Painful scars? Yes, you can do something about it!

 

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I can’t help it. Every time I think scar, I think… Scar (and yes, I used to have a much better picture of Scar from The Lion King for you…but I had to remove it in my attempt to make sure I’m not violating anyone’s copyright laws!)  I was going to try to think of some funny way to explain why scars and Scar are the same… but I can’t… I relate it to the 50,000 times I have watched The Lion King... so I’ll leave it at that.

Scars can be a big pain though– literally! I have treated women who even after several years cannot tolerate pressure on a c-section scar. Men who have nice huge abdominal scars that ultimately contribute to problems with constipation. And moms who have discomfort near their perineal tears every time they have sexual intercourse.  The truth is that scar tissue is often something skilled physical therapists will evaluate and treat as part of a comprehensive program in men and women with pelvic floor dysfunction(and really, with any type of problem!). And the best part– treating scar tissue can make HUGE differences!

So, what is a scar? 

When there is an initial injury (and yes, a surgical incision is an “injury”), the body goes through three phases of healing: Inflamation, Proliferation and Remodeling. Through this process, the body creates scarring to close up the initial injury. Scars are composed of a fibrous protein (collagen) which is the same type of tissue that is in the tissue the body is repairing (i.e. skin, etc).  The difference, however, is that scars are not quite organized the same way as the tissues they replace, and they don’t really do the job quite as well. (i.e. scars are much more permeable to UV rays than skin is). Scars can form in all tissues of the body– even the heart forms scar tissue after someone has a heart attack (myocardial infarction).

How do scars lead to problems? 

After the inflammation and proliferation stage of healing, comes the remodeling. This stage can take months to years! During this time, the body is slowly adapting and changing the scar to the stresses on the tissue. Have you ever noticed that some scars initially are pink and raised and then over time become light/white and flat? That’s remodeling.  Ultimately, there are a few major reasons why a person might develop pain from a scar:

  • Adhesions: Scars are not super selective when it comes to tissues they adhere to. So, sometimes, scars will adhere to lots of tissues around them and this pull can lead to discomfort.
  • Sensitivity: Scars can become very sensitive for a variety of reasons. Sometimes, small nerves can be pulled on by the scar which can lead to irritation. Other times, people themselves will have a significant amount of fear related to the scar. This fear, can often make people avoid touching the scar, and that, along with what we know about how our brain processes fear and pain (See this post, this one, and this one), can lead to a brain that is veeerrrryyy sensitive to the scar. Along with this, muscles near scars can become tender and sensitive. This can occur due to the scar pulling on the muscle or due to the sensitive nerves in the area.
  • Weakness/Poor Muscle firing: So, we know that when our tissues are cut, the muscles around the tissues are inhibited (have you ever seen someone after a knee replacement? It can be quite a bit of work to get those muscles to fire immediately after surgery). That’s why it’s important to get the right muscles firing and moving once a person is safely healed. Moving the right muscles improves blood flow too which promotes healing.
  • Changing Movement: Painful scarring can lead to altered movement. We can especially see this with postural changes after c-sections or other abdominal surgeries, but movement patterns can change with scars all around the body. We also know that abnormal movement patterns over time can lead to dysfunction and pain.

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What can we do about it? 

There are several ways physical therapists can help decrease pain from scars. Can we actually break-up/melt/eliminate scar tissue? I don’t really think so– honestly, scars are made from strong material and truly breaking up the scar is typically something that has to be done surgically– but most of the time, that is not necessary. We can decrease pain from scars by:

  • Improving the mobility of the scar: Gentle techniques to massage the scar and the tissues around the scar can facilitate blood flow to the area and decrease some of the pulling on the tissues around it. There is a thought as well that scar tissue massage can disrupt the fibrotic tissue and improve pliability of the scar (basically, help the scar organize itself a little better, and ultimately move better), and help to promote decreased adhesions of the scar to the tissues around it. Unfortunately, there really is not a lot of great research out there about scar tissue massage. However, this review published in 2012 found that 90% of people with post-surgical scars who were treated by scar massage saw an improvement in either the appearance of the scar or their overall function–which is very promising!
  • Desensitizing the scar and the nervous system: This is where I think we can make huge changes–both by improving someone’s worries/fears about the scar (calming the nervous system) and by slowly desensitizing the scar and the skin around the scar to touch. This is a slow process, but over time, many people who initially can barely tolerate pressure on the scar can be able to easily touch and move the scar without discomfort.
  • Promoting movement: So, we talked about how muscles can become inhibited or tender after a surgery? Part of improving scar tissue related pain is helping the muscles around the scar move well and learn to fire again. This can include some soft tissue treatment to the muscles to reduce the tenderness of the muscles, but ultimately leads to learning to use the muscles again in a variety of movement patterns. Movement is amazing for the body and can not only improve blood flow, but decrease pain too!

