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* Please Note: The following article is provided by Body Mechanics for the sole purpose of
educating and informing our current and future patients.
PELVIS AND SACRAL DYSFUNCTION IN SPORTS AND EXERCISE
Pelvic injuries and dysfunctions are not always included in discussions of sports injuries. One report regarding runners indicated that hip, pelvis, and thigh injuries accounted for 5% of all athletic injuries. Distinguishing how many of these involve only the pelvis is impossible. The general term pelvic injury
has a wide variety of meanings. Healthcare providers often interpret this term
based on their specialty background. The general musculoskeletal practitioner often will focus attention to bony, ligamentous,
joint, and muscle injury. Considerable overlap exists regarding referral of pain to the pelvic region from the spine, hip,
and lower extremity. Likewise, the pelvis holds important visceral structures that are gender-specific and are supported by
the muscular complex comprising the pelvic floor. Trauma or overuse injuries to remote sites can cause adaptive changes in
the pelvic floor, which can produce pain and bowel and bladder dysfunction.
In the past, sports medicine literature has often omitted discussions of pelvic injuries related to the pelvic floor.
This omission is likely related to a lack of research related to exercise and sports injuries specific to the pelvis. An
overlap of problems involving the lumbar spine, hip, and pelvis exists as well. As a result, the healthcare provider needs
to pull information from various sources including primary care, orthopedics, urology, physical medicine and rehabilitation,
and obstetrics and gynecology. The female pelvis acquires changes with aging. These occur as a result of hormonal changes,
pregnancy, childbirth, and menopause. To provide comprehensive management of pelvic and hip problems in women, the
healthcare provider must take into account these changes and adapt the therapeutic approach accordingly.
When indicated, medications addressing neurogenic pain, sleep dysfunction, anxiety, and depression should be used concomitantly with physical therapy.
Pelvic floor biofeedback is especially helpful in the treatment of pain syndromes related Ito dyssynergia. Biofeedback facilitates
coordination of muscle contractions at rest and during activities of daily living. Physical therapy must focus on retraining pelvic
floor muscle activity with proper breathing. This is especially impudent for the athlete performing high-resistance exercise such as
weight lifting, rowing, and bicycling. Activities of daily living involving childcare should be evaluated. During the months after
childbirth, lifting and carrying the child may facilitate a dyssynergic syndrome. Controlling contraction of the pelvic floor during
exhalation facilitates the pelvic and respiratory diaphragms to act in synergy. A physical therapist can help facilitate training the
pelvic floor to contract before lifting, laughing, or coughing. Medications for neurogenic causes may be indicated. Care must be taken
to avoid medications that may adversely affect bladder function.
Urinary Stress Incontinence. Urinary stress incontinence is another pelvic floor dysfunction that adversely affects female athletes. Nygaard and colleagues' surveyed 144 nulliparous elite female athletes and found that 28% reported stress urinary incontinence during exercise or sports participation. Of the athletes studied, gymnasts and tennis players reported a higher incidence of brine loss. The cause of incontinence in athletes is thought to be multifactortal. Contributing factors include inadequate abdominal pressure transmission, pelvic floor muscle fatigue, and changes in collagen or connective tissue.
High-impact sports that require jumping and landing may place participants at greater risk for incontinence because of the sudden increase in intraabdominal pressure. The pelvic floor muscles must be able to contract with enough speed and force to withstand repetitive deceleration of the visceral structures within the. abdomen onto the pelvic floor. The levator anti in particular must have sufficient endurance and strength to support the pelvic organs in humans because of the upright posture.w The chronic pressure of gravity on the pelvic floor is rapidly increased with coughing, sneezing, running, and jumping. Despite ongoing investigations, the question remains as to whether athletes have stronger pelvic muscles or connective tissue because of long-term increases in intraabdominal muscles. In another study Nygaard surveyed previous female Olympic swimmers, gymnasts, and track and field participants from 1960 through 1976. The survey focused on the prevalence of urinary incontinence. The athletes were between 4.2 and 47 years of age at the time of the survey. No differences were found between athletes participating in high- or low-impact sports. Of the 104 responders, 8% and 10% of each group, respectively, reported daily or weekly incontinence. Therefore, a significant number of the athletes were reporting incontinence later in life regardless of the type of impact sport. With further investigations, the risk associated with exercise and sports may be found to be activity-specific rather than associated with exercise in general.
Stress incontinence also occurs in nulliparous women without obvious risk factors associated with activity. Bo and colleagues' found that nulliparous women with stress incontinence had a reduction in tissue collagen concentration as compared with controls. Another study by Al-Rawi and colleagues' showed connective tissue differences in controls and women with genital prolapse. Sixty percent of the group with prolapse had joint hypermobility as compared with 18% of those without prolapse. Collagen architecture or collagen changes related to aging place women at risk for incontinence. The collagen changes may cumulate with the stress of high-impact activities during sports or exercise, resulting in stress incontinence.
In addition to the risks outlined previously, the female athlete or exerciser who has given birth may have other contributing factors to the development of incontinence. Several studies& i& )3. )4 have shown significant denervation in pelvic floor muscles in women who have given birth vaginally. Denervation with subsequent muscle weakness requires adaptations in muscle function and tone to make up for the loss. Such adaptations may put the woman at risk for incontinence and for tnyofascial pain syndromes.
Urinary incontinence also occurs in the nonelite athlete and general exerciser. Often this dysfunction goes under- or unreported. Healthcare providers need to be made aware of such problems so that they may be better addressed. In addition to the risk factors identified earlier, the athlete who is amenorrheic or having irregular menstrual cycles may have low estrogen levels. Low estrogen levels can contribute to the development of incontinence. The importance of completing a directed, detailed history cannot be overemphasized. Women may need to be asked if they experience incontinence. Healthcare providers should not leave it to women to report the problem.
Once stress incontinence during exercise has been identified, a thorough evaluation should ensue. Evaluation of other medical
problems and medications that may predispose the woman to incontinence is necessary. A voiding diary is helpful in determining the
individual's voiding and drinking patterns. This diary can record the types of beverages-consumed arid the number of incontinence
episodes. The urine should be evaluated for infection with a urine dipstick test. Bladder catherization should be completed within 5
min of voiding to measure residual volume after voiding.- A amnia] postvoid residual volume helps to rule out a voiding dysfunction.
Assessing 52 to 54 sensation by pinprick, findings of pressure, and vibration along the vulva, perineum, and inner thighs is important
to detect or rule out a subclinical neuropathic process or injury. A general speculum examination by the primary care physician or
gynecologist should be completed to rule out other medical reasons for urinary dysfunction. Palpation of the pelvic floor is
important to assess muscle tone, strength, -and coordination. The individual pelvic flour muscles should be palpated and their
tone compared from side to side. Muscle strength of the pelvic floor musculature should be evaluated. There are several grading
systems that describe muscle strength from absent to strong. The grading scale, developed by Laycock,l' measures pelvic floor
muscle strength on a scale of 0 to 5.
