By Molly Bachmann PT, DPT, Birth Doula, PHRC San Francisco, CA
One of the most common questions I receive as a physical therapist is “But why does it hurt? How did I get this?” Sometimes, these questions are really challenging to answer. Other times, there is a distinct root cause. Let me tell you the story about a patient with hip and testicular pain and the hunt to find the primary “driver” of my patient’s symptoms.
William had torn the labrum in his left hip several months ago. His case was determined to be non surgical so he sought care from a trusted physical therapist who helped him recover. His treatment plan involved a significant amount of strengthening of the lower extremities and pelvic girdle. Shortly after, right testicular and perineal pain developed. This progressed into left abdominal and anterior thigh pain. He described it as feeling like an “end stage bruise deep inside. In addition, he developed a post-void dribble that occurred almost every time he urinated. He had no changes to bowel function or sexual function. William’s goals were to get back to cycling and swimming without symptoms.
When I evaluated William, I observed that when he squatted, his weight shifted to the right (the formerly injured hip) and the same thing happened with a deadlift. With a single leg sit to stand, he was more steady on the left leg. In testing his hamstring length, this was greatly reduced bilaterally and in testing hip mobility, he had more in his right hip than the left side.
Connective tissue restrictions were present in his left pelvis and adductors as well as hypertonicity in the left pelvic floor muscles (the side where his symptoms were located). The working theory? With so much focus on the right leg in his rehabilitation, the left side became stiff and immobile . . . perhaps as a way to give his body stability while recovering. That’s the thing about the body . . . . it will always get what it wants, even if it means consequences somewhere else.
To start, I sent him home with a half kneel weighted adductor stretch, legs up the wall adductor stretch, happy baby, and foam rolling to the adductors and hamstrings (see video below).
A week later, William returned with improvement in the testicular and perineal pain. He performed his exercises every day and even went to a yoga class to work on hip mobility. Our session continued to address the mobility deficits in the left hip with progressions of his mobility program. We added a reverse clamshell to increase hip gluteus medius strength and to reduce the tone of is left obturator internus muscle, practiced a forward T hip opener for increased proximal pelvic girdle control, and attempted a quadruped hip CAR that provided to be very challenging (see video below). I spent about 20 minutes addressing the tissue restrictions with manual therapy techniques like connective tissue mobilization, trigger point release and soft tissue manipulation. He left without any symptoms that day.
A week later, William returned with 70-80% improvement in his pelvic floor symptoms with the majority of the remaining adverse sensations presenting in the anterior hip. This allowed us to progress his program even further. William no longer needed the foam rolling. After trialing several new movement patterns, we added in a seated straight leg raise to address weakness in his hip flexors, and a shrimp squat to work on single leg strength (see video).
Over the next two sessions (total of 5 sessions), William achieved 100% symptom free status. We established a mobility program for him that included regularly stretching the adductors, and the lateral lunge, quadruped hip CAR and Bulgarian Split squat as a part of his warm up at the gym 4 days a week (see video below).
As you can see from this case, oftentimes symptoms in the pelvic floor involve more than just those structures. They can involve the back, hips, knees . . . even ankles and toes. It is important to work with a PT who is able to assess all aspects of your body to give you the most individualized and specific program possible.
Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. 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.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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