You know more than your PT. What do you do?

In Female Pelvic Pain, Male Pelvic Pain, Uncategorized by Elizabeth Akincilar7 Comments

What do you do when you know more about good PT then your PT does?

This is a question that came up a few blogs ago during a conversation about the proper administrations of estim and biofeedback, and unfortunately, it’s a dilemma that is extremely common for patients dealing with pelvic pain.

The reason for this is that when it comes to  treating pelvic pain,  until recently, there was very little education available for PTs. It’s not a subject that is covered in PT school, so PTs with an interest in treating the pelvic pain population are required to get post-graduate education. The catch-22 is that until the last five or six years, the only post-graduate training in pelvic floor treatment was focused on incontinence, which is a very different animal than pelvic pain.

Therefore, anyone interested in treating pelvic pain had to find a PT who was having success, and set up a mentorship with her.

The good news is that now there are more educational opportunities available for PTs who want to learn how to successfully treat the pelvic pain population. But that said, there is still a huge learning curve to make up for.

Plus when patients turn to the Internet for information, they often come across forums where folks with the same health issue are sharing information. As a result, patients with pelvic pain find out about techniques and treatment methods that others are having success with, which their own PTs may not be aware of.

Connective tissue manipulation and the proper uses of estim and biofeedback are two topics that patients are often more informed about than their PTs. But, trigger point release and even the general fact that you have to do internal work to treat pelvic pain are topics that can also fall into this category.

So that takes us back to our question: How do you tackle a situation where you know more than your PT about good pelvic floor treatment?

Well, first of all, I want to make it clear to you that it’s completely acceptable to ask questions about other treatment strategies that you’ve read about or discussed with other people that are successfully being treated for pelvic pain. If you’re reading this blog because you have pelvic pain, you know firsthand how very high the stakes are. When it comes to your health and quality of life, it falls on you to be your own best advocate.

Secondly, if you’re not getting the best possible treatment, you’re not going to get a good outcome. The best way to approach pelvic pain PT is as a team approach with patients playing an active role in their treatment. Therefore, advocating for yourself by filling your PT in on techniques and strategies that might improve your chances of getting better is one of your responsibilities as a team player.
So why not just go in there and school your PT?

We all know it’s not that simple.

From the patients’ perspective, it’s just not a dynamic that they are used to or comfortable with. How often do you go to the dentist and tell her or him which drill to use! So a patient who has never been in such a situation before is sure to feel awkward and unsure of how to approach it.

On the flip side, from the PTs perspective, right or wrong, PTs are coming into the room with their professional egos, adding another layer to the tricky dynamic.

But at the end of the day, as a patient, it’s up to you to ensure that you’re getting the best care possible. And if you believe in good faith that you’re not, you have to speak up, especially if you’re not improving with PT.

That said, I believe there are some DOs and DON’Ts when it comes to getting your PT up to speed. Let’s begin with what not to do.

For one thing, a little tact and diplomacy are definitely in order. So don’t approach it as, “Okay, this is what I need, and this is what I want you to work on, and I don’t want you to do this, and this is what I know will make me better.”

Remember PTs will have a little bit of an ego, and they are approaching the situation believing that they know what’s best for you. So before you broach the subject, it’s important that you’ve established a good, solid rapport with your PT.

Part of establishing that open channel of communication and good will with your PT involves letting her or him know that as a patient you’re committed to PT, and that you plan to be an active participant in this treatment team. That’s important because it lets the therapist know that you’re not just trying to bulldoze your way through and tell him or her what to do, you just want to get better.

Once you feel like you’ve established a good rapport, you should then feel confident about approaching the conversation.

You might begin something like this, “I totally get that pelvic pain treatment is a relatively new and growing area in medicine. In a way it’s exciting because it means that new treatment methods are becoming available. Speaking of, I was chatting with a friend of mine who also gets pelvic pain PT and she told me of some research that shows…So, I was hoping we could give…a try.”

Which brings me to my next point. Everyone in the medical field responds to research better than anything else. When you bring up research to your PT, you are speaking her or his language. So presenting research or well-written journal articles to back up your suggestions is a DO!