0 none
1 flicker
2 weak
3 moderate
4 good
5 strong
The examiner measures length of contraction up to 10 seconds, records the number of repetitions up to 10, and records the
number of fast 1-sec contractions. Chiarellil also graded pelvic floor muscle strength.
0 no contraction
flicker, only with the muscle stretched
2 a weak squeeze, 2-sec hold
3 a fair squeeze, definite "lift"
4 a good squeeze, good hold with "lift," repeatable
5 a strong squeeze, good lift, repeatable
The examiner must observe the individual's ability to contract the pelvic floor muscles without using accessory muscles and without bearing down. This muscle examination helps to determine if the woman will be a good candidate for pelvic floor exercises. A specific physical therapy prescription can then be written indicating if too much or too little muscle tone, strength, or coordination is the problem. If the woman reports urgency, frequency, or dysuria in the absence of infection, referral for inethrocystoscopy may be indicated, Other indications for referral include women with a history of smoking, or those who are found to have microscopic hematuria. Full urodynamic testing is indicated when conservative treatment fails, voiding dysfunction is found, or there is a history of pelvic surgery or radiation therapy.
Treatment of Urinary Stress Incontinence. Treatment for urinary stress incontinence is tailored to the individual and her lifestyle. Lifestyle measures, support devices, and specific pelvic floor exercises are helpful in managing women whose incontinence occurs primarily during sports and exercise.
Voiding prior to exercise can be suggested if the exerciser with incontinence is not already doing so. Eliminating coffee and caffeine 2 to 3 hrs before exercise can prevent diuresis, thereby decreasing bladder filling. Some women may have already severely reduced their fluid intake before exercise in ettempts to decrease their incontinence. These women should be counseled on the need for proper hydration to prevent severe complications that may arise with dehydration."
Several types of intravaginal support devices are available and can be worn during exercise to help eliminate incontinence. Intravaginal pessaries and tampons have been found to be effective in up to 83%. and 57% of users, respectively. Successful reduction in incontinence was correlated with the severity of the incontinence," The Introl (LfroMed Corporation, Hopkinton, MAI bladder-neck-support prosthesis is similar to a pessary but has projections that fit under the urethra to support it. This prosthesis was found to be 83% effective in one clinical trial." MI of these devices help to prevent incontinence by supporting the bladder neck arid urethra; however, their effectiveness is not universal.
There are several barrier devices that can be useful in controlling incontinence during exercise. These are placed on the external urethral meatus and are secured by adhesive material or suction. Barrier devices work by obstructing the external urethral meatus. They can be somewhat cumbersome because they must be removed in order to void.
Education hi pelvic floor muscle relaxation, coordination, and strengthening is vital for the treatment of urinary stress incontinence in women in whom overflow incontinence or other voiding dysfunction has been ruled out. Instructing the patient in relaxation techniques to counteract increased pelvic flour muscle tone can easily he started during the internal palpatory pelvic examination. Adding biofeedback can be especially helpful. This technique facilitates the patient's awareness of a physiologic change as a response to a voluntary action and assists control of muscle tone. The examiner by commenting on the strength of a muscle contraction during the pelvic examination, can accomplish biofeedback. More sophisticated forms include external perineel and intravaginal moniters that allow the patient to visualize the magnitude of their contraction or relaxation effort on a monitor. This equipment requires specific education in its use and can be expensive. Many companies offer rental programs to support an individual's temporary needs. Facilitating muscle coordination also is important in the treatment of incontinence. The patient must be educated in the sequence of muscle contraction arid relaxation with activities of daily living, voiding, anddefecation. An example is the importance of contracting llae peivk floor muscles without performing a Valsalva maneuver. The latter increases intraabdomma) pressure thereby increasing the amount of force required by the pelvic floor muscles to contract.
Contraction exercises are often used to increase tone and strengthen the pelvic floor muscles. Healthcare providers should be careful in
their recommendations for strengthening exercises in the setting of incontinence. Stress urinary incontinence is not always associated with weak
pelvic floor musculature. Often. dysfunction in muscle tone and coordination can be determined. If these are not first addressed, the patient may
waste time attempting to strengthen muscles that art' either not weak or have not been reset to their appropriate physiologic length to accomplish
strengthening. When weakness has been determined to be a part of the dysfunction, patients should be instructed in the proper technique donne the pal patory physical examination. Close monitoring is needed to 1211'741.TV lollow-ihrough and problem solving. A strengthening program should be indivicitialited to the patient's needs. A program might include a series of 5-sec contractions followed be 111 sec of relaxation performed for 10 min per day. the program may be upgraded by increasing duration and intensity as the patient's accomplishments progress. When satisfactory strength has been achieved, a maintenance program should be created to deter future recurrences. Vaginal cones may be used to facilitate vaginal strengthening. The patient can use a set of cones of various weights. Starting with the lightest cone, the patient holds. it in the vagina for approximately,20 min one to two times per day. As the muscles become stronger, the cone is changed to a heavier weight.
Electrical stimulation is another technique that can be used in the treatment of sine..., urinary incontinence. This is a device that is inverted into the va),,ina and delivers a corrent, -the current's amplitude and frequency are adiotrki to the patient's comfort and sensitivity. The current produces an involuntary contraction of the pelvic floor-muscles. Electrical stimulation may be useful in assisting in the retraining and. strengthening of these muscles. Several stitches have shown this adjunct treatment device to be effective," `"
Though urinary stress incontinence involves visceral structures, primary or secondery musindoekeletal dysfunctions are often identified. These need to be hilly evaluated, and treatment specified to the type of muscle imbalance, coordination, or tone problem. Incontinence has many social implications. Accurate and early diagnosis in the female athlete can prevent a progressive problem that might deter the woman from participating in exercise or sports.
REHABILITATION
The goal of a rehabilitation program fur the exerciser and athlete is to return to the activity or sport without symptoms and improved functional mechanics. Achieving this goal requires a treatment plan that addresses the primary functional deficit and adaptive changes beyond resolution of symptoms. An appropriate program will locus on muscle and joint physiologic restoration. Ultimately this focus should prevent reinniry and future muscle imbalance. Pelvic pain and dysfunction rehabilitation includes restoration of lumbar spine, hip, and pelvic mechanics, Success in treatment relies on a specific and accurate diagnosis.-the rehabilitation model that incorporates the injury cycle and negative feedback described by Kibler and colleagues° anti herring' is followed. Kibler and colleagues' outlined three stages of rehabilitation.
Bony Injuries
Acute Phase (1-3 Days). Bony injuries excluding complete fractures are discussed. During the acute phase of recovery the clinical symptom complex and tissue injury complex ore addressed with measures to decrease weight-bearing and edema. Weight-bearing on the lower extremity should be as tolerated, Crutches may be necessary in die initial stage. Pubic rami stress fractures or overuse injuries resulting in bony edema seen on MK images or bone scan can be particularly painful. lee and antiinflammatory medications will facilitate control of swelling, and pain. Isometric muscle contractions around the involved joint will provide compression to the joint and decrease the deleterious effects of immobiliiation. For pubic rami injuries, lower abdominal, adductor, and pelvic floor isometric exercises that do not cause pain are helpful. "The exerciser or athlete can advance to the recovery phase of healing once pain and swelling are controlled, nearnonnal range of motion is achieved, and strengthening is tolerated. bor pubic rami or iliac crest injuries, pain-free range of motion at the hip and lumbar spine is necessary. Weight-bearing is advanced as pain allows.
