. It should be noted that typically, there is only pain if the tissue is restricted. Healthy connective tissue does not produce pain in response to this test.
At PHRC, we refer to the treatment of connective tissue restriction as “connective tissue manipulation.” However, the common term used to describe connective tissue manipulation is “skin rolling.” The reason we prefer the former phrasing is that “skin rolling” doesn’t seem to do justice to what’s actually going on. After all, it’s the connective tissue, not the skin that’s being taken to task.
Semantics aside, to fully treat connective tissue restriction, a PT has to normalize its mobility, improve circulation to the area, reduce hypersensitivity, and minimize the negative reflexive effects on surrounding muscles, nerves, and organs. A tall order, I know. And that’s why it’s not unusual for us to devote half of an appointment time to connective tissue manipulation for our pelvic pain patients.
Patients with pelvic pain typically have connective tissue restrictions in the thighs, along the pelvis, in the glutes, and in the abdomen. For instance, patients with pain with sitting may have connective tissue restriction, particularly in the medial to ischial tuberosities, glutes and medial and post-thighs. And patients with perineal pain may have connective restriction along the pelvis, abdomen, and/or perineum.
When evaluating for connective restriction, a patient should be examined front and back from navel to knees. Once the restricted areas are isolated, connective tissue manipulation involves the therapist pinch-rolling the affected tissue below the skin and above the muscle between his/her thumb and four other fingers, with both hands. The therapist then palpates to feel where the tissue is thick and restricted and mobilizes the tissue using the thumb and four fingers to improve blood flow, decrease thickness, and restore mobility.
When tissue is restricted, manipulating it typically causes a sharp sensation and may cause tissue soreness in the days following treatment. If symptoms increase, or the patient cannot tolerate the technique, the therapist will postpone the treatment until it’s better tolerated. As the patient’s tissue normalizes over a series of treatments, connective tissue manipulation becomes less painful during and after treatment.
One final thing we’d like to mention about connective tissue manipulation is that it’s not a technique practiced by most pelvic floor PTs. The reason for this is that it’s very rarely taught in PT school or in post-graduate level pelvic floor PT classes. When we see patients who’ve not had success with PT in the past, it’s often due to this missing component.
At the end of the day, successful treatment outcomes are often dependent on including a connective tissue evaluation, and if dysfunctional tissue is found, including connective tissue manipulation in the treatment plan.
If you have any questions about any of the points covered in this post, please don’t hesitate to leave them in the comment section below!
All my best,