Wanna learn more? 

Several of my colleagues have written wonderful information about scar tissue! Check out this great, article and free handout by Kathe Wallace, PT on abdominal scar massage! My colleagues at the Pelvic Health and Rehabilitation Center have also written a few blogs on scars, which you can find here and here.

Have a great rest of your week!

~ Jessica

Pelvic Floor Problems in the Adult Athlete (Part 2): Stress Urinary Incontinence or “I leak when I jump rope, box jump, run…etc”

As promised, this is part 2 of my series on pelvic floor problems in the adult athlete. Part 1 discussed pelvic floor pain- what it is, how it happens, and how it is treated. If you missed it, you can still check it out here. Today, we will cover stress urinary incontinence in athletes.

Guess what? Leaking is not normal. Ever. Never. Nope.

At some point over the years, women became convinced that after having children it suddenly becomes normal to leak urine when coughing or sneezing. Or, that if you work out really really hard, or jump rope really quick, or jump on a trampoline, it’s normal to pee a little bit. But guess what? It’s not. And I firmly believe that no woman (or man!) should have to “just deal with it.”

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Bladder problems during exercise are very common– Here are some stats:

  • This summary article estimated that 47 % of women who regularly engage in exercise report some degree of urinary incontinence. (Other articles have shown big variety, with one review stating the prevalence varies from 10-55%)
  • This study found that in 105 female volleyball players, 65% had at least one symptom of stress urinary incontinence and/or urgency.
  • In elite athletes (including dancers), this study found a prevalence of urinary problems at 52%.

Summary: Urine loss during exercise is COMMON. And it’s about time we do something about it! 

So, what is stress urinary incontinence (SUI)? Basically, SUI is involuntary leakage of urine associated with an increase in intra-abdominal pressure.  For those who exercise regularly, this can occur with running, jumping (jumping rope, jumping jacks, box jumps, trampoline), dancing (zumba, too!), weight lifting, squatting, pilates/yoga, bootcamp classes, kicking, and many other forms of exercise.

**Note: Although SUI is one of the most common forms of urinary dysfunction we see in athletes, other problems can exist as well. This can include stronger urinary urgency, frequency (going too often), and/or difficulties emptying the bladder or starting the stream. Bowel dysfunction is also a problem with many athletes, and can include bowel leakage, constipation, or difficulty emptying the bowels. 

Why does it happen? There are many causes of bladder leakage, so it is always important to be medically evaluated. We know that hormones can play a role, as well as anatomical factors (pelvic organ prolapse or urethral hypermobility). Other factors can include childbirth history, body mechanics, breathing patterns/dysfunction, obesity–and I’ll add here, previous orthopedic injury or low back/pelvic girdle pain.

From a musculoskeletal viewpoint, SUI has to do with a failure of the body to control intra-abdominal pressure. Basically, there are forces through the abdomen and pelvis during movements, and our body has to control and disperse those forces. The deepest layer of muscles that work together for pressure modulation are the pelvic floor muscles, the transverse abdominis, the multifidus, and the diaphragm. In terms of the pelvic floor muscles specifically, remember that we want strong, flexible, well-timed muscles.  Tight irritated muscles can contribute to UI just as much as weak overly stretched out muscles. We have discussed this many many times on this blog, but if you’d like a review of that, read this piece on why kegels are not always appropriate for UI and check out the videos by my colleague, Julie Wiebe, posted there. It is also important that a person has properly firing muscles around the pelvis–especially the glutes! but also the other muscles around the pelvis that help to move you.

The way in which a person moves can also be a significant contributing factor to SUI. For example, if a person holds his or her breath during jump rope, the diaphragm is not able to move well and the entire pressure system will be impacted (leading to possible leaks!). I have also seen women develop SUI or pelvic organ prolapse after performing regular exercise using incorrect form/alignment or after performing exercises that were too difficult for them to do correctly. Often times, this leads to compensatory strategies that can make pressure modulation very difficult for the body.