Recovery Phase (3 Days to 3 Weeks). The tissue overload complex and funciiimal biinlierhanical &licit complex are further addressed during the recovery phase. or the capsule and muscles surrounding the hip is important. Particular attention should be given to the iliopsoas and hip adductors, because muscle tightness here can lead to tightening down of the capsule. If full weight-bearing is painful, flexibility strengthening exercises can begin in a pool program. Cardiovascular training can continue in the pool too. Once full-weight bearing is achieved, lower extremity balance and proprioceptive training can be accomplished. hunk stabili/ation and closed kinetic chain strengthening.exercises for the Inver extremity are added. Advanceinent to die manitenance phase takes place when the athlete or exerciser is pain-free with impact activities, bony healing is complete, range of motion-and flexibility are restored, and strength has returned to 75% of baseline. Appropriate radiographic imaging is required to ensure bone healing.
Maintenance Phase. The functional bioniechanical deficit complex and sub-clinical adaptation complex are addressed. Sports- and exercise-specific activities are advanced. Power and endurance strengthening are tailored to the individual's goals. Review of traininc schedule and techniques is important during this phase Further erg000nuc evaluation and equipment use ;shoes. orthotics, and SO 101-111) Shotilki be completed Trial of return to activity under the :-tiperlision of a eln,acal therarit e,.rec-eil.!v helrru rri-,;:.!ern LNercif,erc OT
athlete can return to ploy they remain pain-tree with full range of motion. normal strength and balance, and demonstrate good mechanics while performing the activity. Appropriate radiographic imaging should be compkted as indicated to follow the progression of bony healing.
Sacroiliac and Pelvic Dysfunctions
Acute Phase (1 to 3 Days). Acute injury is often associated with a fall or marked increase in intensity, frequency, or duration of a specific activity. More commonly, this dysfunction is progressive with fluctuations in symptoms.
1 he athlete may only experience symptoms during sports or exercise participation. In the acute setting, antrinflannuatory agents and icing are helpful. Relative rest after an acute injury assists with pain management. Rest means
Acute stage of rehabilitation
o Focus of treatment
Clinical symptom complex
o Tissue injury complex
o Tools
o Rest and/or immobilization
o Physical modalities
o Medications
o Manual therapy
o Initial exercise
o Surgery
o Criteria for advancement
o Pain control
o Adequate tissue healing
o Near normal range of motion
o Tolerance for strengthening
Recovery stage of rehabilitation
o Focus of treatment
o Tissue overload complex
o Functional biornechanical deficit complex
o Tools
o Manual therapy
o Flexibility
o Proprioceptive neuromuscular control training
o Specific, progressive exercise
o Criteria for return to play
o No pain
o Complete tissue healing
o Essentially pain-free range of motion
o Good flexibility
o 75% to 80% or greater strength, as compared with uninjured side, and good strength balance
Functional stage of rehabilitation
o Focus of treatment
o Functional biornechanical deficit complex
o Subelinical adaptation complex
o Tools
o Power and endurance exercise
o Sports-specific functional progression
o Technique/skills instruction
o Criteria for return to play
No pain
Full pain-free range of motion/normal flexibility
o Normal strength and strength balance
o Good general fitness
° Normal sports mechanics
° Demonstration of sport specific skills
Running and excessive walking should be limited because these activities often provoke SIJ pain. Identifying the activity that may aggravate symptoms is important, especially in those individuals with a progressive onset of symptoms. In general, avoiding activities that require a one-legged stance, such as bowling, skating, running, and using a stairstepper is helpful in alleviating symptoms. Correcting asymmetries in muscle length should start as soon as possible, This correction should be accomplished within the limits of pain. Muscle energy techniques are particularly helpful because they require the patient to activate muscle groups, and therefore pain tolerance is easily monitored. Special care should be taken with early treatment of the pregnant athlete or exerciser. Because of the usual hypes-mobility, associated with pregnancy., stretching or mobilization that is too aggressive can further aggravate her symptoms.
Recovery Phase (3 Days to 8 Weeks). Once pain has been controlled and the injured area has been rested, correction of the functional binmechanical deficit and tissue overload complex becomes the focus of rehabilitation. Balancing lower extremity muscle length and strength is important because they have both direct and indirect effects on the ilium and sacrum. Muscle length must first be restored. The iliopsoas commonly is found to be activating in a shortened position. This shortened position leads to an anteriorly rotated ilium. Hamstring strengthening cannot be accomplished until the iliopsoas is stretched. An ante-liar pelvic tilt forces the hamstring to work in a lengthened position. The hamstring is a key muscle to provide stability to the S1J because of its direct attachment and fascial connections to the sacrotuberous ligament. Other muscles commonly found to be working in a shortened position include the (coils lemons, tensor fascia lata, adductors, quadratus lumborum, latissimus dorsi," and obturatur interims. Achieving appropriate muscle flexibility may require several weeks of stretching two to three times per day. Once appropriate muscle flexibility has been achieved, strengthening of muscles that are inhibited by the biomechanical deficit can be completed. Neuromuscular reeducation and facilitation techniques are helpful with this process. Closed kinetic chain strengthening should be attempted first and is incorporated into the lumbopeleic stabilization exercises. Muscles commonly found to be weak include the gluteus rnedius, gluteus niaximus, lower abdominals, and hamstrings.
SIJ belts can be used to provide compression and thereby proprioceptive feedback to the gluteal muscles (Fig. 11). The author finds SIJ belts especially helpful in patients with hyperrnobility or significant muscle weakness. Care must be taken to ensure that the patient is able to apply the belt appropriately. The belt should be secured posteriorly across the sacral base and anteriorly, inferior to the anterior superior iliac spines.
Other equipment such as orthotics and shoe modification must be assessed. A shoe lift to correct a functional leg length discrepancy can be helpful in the acute setting to manage pain with weight bearing or walking. Further use of the shoe lift should be approached with caution, because the functional leg length discrepancy should be corrected with muscle rebalancing. An inappropriate shoe lift can promote a subclinical adaptation complex. Of course, anatomic leg length discrepancies should be determined as early in treatment as possible so that the appropriate modifications can be completed.
SU injections can he used as an adjunct to a physical therapy program if the athlete reaches a plateau or the program cannot be advanced hecause of pain provocation. The injections can be used diagnostically if done under fluoroscopic guidance (Fig. 12), Maigne and colleagues=' reported 18.5% of 54 patients diagnosed with SIJ pain responded to double SIJ block under fluoroscopic guidance.
