what is CTR

Connective Tissue Restrictions: Causes, Consequences and Treatments

In Pelvic Health by Stephanie PrendergastLeave a Comment

By Stephanie Prendergast, MPT, Cofounder, PHRC Los Angeles


Connective tissue (CT) restrictions are defined as a dense thickening of subcutaneous tissue that’s painful upon pinch-rolling examination. Connective tissue restrictions can contribute to urinary and bowel symptoms and pelvic pain. As this post will explain, CT restrictions can be a cause and consequence of multiple pelvic floor symptoms and syndromes. During a PFPT evaluation for someone with pelvic pain, we examine the CT in the abdomen, the CT attached to the bony pelvis (front & back!), low back, gluteal region & the legs. When CT is restricted there’s less blood flow to the area, which makes tissues more sensitive than they should be when touched.


They’re also more sensitive to other things such as underwear & clothing, or sitting surfaces, which is why they can contribute to pain with sitting. Pelvic pain symptoms are often caused by multiple impairments, CTs should always be evaluated to determine if they are restricted or impaired. When people come to us that have not improved with PFPT previously, this is often a missing piece.


The techniques to examine and treat CT are very specific and must be done properly and consistently to help effectively identify and then treat the issues. In this blog we are going to discuss: the symptoms that CT restrictions  cause, why they develop, how we treat them and what you can do at home to help restore normal and healthy tissue mobility!  Want to read more about Connective Tissue Manipulation? Check out our blog that talks about ‘skin rolling’.


causes of CTR

Research shows that connective tissue restrictions (CTRs) develop because of several reasons. Here are just a few of the main culprits.


Visecro-somatic reflexes: The term ‘Viscero’ means ‘organ’, ‘somatic’ refers to ‘muscle, nerves, and fascia.’ When visceral structures, such as a bladder, uterus, prostate, or part of the GI Tract get irritated they can have consequences in the muscles and tissues and as a result, CTRs can form.


Studies show that fascia above myofascial trigger points can develop CTRs in response to the inflammatory mediators that exist with myofascial trigger points.


When peripheral nerves become irritated there are consequences in the muscles and skin that those nerves innervate. For example, people with sciatic may develop CTRs in their legs in the sensory distribution of the sciatic nerve.


Similar to muscular dysfunction, joint dysfunction can release inflammatory mediators that result in the formation of CTRs superficial to the involved joint.

consequences of CTR

As we mentioned earlier in this post, connective tissue restrictions (CTRs) are dense thickening of fascia that is painful upon examination. CTRs can cause local tissue sensitivity & pain, for example, when they occur near the sit bones people may feel pain when they sit because sensitive, dense tissues are being further compressed and blood flow decreases even further. 


CTRs can be caused by noxious input from visceral structures. For example, UTI ‘s and diseases such as Endometriosis can cause connective tissue to become impaired via the viscero-somatic reflex. The reverse also occurs: CTRs can cause irritative bladder symptoms, vulvar pain, and GI distress via the somatic-visceral reflex.


People with pelvic pain commonly develop CTRs in the dermatomes of peripheral nerves, such as the pudendal nerve, posterior femoral cutaneous nerve, or others. The density of the CTRs can cause mobility issues along the nerve & prevents the nerve from gliding, sliding, and moving normally. The CTRs can also compress peripheral nerves. Both scenarios can result in symptoms of peripheral neuralgia anywhere in the territory of the compromised nerve.


CTRs reduce blood flow to underlying muscles and also impair the ability of the underlying muscle to move normally. This increases the likelihood of the underlying muscles to be injured. In addition, CTRs may impair underlying tight muscles or trigger points to respond to therapies.

treatment for CTR

Connective tissue restrictions (CTRs) are associated with pelvic pain syndromes. They can be a cause or an effect of multiple inputs, and they themselves are a source of pain and dysfunction. While CTRs are problematic, if they are present they can be treated several ways.


PFPTs utilize a manual therapy technique called connective tissue manipulation which involves a ‘skin rolling’ technique to reduce dense tissues, improve blood flow, and help restore normal mobility and sensation to the impaired tissues. When done properly this technique is well tolerated & patients usually feel relief of bothersome symptoms immediately after treatment and over time.


Cupping is a technique that involves using suction to lift fascia. Cupping can be static or the therapist may use dynamic techniques that involve moving the cups or the body to help tissues slide, glide and move more normally.


Foam rolling helps mobilize the fascia as well as reduce myalgia and muscle tension in the underlying muscle group. This is great for the legs and trunk but the areas of the bony pelvis, pudendal nerve, and tissues closest to the vagina & anus are better treated with cupping plus manual therapy. 


Finally, CTRs develop & persist because of visceral, joint, muscular, and neural dysfunction. Treating the underlying causes of the CTRs will allow for normalization of this problematic tissue. Examples of treating underlying causes include eliminating gut pathogens such as SIBO, eliminating UTIs and yeast infections, or treating underlying PFD or Endo.  


Take home message: Connective Tissue Restrictions are associated with pelvic pain and should be evaluated to determine if they are playing a role in someone’s symptoms. If they are present, manual and home therapies can help restore normal mobility and reduce pain and dysfunction!


Read more:

Sitting on painful fascia: connective tissue and pelvic pain

Pelvic Pain: The Role of Scar Tissue



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. 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

Do you enjoy or blog and want more content from PHRC? Please head over to social media!

Like us on Facebook,

Subscribe to our YouTube Channel

and follow us on Twitter, Instagram, Tik Tok and Pinterest!

Leave a Comment