What can you do about it? First things first–stop “just dealing with it!” I recommend a medical evaluation to start, but always encourage people to seek conservative treatments first prior to medications and/or surgery. The best person to evaluate you from a musculoskeletal perspective is a PT who is specialized in treating pelvic floor dysfunction (and if you live in metro Atlanta and have SUI, come and see me!). The physical therapist will do a comprehensive evaluation which will include:

  • A detailed history, including your obstetric history (if applicable), daily habits, diet/fluid intake, and your regular exercise routine
  • Evaluation of your movement patterns (specific exercises, weightlifting, etc.) which are causing you problems
  •  Head to toe evaluation of your spine, ribcage, abdominal wall, hips, breathing patterns, alignment/posture, knees…all the way down to your feet to see how your movement at each spot could be influencing your pressure system. We also look at how your various muscles fire to help to identify which muscles may not be firing at the right times or which muscles may be tight and impacting your movements.
  • Evaluation of the pelvic floor muscles. As the pelvic floor muscles are located internally, the best way to assess them is with an internal vaginal or rectal assessment. That being said, if you are uncomfortable with that, there are options for external assessment that will help the PT gather some information (just know that this will likely be less thorough).

Treatment for SUI often includes: 

  • Re-establishing the proper timing and coordination of the pelvic floor, diaphragm, multifidus and transverse abdominis to stabilize the lumbopelvic region and modulate pressure during movements. Remember, our goal is to optimize this team working together–it’s not just about the pelvic floor, and kegels are not always the answer.
  • Retraining the proper firing of the muscles around the pelvis during movements.
  • Correction of postural/alignment problems which could be contributing factors
  • Manual therapy and specific exercises to improve previous findings in spine, hips, knees, etc.
  • Education on proper alignment, breathing patterns, and movement sequences during preferred exercises.
  • Education on bladder health, dietary patterns, fluid intake, patterns for emptying bladder, toilet positioning, etc. to encourage healthy bladder function.
  • Treatment of co-existing bowel dysfunction, sexual dysfunction or orthopedic pain (as this is often all connected!).
  • **Some women also benefit from using assistive equipment like a tampon or a pessary to help stabilize the urethra or support the vaginal wall during exercise depending on her specific situation.

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My colleagues write very well, and have written several excellent posts on pelvic floor problems in athletes. Here are a few of my favorites:

I hope this was helpful to you! I would love to hear your thoughts– if you have questions or comments please leave them below! Have a great Wednesday!

~ Jessica

**Do you have an idea for blog post or is there a topic you’re just itching to learn about? Feel free to contact me or comment on any post to share your ideas! 

Do we move differently in pain?

For the past few years, my studies in pelvic health have taken me further and further outside of the pelvis.  I have learned and continue to learn how amazingly interconnected our bodies actually are. The pelvis can be influenced by the ankle, the knees—and even the neck! It is amazing and awe-inspiring. This past weekend, my studies took me to the Level 1 Selective Functional Movement Assessment (SFMA), where I spent 2 days learning a systematic way to evaluate movement and identify where dysfunctional patterns exist—head to toe! (How awesome is that?!) There are many different systems and programs out there for evaluating someone’s movement, and honestly, I don’t necessarily think one is superior to the other. I liked this one though, as it made sense to me and the initial screen could be completed in 2 minutes :).

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So, why is it important to look globally at human movement when a person is experiencing pain anywhere in the body? For lots of reasons, like I said above—but for the purpose of today’s post—because we now know that movement patterns do really change when a person is experiencing pain—and this is helpful initially and important—remember, your brain wants to protect you from experiencing harm! However, dysfunctional movement patterns, although helpful to the body in that moment, can persist and lead to further problems down the road.

Paul Hodges (a favorite researcher of mine!) and Kylie Tucker examined the current theories regarding movement adaptations to pain in a 2011 review published in the International Association for the Study of Pain. They looked at the current research regarding movement variations in pain, and frankly poked holes in the theories where holes needed poking.  They then presented a new theory on the motor adaptations to pain, and that’s what I would like to share with you today.