Muscle Strains Involving the Groin
Acute Phase (0 to 3 Days). Muscles most often involved in groin strains injury include the adductor longus at the proximal musculotendinous junction, tendon to osseus insertion onto the inferior pubic tubercle, or muscle belly. During the acute stage, ice and relative rest are important. The athlete or exerciser should avoid repeated hip abduction or resisted hip adduction. If pain is significant with weight bearing, crutches may be necessary to facilitate pain control. Stretching during this stage should be limited to a pain-free range of motion. Modalities such as ice and electrical stimulation may be used as adjuncts to pain management. Antiinflammatory medications can also help relieve edema amid facilitate pain management:
Recovery Phase (3 Days to 6 Weekg). Again during this phase, the focus of rehabilitation turns to correcting the biornechanical deficits and tissue overload complex. Modalities and medications may be continued during the first few weeks for adequate pain management. Active range of motion is advanced in the pain-free range. Myofascial releifse and muscle. energy techniques may further promote increased range of [notion. The patient should be independent in self-stretching;" pelvic tilts, and concentric contraction of the antagonistic hip 11. iluctiors. Four to six weeks after injury superficial heat and ultrasound may further expedite muscle stretching. Strengthening. is added during this phase. Initially stretching should be limited to multilevel isometric exercise within a pain-free range. Proprioceptive reeducation can be added with balance retraining. Care should be taken to. monitor the position of the pubic symphysis during this phase. Muscle shortening or instability may be recognized because of difference in pubic symphysis heights and rotation on palpation. Muscle energy techniques can be useful in correcting this dysfunction. The patient can become independent in self-correction. Retraining proper sequence of firing of hip abductors is important. Balance must be achieved between the contraction of usually weak lower abdominal muscles and tight hip adductors. The latter address the functional adaptation complex. True patient advances to the maintenance phase when pain and inflammation are controlled. Range of motion should be pain-free and symmetric on side-to-side comparison. There should be LIU limitation in activities of daily living, including walking, and no recurrent pubic symphysis dysfunction.
Maintenance Phase. During the maintenance phase the functional biomechanical deficit continues to be addressed through stretching and
strengthening of the adductor muscle group. Attention to the tissue overload complex is begun with avoidance of excessive strain and
inflanmiation to the lateral hip and pelvic structures. In particular, avoidance of tensor fascia lata overuse is enforced. Continued
stabilization concentrates on coordinated lower abdominal contraction with the adductor group. Resistance can be added to the stabilization
program with graduated weights. Before weight training for hip abduction is initiated, proper sequence of muscle contraction should be noted.
If not, the tensor fascia lata will continue to be strengthened and the adductors will continue to be inhibited. In addition to advancing
walking and running, kicking chanics should be reviewed.
Rehabilitation
As healthcare providers direct their treatment plans toward restoration of nction after an injury, more will be ondr.rsiond about what is necessary to !veto') an appropriate prehabilitation program. l'n.,habilitation is based on the dividual's needs regarding restoration and education of appropriate mechans. The individual athlete's needs are then taken into account when applying ion-specific training techniques. Advancing .1 training program's intensity, J ration, and repetitions should not be a cookbook formulary. Instead, progres. on of the training program should coincide with the individual's capability of erforming the activity with proper mechanics. phis technique potentially could revert subsequent overuse injuries. With regard to the hip 31T111 prevenon of injury should focus on the assurance of proper joint mechanics and Glanced muscle flexibility and strength. This balance is an evolving process ith aging.
Women in particular have life cycle changes that affect musculuskeletal Inchon, As adolescents, some girls are prune to joint hyperrnobiliiy and laxity, rhich places them at increased risk for injury. During the early adult years, -zinnia to the pelvic floor as a result of childbirth can place the woman at icreased risk for pelvic floor pain, pelvic pain, and urinary incontinence. Some
I these dysfunctions may be subtle and become clinically relevant when the woman returns to exercise or spurt participation. With middle ago, hormonal hanges may facilitate soft-tissue atrophy and soften bones. placing the i.yriman t increased risk for overuse injuries. Surgeries involving the pelvis such as iysterectornies and bladder suspensions place the woman at risk for developing ielvic floor pain dysfunctions. Degenerative changes begin and may limn joint notion with subsequent loss in muscle flexibility. Some of these changes may ause symptoms only when the woman increases or changes her activity level. \dapting training and exercise prescriptions to the individual is important. liking into account where the woman is in the life cycle of aging and hormonal :hanges is vital,
Men acquire adaptive changes with aging as %Sell. Loss of motion at the SI) end hip occur with regularity. The lumbar spine or hip mar attempt to make up :or the loss of motion at the pelvis. Adaptive patterns ensue and bring additive risk for injury. Elderly men with metabolic disease are susceptible to loss of None mass. Care should be taken in ruling out fracture in elderly athletes.
Both male and female athletes should work to maintain appropriate muscle activation sequences with functional activities. An example includes eliminating early lumbar erector spina activation with hip extension. The appropriate sequence can be accomplished only if the muscles about the hip and pelvis remain balanced between length and strength. Focusing on muscles that have a tendency to be tight (i.e., the iliopsoas) or inhibited (i.e., gluteus medics) is important in preventing overuse injuries at the pelvis.
The innervation of the joint is from multiple root levels of the hambosacral pelvis. The posterior joint receives innervation from 13 to 53, whereas the anterior joint receives innervation from L2 to 52. The primary innervation is thought to be from the St root level.° because of the various levels of innervation, sacroiliac joint pain may present with a variety of pain locations. Similar to its primary level of innervation, SIJ pain often presents with St distribution symptoms in the form of pain or numbness.
The bionlechanics regarding the 511 are complex. Most research has looked at one or two components of force and movement, Motion at the SI) occurs indirectly. body weight and postural changes may create or inhibit motion at the 5IJ. Muscle groups surrounding the joint also cause indirect motion. These Wimps include &Ideals, hamstrings, hip external rotators, psoas, abdominals, latissimus dorsi, quadratus lumborom, and erector spinae. Myofascial changes associated with these muscle groups will alter mechanics. The SIJ forms the base of support for the spine. The joint receives and transmits forces from the trunk and from the lower and upper extremities. Forces absorbed through the SIJ alloiv changes ill body weight transmission to occur while providing stability. SII motion is affected by motion at the spine, ilium, pubic svmphysis, and hip Studies have shown various ranges of mutton but most agree that approximately, 4° of rotation and 1.6 mm of translation occur." The amount of joint motion decreases with age. Women develop degenerative changes that restrict motion at age 50 years; men develop them around age 40 years. it is not dear that change in motion at one joint is the source of pain at that joint. Gender differences in flexibility and range of motion that may affect performance have been well documented. Reports indicate that women have greater range of motion -and flexibility."' This greater range of motion further suggests that relative `ma balances in muscle length and strength may place the female athlete at risk `for Sri dysfunction.
Acquired hyper- or hypomobility results in altered load transmission, which may lead to muscle and other joint dysfunction secondary to adaptations. Women develop relative changes in motion based on hormonal fluctuations a;-Th, well. During pregnancy, estrogen and relaxin play a key role in promoting increased Ligamentous laxity. If the secondary stabilizers (musculature of the hip, spine, and pelvis) do not provide the stability needed, the joint may enter a relatively hypermobile state. Estrogen level changes continue in the postpartum period. During this time the supporting musculature is developing new adaptive patterns as a result of the pregnancy and delivery. These circumstances may put the female athlete at greater risk for injury. With aging, degenerative changes direct the joint into a relative hypomobile state. Often, motion lost at the Si) is attempted to be regained at another joint. Examples include the hip, lumbosacral segements, and pubic symphysis. So although changes in motion at the SI) may not cause direct injury to the joint, they place peripheral joints at risk for altered adaptive patterns. Changes in adaptive patterns and mechanics may make these joints more susceptible to injury.