A great source of this kind of research is a PT named Rhonda Kotarinos. She is an excellent pelvic floor PT who has co-written several articles and has been involved in exciting research in this specific area. For instance, just in the past couple of years she conducted research that has shown that connective tissue manipulation is more beneficial than other types of myofacial work when treating pelvic pain. (At the end of the post is short list of some articles that I recommend. They are available on PubMed which your PT should be able to get access to.)

I honestly believe that the majority of PTs practicing in this area will be open to your suggestions. Most are in it to do whatever it takes to make you better. But if you find that your PT doesn’t respond well to the conversation, then it might be a red flag that it’s time for you to fire her/him and look to hire another.

I hope this post is helpful. Now, I want to hear from you.

Do you have any questions about any points that I haven’t covered?

Have you found yourself in a situation where you know more about good PT than your PT? If so, how did you handle it? What was the outcome?

If you have successfully navigated this issue, is there any additional advice you can give to others in this situation?

Thanks for reading and be well,

Pelvic Pain PT Research:

“Rehabilitation of the short pelvic floor. I: Background and patient evaluation.” FitzGerald MP, Kotarinos R.

“Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor.” FitzGerald MP, Kotarinos R.

“Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness.”


  1. My biggest problem has been that although the therapist is willing to listen to new research and my desires for new/different techniques, the therapist isn’t skilled to do things like connective tissue manipulation/external myofascial release. I live in an area with poor access to pelvic floor PTs and the 3 that are available are trained mostly in treating incontinence. They also do not have enough patients to only treat women’s health so they split their time b/w ortho and pelvic floor and unforutnately their skills are lacking (i.e. don’t know the pelvic floor muslces very well, are often overly aggressive which almost always ends in a flare, and seem to have trouble figuring out what to do in an hour session – they don’t have a good treatment plan and it feels like a waste of time honestly). What do you do in this situation?

    1. Thank you for your comment. Unfortunately, your situation is quite common and very difficult to manage. If you have established a good rapport with your PT, you could ask him/her if he/she has any interest in advancing their pelvic pain treatment strategies. If your PT is interested, you could recommend a number of continuing education courses for physical therapists treating pelvic pain specifically. Stephanie and I teach a course for chronic pelvic pain/pudendal neuralgia,, and the Herman and Wallace Pelvic Rehabilitation Institute,, also offers several courses focused on pelvic pain. Other than encouraging your physical therapist to further his/her training, you could also travel a little farther for good PT. I know this is much more difficult, but it is an option. Our Center, as well as a couple others in the country, offer programs for patients traveling from other states/countries. You can visit to find out more about our out-of-town program. Good luck!

  2. I’m having this problem with my physical therapist. She’s pushing kegels on me using the “reflexive relaxation” argument or whatever it’s called. She has me doing 20 minutes of 10-second contractions every day

    I know my pelvic floor muscles are extremely weak, but I also know they’re extremely tight.

    When I told her that the kegels seemed to be counterproductive and it was making me experience even more urge frequency, she said that it was because I wasn’t doing them right, and being at that point in the menstrual cycle also contributed.

    I’m in rural area and already travel an hour each way to see her, so I don’t really have other options. What do you suggest?

    1. Dear MM,

      You are correct. If you have both a hypertonic and hypotonic pelvic floor, then doing kegels may not be a good option for you just yet. You will need to work on relaxing the tight muscles first, and then move on to an uptraining, or exercise program. Where do you live? Perhaps we can recommend a therapist that is closer to you.

      All my best,


  3. I have been in PT going on my 3rd month now. I saw an immediate, positive response with the intravaginal trigger point release. Now, we are working on the obturator internus and we seem to be at a stand still. I realize that this takes time, and that there is no magical number of days for each person. However, I am beginning to become discouraged and I am wanting to know if there are more effective options out there, or if I need to stick it out. Like I said, she resolved 75% of my issue in the first few months. Now, it seems like I am going out backwards. Any info would be helpful and very much appreciated!!

    1. Hello Courtney,

      Without evaluating you it is difficult to say whether you have plateaued, whether your therapist is missing something, or if you’d benefit from alternative treatment such as acupuncture. I would encourage you to first communicate with your therapist about your concerns. If necessary, there may be a local therapist that I can recommend for a second opinion.

      All my best,


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