The theory they presented is based on the premise that movement adaptations occur to reduce pain and protect the painful part. The way in which a person does that actually varies and is flexible. Here are the basics of their theory, simplified, of course. I do encourage you to read the paper if you’re interested—it’s great!

  • Adaptation to pain involves redistribution of activity within and between muscles. Basically, the brain varies which pools of motoneurons fire in a muscle based on the individual and the task requirement. The common goal still is to protect the painful part from pain or injury, but the way the body does this can vary greatly. Interestingly, we know that the motoneurons active before and during pain tend to reduce activity, and the production of force actually seems to be maintained by a new population of units who were previously inactive. Normally, motoneuron units are recruited from smaller to larger pools to allow for a gradual increase in force—but in pain, a person often will have earlier recruitment of larger pools to basically allow for a faster development of force to get away from pain (think fight or flight response!). Also, the new population of active units may be altered to change the direction of the force generated by the muscle (again, aiming to help protect the painful structure). We also can see in some areas, like the trunk, that one muscle may become inhibited (like the transverse abdominis) while other larger muscles become more activated. This again, makes sense with the body’s goal of protection. Quick activation of larger motor units allows for a quick activation of a muscle to help protect and escape pain.
  • Adaptation to pain changes mechanical behavior. Basically, like we just discussed, the redistribution of activity within and between muscles changes the force and output of the muscle. Hodges & Tucker give us a few examples of this. First, they’ve found that when someone has knee pain, the quadriceps muscles fire differently to change the direction of knee extension by a few degrees. They also explain that the changes in muscle firing in the trunk muscles in someone with back pain leads to more stiffness and less control of movements and less anticipatory action. Basically, in each of these cases, the big picture motion stays the same, but there are small changes within how the body accomplishes those tasks.
  • Adaptation to pain leads to protection from pain or injury, or threatened pain or injury. Basically, this redistribution of muscle firing is done to protect against pain—or even the threat of pain. When a person experiences pain, the brain choses a new pattern to move to either splint the injured area, reduce the movement of the area, or alter the force on the area. The interesting piece here is that the body responds this way even when there is a perceived threat of pain! The key with all of this is that the adaptation varies significantly—not one pattern is seen for all types of pain, but the nervous system has a variety of options for protection!
  • Adaptation to pain involves changes at multiple levels of the motor system. So, although we know that the activation of motoneuron pools can change during pain, that alone does not describe the variability we see. We know now that the way the body changes movement can be influenced by structures in the brain, spinal cord or at the local level of the motoneuron. All of this is going to be influenced by the task at hand and the individual (thoughts about the pain, emotions, stressors, and previous experiences)
  • Adaptation to pain has short-term benefit, but with potential long-term consequences. Although the short-term benefit is protection of the painful area and prevention of further pain, this may lead to consequences down the road if the adaptation persists. Of course, we assume in this case that movement in a non-pain state is likely the most efficient and optimal way to move. So, changes over time could produce decreased movement variability, modified joint loading, modifications in walking patterns, joint load and ligamentous stress. Hodges and Tucker state that in order for these long-term consequences to occur, there would likely need to be a gradual maintaining of the compensation, thus that the nervous system did not recognize it being problematic. Basically, the brain slowly adapts to the new pattern and does not recognize the problems it could cause down the road.

Interesting stuff right? The tricky thing is, we don’t really know for certain how these long-term changes can impact the body—but we do know that one of the biggest risks for injury is previous injury. I can’t help but think that movement changes could possibly contribute. But how do we change this in a positive way?  I think the first step is understanding pain, learning what pain is and what pain is, and developing a healthy mindset toward pain—this alone goes a long way! We also have to look closely at our own emotions, our psychological state, our previous experiences, and understand how all of these things can influence how are brain chooses to respond to pain. But then, we need to identify which movements the body has changed, understand how the brain is varying movements to protect against pain, and then slowly provide variability with good force modulation in those movements to help the brain learn optimal, safe and pain-free ways to move again.

What do you think? I’d love to hear from you in the comments below!

Cheers!

Jessica

What’s new in pelvic health? Reading homework included.