PAIN AND INJURY
Injuries or pain syndromes that involve the lumbar spine-pelvis-hip complex can present with a wide array of symptoms. Again, the risk factors for such injuries are often sport- or exercise-specific. However, recurrent injury or reinjury may be an indicator of more serious systemic problems. A runner with recurrent stress fractures may have more than an overuse syndrome. Assessing bone mineral density in such patients may reveal underlying systemic problems. Women in particular are susceptible to physiologic changes that put them at risk for low bone mineral density and osteoporosis. For comprehensive care to be initiated, the healthcare provider must be aware of these scenarios.
Pelvic injuries that athletes and exercisers may encounter are outlined in the following paragraphs. A few injuries involving the hip joint will be discussed, because they may present with groin or lower abdominal pain. Hip and pelvic injuries occur in both men and women. Specifics regarding pelvic floor injuries will be limited to the female population. Certainly, men are susceptible to pelvic floor trauma but it is difficult to assess anatomically and biorriedianically; as a result little information is available in the literature.
Bony Injuries
Weight-bearing exercise is protective because it helps build bone mass. Excessive activity increases the risk of stress fracture. Determining what is excessive is specific to the individual's circumstances. Athletes participating in endurance type exercise or sports are at increased risk for these fractures. Bony injuries involving the hip and pelvis may occur because of overuse or trauma. The hip joint accounts for 37% of all athletic injuries, of which the majority are overuse injuriee.*1 Stress fractures may occur at various sites, including the ilium, lesser neodearster, femoral neck, pubis, and sacrum. Early diagnosis is important to prevent further injury or complete fracture. Recurrent stress fractures may be a sign of an underlying systemic problem. The healthcare provider needs to investigate reasons other than exercise or sports participation for repeated injury. The adolescent or young adult athlete should be questioned regarding other symptoms of the female triad including amenorrhea and eating disorders. The older female athlete or exerciser should be examined for osteopenia or osteoporosis. Early intervention will decrease the risk of repeated injury.
Other bony injuries to the hip and pelvis often are sustained as a result of high impact or trauma. These include avulsion injuries, acetabutar labral tears, arid complete fractures. Avulsion injuries occur at the attachment of a tendon or ligament to bone. They occur as a result of a strong and rapid muscle contraction and are seen most commonly in adolescents participating in sports. The most common sites for avulsion injuries include the anterior superior and inferior iliac spines, ischial tuberosity, and iliac crest. Clinically, avulsion injuries present with tenderness at the site of muscle origin and demonstrate weakness of the isolated muscle. Apophysitis has a similar clinical presentation. The latter is an inflammation at the tendon-periosteal junction but with no avulsion of bone. In contrast, apophysitis results from an overuse injury, Radiographs can differentiate the two injuries because a fracture will be identified in avulsion injuries. Apophysitis may be noted on imaging such as bone scan or magnetic resonance (MR) imaging that show edema at the site of injury.
Acetabular labrum tears often result from trauma or repetitive twisting injury. Presenting symptoms include a catching and giveaway sensation in the anterior hip and groin. Pain may occur with pivoting or transitional movements, as when arising from a chair. Clicking may be noted when the hip is passively extended, internally rotated, and adducted.)2 Once radiographs have been completed and show no fracture, an MR imaging arthrogram has a high sensitivity and specificity in identifying labral tears. Laparoscopic hip procedures now provide a, minimally invasive definitive treatment in cases in which conservative management has failed.
Avascular necrosis of the femoral head is uncommon in specific sporting or exercise events, but may occur as the result of repetitive trauma. Those athletes at increased risk may have a history of alcohol use or abuse or corticosteroid use. It roost commonly occurs in men between 30 and 70 years of age. Clinical "presentation includes sudden onset of hip or groin pain and change in gait pattern. Early diagnosis is important in improving long-term outcome. Radiographs may not show the early changes of avascular necrosis, and an MR image should be obtained in suspected cases.
Osteoarthritis is the most common hip disorder in the general population. The cause is multifactorial including familial predisposition, obesity, and history of hip injury or disease. Men and women are equally prone to hip pathology. Recent studies outline concern for the development of an increased risk of hip oetteciarthritis in women who participate in sports and exercise. Lane andcolleaguesz' compared self-reported activity levels and hip radiographic tindinp and pain in elderly women. Women who exercised more than four times per week had a marginally increased risk of hip osteoarthritis. Vingard and coworker?" compared self-reported sports activities in women who underwent total hip replacement for osteoarthritis with control women without hip problems. Those women with high sports exposure were 2.3 times more likely to develop hip osteoarthritis leading to total hip replacement. Both of these studies are retrospective and rely on the subject to recall activity level over a lifetime. Caution should be used in advising women to abstain from physical activity because of the risk of osteoarthritis. Although activity may increase the risk of osteoarthritis, better skill training and prehabilitation for women in the future may show a plateau in the incidence of activity-associated osteoarthritis.
Although hip osteoarthritis may not be caused by a specific sports injury, many exercisers and athletes must overcome the limitations of osteoarthritis to participate. Managing an exerciser with hip pain related to osteoarthritis encompasses possibly altering the type of activity or weight-bearing while trying to restore muscle, fascial, and capsular mechanical balance. Prevention of impairing soft tissue adaptations such as a hip flexion contracture is essential in keeping the exerciser with hip osteoarthritis on the playing field.
Osteitis pubis is a syndrome involving bony change that often occurs as a result of an overuse injury. Pubic symphysitis and recurrent groin injuries may, in fact, be precursors of the degenerative changes described as osteitis pubis. Exercisers or athletes participating in repetitive kicking, pivoting, and running are at risk for this injury. Nonathletic risks include previous bladder ur prostate surgery or pelvic floor trauma. Symptoms at presentation include groin, anterior hip, and lower abdominal pain. The exerciser may have a recurrent or long history of groin pulls. Antalgic gait and pain on palpation of the pubic eyphy- sis that increases with resisted hip motion are often noted on physical examination. Radiographs may show- sclerotic changes but often are normal. A bone scan may show asymmetric uptake at the pubic symphysis. MR imaging is helpful in delineating stress fracture from stress reaction (Fig. 6). Arriving at the diagnosis of osteitis pubis takes coordination of history and physical examination, because adjunct testing is limited. Addressing the pain complaints before radiographic changes occur is essential.
