By Melinda Fontaine
The physical therapists at PHRC work as a team to help each other figure out the most efficient ways to help our patients. One way we share information is through weekly case studies, where one of our physical therapists describes a patient’s case, why they chose to evaluate the structures they did, how the results of the evaluation lead to an assessment and treatment plan, and how the therapists carried out the treatment plan to help the patient reach their goals. This week’s blog features a case study by Melinda Fontaine, a PHRC physical therapist in our Berkeley location.
Here is what Melinda has to say:
Robert, a healthy 34 year old man, started having pain in his tailbone, especially with sitting, driving, having sex, having bowel movements, and exercising. The only things he could think that might have contributed to his pain were heavy squats and abdominal workouts. He later started to have scrotal pain as well. Robert went to a doctor who did a pudendal nerve block. After the nerve block, he developed a rectal abscess at the site of the injection, which is an uncommon response to the procedure. This abscess then turned into a fistula, which is an abnormal tunnel between the anal canal and the skin. Fistulas are problematic because they can lead to serious infections. Because of this risk Robert underwent a fistulotomy, a surgical procedure to open a fistula and help it heal. This helped the fistula but his pain persisted. Robert started seeing a physical therapist, but had to stop because the drive was too long and he had tailbone pain with sitting.
ROBERT’S PHYSICAL THERAPY FINDINGS
Four years after the start of his pain, and with no relief, Robert decided to seek out pelvic floor physical therapy. He found PHRC on the web and came in for an evaluation. Since the pain started with heavy abdominal workouts, I examined the abdomen for a cause and found tight rectus abdominus muscles with trigger points. The rectus abdominus commonly refers pain to the genitals, so I confirmed that he should not be doing abdominal exercise until his rectus abdominus issues had been addressed. I looked at the muscles near the tailbone for sources of the tailbone pain and found left coccygeus trigger points externally that reproduced his tailbone pain. Also, Robert had fascial restrictions around his ischial tuberosities, or ‘sitz bones’. Because of his scrotal pain and urinary hesitancy, I also examined the muscles of the pelvic floor located near the urethra and found high tone in ischiocavernosus and bulbospongiosus. Because of their connections near the urethra, the ischiocavernosus muscles can lead to urinary hesitancy by not releasing fully and immediately. I also looked for any signs of the abscess and fistula and could not find any adherent scar tissue.
I explained how repeated heavy squatting created coccygeus trigger points and fascial restrictions at the ischial tuberosities. This pulled on Robert’s tailbone creating pain. His pelvic floor started to become tight in response to the tailbone pain and new length-tension relationship in the posterior pelvic floor muscles because of the abdominal workouts. Robert reported that manual therapy had helped previously, which is often the case when there is a muscular issue. For Robert’s particular case, we don’t know if the pudendal nerve block helped because it immediately turned into an abscess. I concluded the scrotal pain and urinary hesitancy are results of the tight anterior pelvic floor muscles around the urethra and the rectus abdominis trigger points.
The initial plan was to perform manual trigger point release to the rectus abdominus and coccygeus muscles, connective tissue manipulation around the ischial tuberosities, and myofascial release to the ischiocavernosus and bulbospongiosus muscles internally and externally for 8-12 weeks. Robert’s home program consisted of pelvic floor drops/releases and self myofascial release using a tennis ball around the coccygeus and pelvic girdle muscles. He was already doing a stretching routine of pigeon, butterfly, and cat/cow stretches, which he reported felt good, so he continued with these stretches.
Robert’s goals for physical therapy were:
- Tolerate sitting 1 hour at a time repeatedly for a full day of work
- Tolerate sitting 2.5 hours for car ride, which he does often with family
- Return to weight lifting without pain
- No pain with sex
- No pain with bowel movements
At the third visit, Robert reported feeling “a lot better”. When the trigger points in his rectus abdominis were reduced, we started core strengthening. His transversus abdominis was weak, and I wanted it to work harder especially during his weightlifting, so that his pelvic floor did not have to work as hard, which can result in injury and likely the coccygeus, pain-causing trigger point. I waited until the point when the trigger points were relieved because I was concerned that he would activate his rectus abdominus during transversus abdominus exercises. People with pain/trigger points often have faulty motor recruitment patterns which can lead to further pain/dysfunction. When left uncorrected, the faulty motor patterns can result in normal movements causing abnormal stress on structures and subsequent impairments and pain. Once corrected, people can resume exercise without trouble. Next, we added light weight lifting exercises for the upper body in a seated position to ease the demand on the pelvic floor. At visit 4, he was sitting for 4 hours at work with standing breaks and the coccygeus trigger points were gone. Robert reported no pain with bowel movements and less pain after sex. He gradually increased the intensity of his workouts. On the 5th visit, he was sitting for a full work day with standing breaks. On the 9th visit, he increased exercises too much and felt a pull in his abdominal muscles. I treated the attachment of rectus abdominis at the pubic symphysis which reproduced his pain, and his pelvic floor muscles were more hypertonic that day as well in response to this incident. This eliminated his symptoms. After the 10th visit, he took a 5 hour flight. He had a little discomfort on the way there because he sat for almost the whole 5 hours. Otherwise, he reported no pain on the trip or after he returned! Robert and I were both pleased that his goals have been met. His progression followed what I expected given his initial assessment. We planned to have Robert increase his workout intensity and follow up with me in 3-4 weeks.
Now, several months later, Robert’s goals have been met and he has been discharged from physical therapy.
Take Away Messages from the PHRC team
Melinda did a great job identifying that Robert’s exercise routine may have specific implications to his abdominal wall and pelvic floor muscles. This suspicion guided her evaluation; she identified that palpation of these structures reproduced the pain Robert was experiencing. Malinda’s treatment plan was effective because she began with manual therapy to treat his impairments and supplemented the therapy with a home program. Then, she helped him identify faulty movement problems and weak muscles. She was able to help him correct these deficiencies and help return to exercise in a manner that was therapeutic versus provocative. The timing on how and when to introduce activities is important when restoring function and transitioning back into the very activities that initially caused problems. With proper rehabilitation it is possible!