I was first exposed to the world of pelvic health as a curious first year physical therapy student when I attended a lecture about pelvic floor dysfunction at the APTA’s Combined Sections Meeting. The moment I heard that there were women out there who thought it was normal to leak urine when they sneeze after having kids, I was hooked. As a childless woman in my early 20s, I had no idea what kind of pelvic floor issues postpartum women dealt with or that we had all collectively decided that stress urinary incontinence was an inevitable consequence of childbirth. The speakers went on to discuss other pelvic floor issues that are “common but not normal” and explained that physical therapists can make a huge impact on quality of life for people struggling with pelvic floor dysfunction. By the end of the talk, I was fired up and determined to learn more.
“Traditional physical therapy school curriculum doesn’t dig very deep into pelvic floor dysfunction, so I had to find mentors outside of school to learn more about this niche.”
I was fortunate to find several pelvic floor physical therapists in my area who were very generous with their time and gave me great advice on how to start treating this population. Perhaps the most valuable advice I received was to get a strong orthopedic background before specializing in pelvic health. To successfully treat the pelvic floor, you can’t get stuck in the pelvis; you have to understand how everything else in the body could be affecting it. I took this advice to heart and dove straight into an orthopedic residency after graduation.
You don’t need an OCS to successfully treat pelvic floor dysfunction, but having experience in orthopedics can help improve your ability to help your pelvic floor patients in several ways:
1.Being able to perform a more comprehensive evaluation
In physical therapy school, we are taught about the importance of regional interdependence. If someone comes in with knee pain, you wouldn’t just look at the knee. You would look at the hip, the ankle, and probably the lumbar spine. You would look at functional movement patterns, balance, gait, etc. So if someone comes in with pelvic floor dysfunction, you wouldn’t want to just look at the pelvic floor, right?
I use my orthopedic evaluation skills in every pelvic floor evaluation to assess each person from head to toe. Before we do anything internal, I want to look at the person as whole. My initial evaluation generally includes a postural assessment, gait analysis, range of motion measurements, manual muscle tests, joint mobility testing, and appropriate special tests. It does not look very different from how I would assess someone with an orthopedic injury. The actual internal assessment of the pelvic floor itself is a relatively small part of the entire exam. Sometimes I don’t even get to the internal portion on an initial visit and still have plenty to work on!
2. Having experience with treating adjacent muscles and joints
The pelvic floor doesn’t work in isolation - it likes to work with the muscles around it, including the glutes, deep hip rotators, hip adductors, and transverse abdominus (1, 2). Using these synergistic relationships can help retrain a dysfunctional pelvic floor. You may even find that someone’s pelvic floor problem is being driven by muscle imbalances outside of the pelvic floor. For example, an overactive pelvic floor may be compensating for weakness in another muscle in an effort to provide lumbopelvic stability (3). Orthopedic therapists get lots of experience with helping patients strengthen their hip and core muscles, and you can use similar strategies with your pelvic floor patients.
The interconnectedness of the pelvic floor with surrounding structures doesn’t end with muscles - the joints around it can also affect pelvic floor symptoms. There was even a study that showed that some patients who had both femoral acetabular impingement (FAI) and vulvodynia had lasting improvements in vulvar pain after arthroscopic surgery for FAI (4). Obviously, we are not performing surgical interventions on our patients as physical therapists, but we can use our manual joint mobilization techniques on the hip, lumbar spine, and SI joint to treat impairments that may be contributing to pelvic floor symptoms.
3. Having experience with treating distal muscles and joints
Sometimes we need to look further up or down the kinetic chain to find the true driver of a patient’s symptoms. Is your patient’s pelvic pain driven by overactivity of their pelvic floor muscles or is their pelvic floor overactivity driven by their chronic TMJ dysfunction? There is an established relationship between TMJ pain and pelvic pain (5, 6), and clinically I have seen some patients have an easier time relaxing their pelvic floor after improving tension in the neck and the jaw.
A patient’s foot could also be a driver of their pelvic floor symptoms. If someone’s arch is weak and collapsed, that could lead to increased femoral adduction and internal rotation with the hip external rotators overworking to compensate. Overactivity in these muscles, which you can actually feel on an internal assessment, can result in pelvic pain and/or pelvic floor dysfunction. In this case, your evaluation and treatment techniques for the foot and ankle would be very valuable!
4. Going beyond kegels...or maybe not using them at all!
One of the biggest myths about pelvic floor physical therapy is that it is just about learning how to do kegels. While some patients do benefit from learning how to perform an isolated contraction of their pelvic floor muscles, we want progress to using the pelvic floor muscles in functional movements and exercises. These progressions are similar to what you would use with orthopedic patients. And not all patients with pelvic floor dysfunction need kegels. For these patients, your toolbox of exercises beyond the pelvic floor will be especially useful.
5. Being able to treat your pelvic floor patient’s unrelated musculoskeletal issues
Patients often come to us with multiple complaints that may or may not be related. If your postpartum runner with stress incontinence also has plantar fasciitis, eliminating her heel pain might not help her leakage, but it will help her reach her ultimate goal of returning to running at her prior level of function. It is nice to not have to refer out when your patients need more orthopedic specific treatment that is not related to the pelvic floor. You will also develop loyal patients that will come see you for future orthopedic injuries after you have treated them for a pelvic floor issue.
Ultimately, we don’t need to place pelvic floor physical therapy in a box completely separate from orthopedic physical therapy.
Orthopedic impairments outside of the pelvic floor can contribute to pelvic floor dysfunction and vice versa. If you are an orthopedic physical therapist interested in specializing in pelvic health, you are closer than you think. Many of the skills you already have will help patients with pelvic floor dysfunction. And if you are a new graduate looking to specialize, don’t forget about the rest of the body. Take a wide variety of continuing education courses - not just pelvic health specific ones - and try to treat a diverse patient population. Experience with treating patients with different orthopedic injuries will help you become a more well rounded physical therapist for your pelvic floor patients.
Morin M. Dumoulin C. Co-activation of the pelvic floor muscles during contraction of the hip external rotators. University of Montreal.
Bø K, Stien R. Needle EMG registration of striated urethral wall and pelvic floor muscle activity patterns during cough, Valsalva, abdominal, hip adductor, and gluteal muscle contractions in nulliparous healthy females. Neurourol Urodyn. 1994;13(1):35-41.
Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187-93.
Coady D, Futterman S, Harris D, Coleman SH. Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long-Term Follow-up After Hip Arthroscopy. J Low Genit Tract Dis. 2015;19(3):253-6.
Zolnoun DA, Rohl J, Moore CG, Perinetti-liebert C, Lamvu GM, Maixner W. Overlap between orofacial pain and vulvar vestibulitis syndrome. Clin J Pain. 2008;24(3):187-91.
Chen H, Slade G, Lim PF, Miller V, Maixner W, Diatchenko L. Relationship between temporomandibular disorders, widespread palpation tenderness, and multiple pain conditions: a case-control study. J Pain. 2012;13(10):1016-27.