Soft Tissue, Nerve, and Muscle Injury
Tendonitis, muscle strains, and muscle imbalances are common types of injuries in exercisers and athletes. Muscle and tendon dysfunctions can lead to friction and, at specific sites, cause bursitis, There are several theories regarding the concept of muscle imbalance, which are listed below.6 Therefore, trauma or injury is not the only way muscle imbalances develop. Janda" has studied muscle imbalance and adaptations in children and adolescents He found a 21% incidence of short muscles in 115 school-aged children. Follow-up examinations at ages 12 and 16 showed that muscle tightness increased and then plateaued. These muscle imbalances did not correct without intervention.L6 Muscles involving the hip and pelvis that are prone to tightness include the iliopsoas, rectos lemons, tensor fascia lata, short adductors, hamstrings, quadratus lumborum, and piriformis, Strains and muscle tears often occur in muscles that are prune to tightness. Tendonitis often occurs in weak, inhibited muscle groups. Examples at the hip and pelvis include the gluteus rued ius, gluteus maximus, abdominals, and quadriceps." Identifying muscles that are functioning in a shortened pLisition or are inhibited is key to devising a rehabilitation or prehabilitation.
Theoretical Causes of Muscle imbalances
1. Postural adaptation to gravity
2. Neuroreflexive due to joint blockage
3. Central nervous system malregulation (impaired programming)
4. Response to painful stimuli
5. Response to physical demands
6. Lack of variety of movement patterns
7. Psychologic influences
8. Histochernical differences
Bursitis also can accompany a primary muscle or tendon dysfunction. A bursa becomes filled with fluid as a result of inflammation that develops because of friction. This friction occurs because a tendon is not able to glide efficiently across a region. This inefficiency may he because of bony protrusions or primary muscle or tendon injury, Common sites for bursitis involvinp, the hip and pelvis include iliopsoas at the ischial pectineal greater trochanter of the hip, ischiogluleal area, and origin of the obturator interims. Determining the primary mechanism of injury will facilitate a treatment program and prevent reinjury.
Identifying the mechanism of injury in the history coupled with a comprehensive physical examination leads to a specific diagnosis. The healthcare provider must have a good understanding of muscle balance and function. Subtle imbalances of agoinst and antagonist muscle groups are often not tomtit on a standard physical examination. Muscle weakness sometimes cannot be identitied unless the muscle is latigued. Poor endurance in a quadricep may be detected with single leg squats. I lamstring weakness may be noted with repealed wall squats or bridging from a supine position. Examining individual muscle length is also key in terming a specific rehabilitation prescription, If a tight iliopsoas goes unnoticed, a strengthening program for the hamstrings may be fraught with pniblems. A tight iliopsoas often leads to an anterior pelvic tilt. Art increase in antes ior pelvic till then leads to the hamstrings firing in a lengthened position. Strengthening the hamstrings in :1 lengthened position may lead to subma \knot ..trength benefit and overload rimy cause subsequent hamstring injury. Observing quality of motion also is important. Examining lumbopelvic rhythm is an exam, Fill' of observing quality of motion. With forward flexion, the lumbar spine should move initially, followed by the pelvis and hips. Initiation of motion nom the pelvis or hip indicates a breakdown in muscle function. Incorrect of [tuition may be a result of lumbon-spine dysfunction or muscle imbalance at the hip and pelvis. Measuring fingertip distance from the flour at end range et (lesion is not as useful as determining the quality of motion demonstrated to achieve the position. Recurrent muscle and tendon injuries most be carefully reviewed so that an underlying bony or systemic problem is not overlooked. If indeed the injure is recurrent to the soft tissue, the healthcare provider must investigate the mechanism of injury, training patterns, C110100-hictors, and equipment to ensure complete Specifying; the precise muscle, tendon: or soft liSS11e involved in an injury leads to a specific treatment program and preventative maintenance program.
Several specific muscle imbalance syndromes occur 31 the hip and pelvis. These are sport- or activity _specific. They may present with a wide range of symptoms including pain in the buttocks, groin, lumbar spine, arid knee.
Pinformis syndrome may present with a variety of complaints. These include back or buttocks pain, and lower extremily pain or numbness. The true syndanne, by definition, includes electrophysiologic charig,es along the distribution of the sciatic nerve as a result of compression by the piriformis. The sciatic nerve trivets through the sciatic notch and passes anterior to the piriformis 85% of the tinge (Fig. 7). Variations to this relationship exist. In 10% of the population, the sciatic nerve divides before passing through the gluteol region. The common peroneal portion passes through the piriformis and the tibial portion passes anterior to the piriformis. In 2% to 3% of cadavers, the peroneal portion loops superior and posterior to the piriformis and the tibial portion travels anterior to the muscle. Another variation, found in fewer than 1% of the cadavers, is an undivided nerve that passes through the piriformis. Regardless of its position, the sciatic nerve is vulnerable to compression or irritation at the site of the
The piriformis facilitates different motions at the hip based. on the position of the hip. In hip extension, the piriformis is an external rotator of the hip. lo Ott' tit hip flexion, the piriformis is an abductor. With the hip positioned at YIP of flexion, the piriformis internally rotates the hip.' Because the muscle performs different ;notions in to-Mb..orent hip positions, the examiner must include
positions lo (idly examine the muscle (Fig. 8). An imbalance in muscle length and strength may (reale a dysfunction, resulting in pain. The author postulates 1101 a number of patients present with a symptom complex related to pirnorinis
dysfunction without etectrophysiologic changes on electromyography. Lack of electromyographic changes may be a result of inherent muscle weakness or may occur because neurogenic compression is only intermittent. piriformis irritability and dysfunction may occur even though electrodiagnostic testing results do not fulfill the criteria for piriformis syndrome. Even if test results do not meet the definition of piriformis syndrome, the area needs to be treated to prevent further regional breakdown in mechanics. A painful piriformis by history and on physical examination may be part of a symptom complex of another regional diagnosis. Esamples include LS to S4 radiculopathy, intrinsic hip pathology, and all dysfunction. These areas need to be further investigated so as not to incompletely treat the athlete or exerciser. Activities that require one-legged activity or stance such as bowling or skating may place the athlete at risk for pain associated with the piriformis muscle, Shifting from one extremity to the other in activities like running and using a stairstepper may also increase the risk for breakdown in mechanics.
The exerciser may present with low back, buttocks, and lower extremity pain or numbness. Lower extremity symptoms may not pass far beyond the gluteal fold or may involve the foot. On examination, pain with palpation of the muscle may be noted, and pain may be further exacerbated with stretch or with resisted activation. The examiner must be careful to stretch and activate the muscle according to the function it performs in different hip positions. Specific positioning for testing relative muscle strength and length is essential to formulate a specific rehabilitation plan. Positioning alscemay reveal symptoms other than pain such as numbness or tingling, which should be noted. Further internal palpation by a rectal examination can help clarify the clinical diagnosis in questionable cases. Muscle stretch reflexes and sensory deficits may be reduced in the tibial or peroneal distribution.