I love reading blogs about pelvic health, the human body, chronic pain, movement, neuroscience–and especially get excited if these things get combined together. Periodically, I’d love to simply do a blog on blogs, so that is what you get today. Basically, it is a quick list of blogs, journal articles, random articles, and possibly books that I am reading right now. There are SO many great things out there. I hope you enjoy, and have a great friday! 🙂

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1. The Pudendal Neuralgia Wrecking Ball. Of the different diagnoses in the chronic pelvic pain world, pudendal neuralgia is often a scary one for a patient to hear. Not because it’s untreatable–it IS treatable. But simply, because , and unfortunately, many patients with this type of problem (like SO many other problems related to pelvic pain) are often misdiagnosed many times before receiving help and assurance, and often find scary and less than assuring things when researching online (leading to high levels of worry and fear).  So, this article on US News and Reports came out recently. As pelvic PTs, we always love to have big news websites post information to bring awareness to pelvic pain problems. But we took some issue with exactly how that was done and some of the information which was provided…which lead to this excellent response by Stephanie Prendergast, PT of the Pelvic Health and Rehabilitation Center in California (If you don’t follow their blog, you really should! They consistently put out fantastic, high quality information.) And then, led to this response by Sara Sauder, PT, who writes her own blog, focusing all on pelvic pain (it’s great too!). Read these posts–they have great information in them!

2. Can’t Get Enough of the Diaphragm. March was really the month of the diaphragm. Not only did you get my post on the 6 reasons why the diaphragm is the coolest muscle ever, but Ginger Garner (who also has a great blog with a big emphasis on women’s health) went into great detail on this post, expanding on how important the breath really is. I’ve written a lot recently on the importance of breathing with movement and coordinating the breath with other muscle activation, but is holding the breath ever a good strategy? Julie Wiebe gave great insight into that in this post here. (And you know Julie posts awesome stuff!).

3. Movement Variability. As humans, we are designed for movement. Typically when people have pain, their movement patterns become more rigid, and they can often develop alterations where their bodies are guarding movements by pain. Retraining slow, controlled motions with a lot of variations is an important component of treatment! For those without pain, movement variety is key to keeping healthy bodies! That’s why I loved this post by Katy Bowman (my favorite biomechanist) on sitting variations while playing with her child.

4. Share MayFlowers: Women’s Health Awareness. My list would not be complete without a shout-out to Jessica McKinney’s excellent work with Share MayFlowers. SMF is a public health initiative aimed at improving awareness in Women’s Health, and Jessica has been posting excellent information all month long! She highlights women who are doing fantastic things to support WH initiatives, and links to great blogs, articles, etc. out there! A few of my faves from this month are this New York Times article which discussed an innovative form of sex education for adolescents, and this post, bringing awareness of obstetric fisulas.

Hope you enjoy! Now it’s your turn– what are you reading? I’d love to hear in the comments below!

Do men have pelvic floors too? The truth about 10 common pelvic myths

Earlier this week, I asked the Twitter and Facebook PT world a simple question:

What are the common misconceptions you hear about the body?

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My initial goal was a fun blog post on common misconceptions about anatomy, etc…but I was not prepared for the huge response I received—over 40 responses with SO many different things that people often misunderstand! Some pelvic, some general—and it made me realize there is SO much bad information out there!! So, what once was one post will become two. Today, we’ll hit on 10 common myths related to the pelvis (you knew I’d start there!). Then stay tuned for a future post hitting other misconceptions related to…well… the rest of the body, fitness, wellness, pain etc.  So, here we go:

1. Men don’t have pelvic floor muscles: They do, I promise. And guess what? The anatomy is not quite as different as you would think! The same muscles that contribute to urinary, bowel and sexual function as well as lumbopelvic stability in women do that in men too. Pelvic PTs treat men with incontinence, pelvic pain, constipation, painful sexual intercourse and much more.

 2. Vaginas need a lot of work to keep clean. No, they don’t. The Vulva (vagina really just refers to the canal itself) is actually self-cleaning. It does not need to be scrubbed with soap. You can totally just shower and run water over it, and it will be just fine. In fact, scrubbing the vulva can irritate it and even kill the good bacteria that prevent infections! I could say so much more, but you really should just read this article on Pelvic Guru by Sara Sauder, PT and this one by Dr. Jen Gunter.

