By: Kimberly Buonomo, PT, DPT, PHRC Lexington
Christina is a 75 year old patient I had the pleasure of seeing last summer. She came to me with a 30+ year history of pain which started as back pain during pregnancy. By the time she got to PHRC, her pain had spread to her pelvic floor, groin, adductors, low back, piriformis and SI joint. She also reported a feeling of hip impingement and was starting to lose sleep due to her ongoing pain.
She had seen many providers since her symptoms started including orthopedic physical therapists, chiropractors, massage therapists, and a podiatrist. She tried myofascial release, trigger point injections, stretching, corticosteroid injections, muscle relaxers, inversion table, orthotics and rolfing. Nothing really seemed to help and she couldn’t figure out why her symptoms weren’t responding to stretches or exercises and why her whole body continued to feel so tight. It wasn’t until she developed pelvic pain that she found us online.
My First Thoughts:
This patient had been in pain for so long without much relief from anything she had tried. What was being missed? Since no one had examined her pelvic floor yet, her symptoms started after a vaginal delivery, and the connective tissue techniques I used were different than what Christina had tried in the past. I was confident that we were trying something new for her, and was hopeful that we would be able to get some good findings that could lead us to the root of the problem.
When I examined Christina, I found significant connective tissue restrictions in her abdomen near her diaphragm, and moderate connective tissue restrictions above her pubic bone and through the bony pelvis. Her internal exam showed significant restrictions of the muscles, especially her obturator internus and piriformis, which are responsible for hip external rotation and were likely influencing her back pain. I didn’t get to look at everything I wanted on day one, since we spent a good amount of the evaluation getting a thorough history of her symptoms (with 30 years of pain, we had a lot to review). During the next few sessions, I completed my assessment and found more connective tissue restrictions and hypertonus in her quadratus lumborum and adductors. Her adductors and glutes also had myofascial trigger points. For a great anatomy review, check out Shannon’s article!
I thought that Christina’s issues probably stemmed from the excess strain to her pelvic floor during her pregnancy, as that’s when these symptoms started. This made sense as a continued pain generator years later, as no one had examined her pelvic floor muscles internally yet, so all of her work externally was not getting to the true root of the problem. I think that many of her external findings were probably stemming from ineffective use of her glutes and compensation by using her hip external rotators.
The restrictions in connective tissue through her diaphragm and pubic bone were likely also contributing to her ongoing back and hip pain, and this restriction anteriorly is why stretching her posterior chain did not help much. We often see this “snowball effect” with patients, where you need to look at the bigger picture in order to fully appreciate where her pain was coming from. Even though her pain started as back pain, it seemed like the root of the problem was her pelvic floor and her connective tissue.
I decided to see Christina weekly. We focused initially on manual therapy to address her restrictions, pelvic floor hypertonicity, and trigger points. As these restrictions improved, she had better mobility, especially through her diaphragm, which helped her breath more effectively. Lack of diaphragmatic breathing can limit the ability of the pelvic floor to relax, since these structures are linked like a piston. For more information on this, check out this blog post. We also worked on her motor control so that she could use her new range of motion as effectively as possible to prevent things from becoming restricted again in the future. We spent a lot of time working on education. We talked about the different factors that were contributing to her pain and created a guided (and evolving) home exercise program to get her back to her healthy lifestyle without pain. Within a month, she reported that her pain was starting to change and I was finding that her restrictions were starting to improve. On our sixth week, she told me that her pain was decreasing, even though she was doing more activity at home. We did have a discussion about her stretches around this time. It turns out that she was stretching muscles with active trigger points. This is a big no-no, as stretching or strengthening a muscle with active trigger points can further exacerbate pain. This is why we recommend that most of our patients use foam rollers, to address these tissues without overworking or exacerbating them. Steph goes over the in’s and out’s of trigger points here! By three months in, she was completely pain free for a couple of days at a time and I noted that her trigger points were significantly improved. She also had started working with another provider who performed dry needling as a complementary therapy to PT, as well as seeing a massage therapist regularly. I started seeing her every two to three weeks for symptom management and within five months of our evaluation, she was pretty much pain free for the first time in decades! At this point, she had no more trigger points and only minimal connective tissue restrictions, though her muscles, especially her adductors had some tightness, and she was back to doing everything she had wanted to do at home and taking care of her grandson!
Here’s what Christina had to say about her story:
Pain became a part of my daily life while I was pregnant and for 35 years after I delivered my daughter. I was led to believe that back pain, piriformis pain and overall lower body pain that I was experiencing were my fault, since I was told repeatedly that I was not stretching enough or not stretching the right way. I spent a fortune on deep tissue massages, physical therapists, chiropractors, foam rolling and other types of body manipulation equipment, as well as rolfing. Nothing helped. Doctors told me that I would “never be right” since I delivered my daughter at age 39.
The treatments that I received at Pelvic Health and Rehabilitation Center were life-changing. Back pain slowly subsided, eventually disappearing and the “piriformis syndrome” vanished. The therapist, Kim Buonomo, identified root causes of my pain areas and her hands-on treatments brought relief and healing to my body. I am extremely grateful to Kim and the Pelvic Health and Rehabilitation Center for enabling me to walk through life pain free. I wish that I had known about pelvic floor therapy sooner.
My Take Home Points:
- Education- Christina’s treatment was largely impacted by the conversations that we had about her symptoms. We talked a lot about what she had tried, what she was doing at home, and how we could make things better. I think that understanding the “why” behind the “what” allowed her to see connections to her symptoms and bring up questions in our sessions that led us to changing her plan or treatment approach for the better.
- Patient involvement- Christina was always doing her own research, asking questions, and taking it upon herself to show me what she was working on. She took a very active role in her recovery and I feel that it helped her tremendously!
- Collaboration- At that time, I was not certified in dry needling. (Proud to say that I am now!) So working with providers who could provide this as an adjunct treatment was really helpful in getting her feeling better faster.
- Look at the whole picture- Despite her decades of pain throughout her pelvic girdle, no one had recommended that she see a pelvic floor physical therapist. Within our first treatment, I was able to identify dysfunction in her hip external rotators that ended up being a significant factor in her recovery! If I had just examined her back, I would have been missing a big part of the picture. I was happy that we were able to assess her thoroughly and use a different treatment approach that ended up providing a lot of pain relief for her!
If you’ve been having pelvic girdle pain and you think your pelvic floor may be involved, schedule an appointment for an evaluation with one of our offices!