Snapping hip syndrome is another common symptom complex that afflicts exercisers and athletes. A snapping or clicking sensation during activity may be associated with pain. The cause of the click is site-specific. The most common cause is the hip suction phenomenon. Other intraarticular causes that should be carefully ruled out include subluxation, acetabular labral tear, loose body, and osteochondromatosis. Other common tendon causes include the iliopsoas snapping over the iliopectineal eminence and the iliotibial band moving over the greater trochanter. Pubic syniphysis instability may present with clicking in the groin region. The instability may be related to trauma such as that experienced with childbirth or generalized ligamentous laxity. Determining the site of the clicking is important but can be difficult. The examiner should palpate the area of the snapping during active and passive hip range of motion to distinguish the structure." Regional muscle imbalance should be considered once the source of snapping has been determined. The iliotibial band may tighten because the muscle is serving as a hip abductor as the result of an inhibited gluteus medius. The healthcare provider should not expect the snapping hip syndrome to remain resolved solely with iliotibial bond (ITI:1) stretching. Gluteus medius strengthening in the appropriate hip position will allow the rrB to remain in its new lengthened position.
Other sources of pain and dysfunction include muscle imbalances causing relative overuse syndromes. Janda and colleagues' have described a muscle imbalance syndrome at die hip and pelvis as the pelvic crossed syndrome. This includes a muscle imbalance pattern of tight hip flexors and hamstrings with inhibited glutei and lumbar erector spinae muscles. Quality of muscle activation and firing patterns are noted. An example includes noting the succession of muscle firing in hip extension from the prone position. The order of firing involves the ipsilateral hamstring, gluteus maximus, contralateral lumbosacralparaspinals, contralateral thoracolumbar paraspinals, and finally the ipsilateral thoracolumbar paraspinals. Commonly, the gluteus maximus is weak and fires late in the sequence, which may then allow breakdown somewhere proximal or 5 distal such as the lumbar spine or hip.16
Sahrmann" describes a series of muscle imbalances at the hip called hip impingement syndromes. Anteromedial impingement presents with groin pain with hip flexion and posterior pain with weightbearing. On physical examination there is anteromedial displacement of the greater trochanter when the knee is moved to the chest. With hip extension, hamstring activity is dominant over gluteus maximus. lightness may be found in the tensor fascia latae. Anterolateral impingement presents with hip pain with weight bearing, which is relieved with external rotation of the lower extremity in stance. As a result, hip external rotators and hamstrings are tight. Proximal impingement syndrome is diagnosed in individuals presenting with complaints of deep hip pain and pain on palpation lateral to the tensor fascia lata. Pain may be described in the inner thigh region. The exerciser may complain of early morning stiffness or discomfort that increases with activity. Decreased range of motion is found in a capsular pattern, including decreased hip flexion and internal rotation. Tightness is found in the iliopsoas, mons femoris, and tensor fascia lata. Osteoarthritis is often found in association with this hip impingement syndrome.
Muscle contusions should be identified early in the athlete so as to rule out underlying bony injuries. A contusion usually develops as a result of a direct blow or trauma. A hip pointer occurs as a result of a blow to the anterior iliac crest. A tear to the muscle aponeurosis.or avulsion of the apophysis should be excluded. Myositis ossificans also may develop as a result of muscle trauma. The athlete may prevent with hardening of the .hemaloma and decreasing range of motion. Osteoblasts furor within the hematoma to replace the fibroblasts in the traumatized muscle. Calcification within the muscle belly may be seen as early as 7 to 10 days after the injury on radiographs. The individual usually complains that pain occurs with concentric 111U5de contraction or passive stretch. Heterotopic bone growth may be evident between 2 and 3 weeks after the trauma, }Bone scan may give positive results before changes are found on radiographs.
Neurogenic pain should be considered in the differential diagnosis for pelvic and groin pain. Meralgia paresthetica is one common nerve entrapment that occurs at the pelvis. The lateral femoral cutaneous nerve is entrapped in the pelvis as it crosses the groin medial to the anterosuperior iliac spine. Fibrous tunnels may exist that the nerve or branches may cross through. Overweight or pant exercisers are at increased risk for developing an entrapment. Nerve Miluction studies are helpful in confirming the diagnosis. Reducing equipment or clothing restrictions at the hip and groin can be helpful in reducing symptoms. Other neurogenic causes for pain at the groin and pelvis include high lumbar radiculopathy, entrapment of the genital branch of the genitofemoral cutaneous nerve, obturator nerve entrapment at the pelvis, and pudendal nerve injury should be excluded. Previous trauma or spine or pelvic surgery may place the individual at increased risk for these problems. Pudendal nerve injury in particular can lead to a number of pelvic floor dysfunctions described elsewhere in this article.
Sacroiliac Joint Dyslunction
The 511 is a controversial instigator of pain and dysfunction. Reasons (or controversy are multifactorial The joint is narrow with only a few degrees of
Motion and degenerates with aging, losing further motion The biumechanics regarding the joint are complex. Research is ongoing regarding joint mechanics and load transmission. There are no specific standards for evaluation of SIJ dysfunction, and often SIJ dysfunction is a diagnosis of exclusion. Imaging of the joint commonly reveals changes associated with aging but does not distinguish asymptomatic horn symptomatic individuals. For women, SIJ pain and dysfunction rriay be underdiagnosed because of coexisting gynecologic problems or because of pelvic changes that occur during and after pregnancy.
The prevalence of SIJ pain is unknown. Bernard and colleagues' reported that of 1293 patients with low back pain, SIJ dysfunction was thought to be the pain source in 22.5% based on history and physical examination. Another study showed that 58% of those individuals with SIJ dysfunction by history and physical examination had a history of trauma.' Sports and training equipment that require repetitive unidirectional pelvic shear and torsional forces may be important risk factors for SIJ dysfunction (Fig. 9). These sports include skating, gymnastics, golfing, and bowling. Asymmetric shear forces can be distributed through the SIJ during the use of a stairstepper, elliptical trainer, or workouts including step aerobics.
51J dysfunction may present in various patterns. Athletes commonly complain of pain in the Vow back or buttock near the posterior superior iliac spine. Pain may radiate down the posterior leg or anterior groin. Pain may be exacerbated with repetitive overload activity, transitional movements, and unsupported sitting. There are no specific examination techniques or diagnostic tests that consistently or accurately identify SIJ pain. The examiner must have a clear understanding of biornechanics and process through a multi-item differential diagnostic evaluation. SlJ dysfunction is often determined by exercise.
Physical examination should include the usual gait analysis and neurologic, postural, joint range of motion, flexibility, and strength evaluation.
Gillet's test assesses side-to-side ilial-sacral motion. Lack of posterior rotation of the ilium on single leg stance indicates an alteration in range of motion. This is not necessarily indicative of the side of pain or dysfunction (Fig. 10). Observation and palpation of bony landmarks in weight-bearing and nonweightbearing positions are important. Asymmetric lumbopelvic rhythm in standing or sitting can help identify problem areas to address. Determining if a functional or anatomic leg length discrepancy exists is necessary. Patients often have pain on palpation along the posterior superior iliac spine (PSIS) and sacral sulci. Provocative testing such as Caenselen's test, Patrick's test, or pelvic compression may help direct the diagnosis, but a negative test result does not exclude SIJ dysfunction.
The differential diagnosis of SIJ pain is all encompassing. inflammation of the SIJ may occur as a result of metabolic changes, arthritis, trauma, or infection. Primary tumors of the SIJ are rare. Iatrogenic instability may result front graft harvesting. Osteitis condensans, increased density on the dial side of the inferior SIJ, occurs in 2.2% of the multiparous female population and is usually self-limiting. Sacroiliitis may develop as a part of pelvic inflammatory disease. Changes that occur during pregnancy, as described previously, must be considered. Pain may be referred from other sites of dysfunction, including lumbar radiculopathy, lumbar facet joint pain, Idrnbar central or lateral recess stenosis, lumbar discogenic pain, hip disease, and Maigne's syndrome. Radiographs of the SIJ are important to rule out infection, metabolic changes, fracture, or tumor. Computed tomography (CO, MR imaging, bone scan, or single photon emission computed tomography (SPECT) provides more detailed information regarding the joint. Rarely will imaging clearly define SIJ dysfunction. The healthcare provider must consider the information gained from the history and correlate it with clinical observation to arrive at the diagnosis. The physical examination includes noting subtle changes is flexibility, strength, and eliminates neurogenic causes of the pain. When clarification is necessary, diagnostic fluroscopically guided sacroiliac joint injection can be helpful in confirming the diagnosis.
Pelvic.
Floor Dysfunction
Pelvic floor pain and dysfunction can cause considerable impairment for the female exerciser and athlete. Unfortunately, sports literature rarely focuses on such problems and is often left as a gynecologic problem. The pelvic floor is a group of muscles that must act in coordination with their surrounding joints including the lumbar spine, SIJ, hip joint, and pubic symphysis. In addition, the pelvic floor must function in coordination with visceral structures, including the bladder~ vagina, uterus, ovaries, and colon. The muscles of the pelvic floor may Iespond adaptively to a primary visceral problem. An example is an increased muscle lone that may occur in the levator ani on the ipsilateral side of an Ovarian cyst. The athlete may present with primary complaints of pelvic pain with urination, defecation, intercourse, or around the time of menstruation. Primary hormonal dysfunction, visceral problem, and infection should be ruled out. When the listed problems are excluded, determining the musculoskeletal dysfunction will facilitate recovery and treatment program.
Pelvic Floor Pain Dysfunctions. Adaptive patterns in the pelvic floor can develop as a result of a primary joint injury. A hip with osteoarthritic changes and loss of range of motion may refer pain to the groin and pelvic floor. Muscle guarding may occur, causing increased tone within the pelvic floor. Increased muscle tone within the pelvic floor may lead to pain and dyssynergic problems. Primary muscle imbalances also can refer or cause subsequent pelvic floor muscle imbalance. An athlete with piriformis syndrome owith an inhibited gluteus medius may develop obturator internus pain noted in the pelvic floor. The obturator internus acts as a secondary hip abductor. Overload may occur because of the inhibited gluteus medius with resultant obturator internus pain. Pelvic floor enyofascial pain in female exercisers arid athletes is often associated with asymmetrical tautness in the sacrotuberous ligament and the surrounding muscles and fascia. Facilitating muscle tone symmetry is key for appropriate treatment. Because overlap exists in hip, back, and pelvic injuries and dysfunction, the biomechanics of the pelvic floor should be addressed just as they are addressed for an external pelvic dysfunction.
Tension myalgia is another label often given to general pelvic floor pain. Diagnoses included under this heading include piriforrnis syndrome, levator ani syndrome, coccyxdynia, and vagismus. Dysfunctions involving increased muscle tone of the musculoskeletal and urogynecologic systems are often referred to as levator ani syndrome. Increased pelvic floor muscle tone may be an adaptive component to other primary dysfunctions, including low back pain, chronic pelvic pain with negative laparoscopy results, endornetriosis, interstitial cystitis, urethral syndrome, and sphincter dyssynergia. Women often present with pain in the general region of the vagina, rectum, lower abdominal quadrants, and posterior pelvis. Other areas of discomfort can include the coccyx, pubic symphysis, and posterior thigh. Functional limitations because of pain often are reported. These limitations include dyspareunia, sexual dysfunction, and difficulty with voiding and constipation. Urinary frequency and urgency may be present.
Increased muscle tone in the pelvic floor may occur for several reasons; direct trauma to the pelvis, as with fractures or joint injuries involving the hip, ilium, and sacrum, may be responsible. Abnormal use or adaptive muscle imlaatanoe syndromes can contribute to increased pelvic fluor muscle tone. Myofascial pain syndromes may develop primarily or secondary to trauma or muscle unbalance. Travel and Simons-1s have identified specific pelvic floormuscles that may cause symptoms. Trigger points within these muscle f,r0Up can refer pain.
Pelvic floor muscles susceptible to trigger point formation resulting in pelvic pain:
o Coccygeus
o Levator ani
o Obturator internus
o Adductor magnus
o piriforniis
o Oblique abdorninals
Muscles susceptible to trigger point formation resulting in iliosacral pain:
o Coccygeus
o Levator ani
o Gluteus medius
o Quadratus lumbonun
o Gluteus maximus
o Multifidi
o Rectus abdominus
o Suleus
A history of sexual abuse, anxiety, depression, and general lifestyle stress can cause muscle tension:" Concomitant.evaluation of psychosocial factors is imperative to evaluate and treat the pain syndrome- comprehensively.
Evaluations for pelvic floor dysfunctions involving increased muscle tone include a manual examination of the pelvic floor and musculoskeletal, neurologic, and posture evaluation. The internal and external pelvic floor examination identifies the specific location of the pain. The musculoskeletal and neurologic examinations of the hip, pelvis, and lumbar spine help identify primary or secondary causes for pelvic floor pain. Surface electromyography (EMG) -back evaluation performed with internal and external electrodes is helpful in determining baseline resting muscle activity. Tone changes that occur with position changes, exercise, or functional activities can also be identified.
Pelvic floor muscle dyssynergia is another cause of pelvic floor pain. Muscles must fire at the appropriate place, time, and intensity. If muscles are unable to coordinate contraction and relaxation, dysfunctions in michirition and defecation may occur. This complex of symptoms is referred to as pelvic floor dyssynergia. Several causes for pelvic floor dyssynergia exist. Pudendal nerve injury can result in sensory and motor deficits inhibiting appropriate muscle functioning. Improper technique during exercise that causes a bearing down on the pelvic floor rather than lifting of the pelvic floor can facilitate dyssynergia. Other neurologic diseases or injury and inability to isolate pelvic floor muscle contractions from abdominal or gluteal muscle contractions can lead to muscle incoordination-and dyssynergia.
Treatment of Pelvic Fluor Pain Dysfunctions. When infection and other serious medical causes have been ruled out, hypertonic pelvic floor muscle pain should be managed by addressing psychulogic, neurochemical, and mechanical factors. Physical therapy can address specific muscle imbalances with appropriate flexibility and strengthening exercises. Various techniques such as myofascial release, muscle energy, joint mobilization, and posture education can be incorporated. Surface EMG biofeedback is helpful in identifying the muscles with increased tone and facilitates relaxation techniques used to reduce tone. Modalities such as heat and cold may facilitate pain management and relaxation.
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