 3. Abdominal pain is always caused by organ problems. Not necessarily. Now, don’t get me wrong, abdominal pain can definitely happen with ovarian cysts, appendicitis, constipation, and much more—but abdominal pain can also happen when the organ is not to blame. This is so common in men and women with chronic pelvic pain. These people often will have very sensitive nervous systems, tender muscles around the pelvis and in the pelvic floor, as well as even neural irritation (lots of nerves run through the abdominal wall!). So, if the organ has been ruled out as a source of pain and the pain persists- it may be worth considering something different.

4. Not having enough sex OR having too much sex OR masturbating too frequently causes pelvic pain. I cannot tell you how many times I have had a patient timidly ask me if there sexual habits or frequency are to blame for their pain. No. Just no. You should be able to have sex as little or as frequently as you want without any problems or pain. Now, being forced to have sex—that may cause a strong protective response of the pelvic floor muscles. But, consensual sexual activity is normal and should be enjoyed by all without worrying about pain. And if you are having pain? Don’t ignore it– go talk with your physician or physical therapist!

 5. Tight pelvic floor muscles are healthy pelvic floor muscles. Guess what? Tight ≠ strong. Flexible ≠ weak. Strong ≠ Well-timed. Functional pelvic floor muscles are non-tender, flexible muscles that are able to activate when they should activate (well-timed). We want the pelvic floor to stretch to allow you to poop and have sex, and we want the muscle to activate at the right time with enough strength to help you not leak urine when you cough.

6. If the doctor says “all looks good” 6 weeks after having a baby, it means your body is completely back to normal. Newsflash here, you’re body isn’t really going to go back to being exactly what it was like before the baby. It’s not meant to, and that is ok! It can still be an awesome, strong and well-functioning body– but you do need to take care of it. Remember that urinary or bowel leakage, constipation, persistent low back/pelvic pain, vulvar pain, and pain with sexual activity are NOT normal. If “all looks good” at 6 weeks, but you are having these problems, find a skilled pelvic PT near you to get evaluated and get some help! And even if you are not having these issues—your body has been through a lot! Take time and care in slowly getting your body back into good movements. Also, check out this article by Ann Wendel, PT on 5 myths surrounding the pelvic floor after pregnancy.

 7. If a woman had a c-section, her pelvic floor was not impacted, and she doesn’t need to think about it. Guess what the biggest risk factor for urinary incontinence is? PREGNANCY. Although mode of delivery is important, simply being pregnant and carrying a baby puts significant pressure on the pelvic floor. Both vaginal deliveries and c-sections impact the body—remember, a c-section cuts through the abdominal wall! Remember that team of muscles that work together for lumbopelvic stability? The abdominal wall is a KEY member. Regardless of your mode of delivery, seeing a skilled physical therapist after having a baby is crucial to help your musculoskeletal system function optimally, manage unwanted pain or leakage, and get back to the fitness activities you enjoy. And guess what? It’s standard care for all ladies postpartum in many countries around the world.

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8. Urinary incontinence is always due to a weak pelvic floor muscle group. I wrote a whole blog on this one, so I recommend you read it here. The short answer is, No. No problem is due to solely one muscle. Our body is a system, and we have to always treat it like that.

 9. Hips and sacrums dislocate regularly in some people. This is such a common one too—I’ll have patients come in and say, “My hip keeps ‘going out’ and I have to do this <does weird hip movement> to put it back in.” OR “My SI joint keeps ‘popping out of place.’” Let’s all be honest about this- dislocations of joints do happen, but it tends to be pretty painful, likely traumatic, and if your hip dislocates, you bet you are going to the ER. That “pop” you hear? It’s likely just a joint cavitation- basically a decrease in pressure causes dissolved gasses in the joint fluid to be released into the joint. Same thing happens when you pop your knuckles. If it happens frequently and is associated with pain, talk with a physical therapist.

10. Sucking in the stomach constantly creates a strong “core” and a flat abdomen. You know what creates a flat abdomen? Eating healthy and exercising regularly. Contracting any muscle constantly is not functional, nor does it really do what we want it to do. Sucking in the stomach actually tends to make it more difficult for your diaphragm to move well when you breathe and also can cause the pelvic floor muscles to over contract and become tender/uncomfortable. It can also inhibit movement, and we know moving well with variety is SO key to a happy body. So, relax your stomach and allow yourself to breathe (remember how important that diaphragm is!)

I hope you gained a little insight with this list—it was fun to write! This is by no means an exhaustive list (over 40 responses, remember?), and I’d love to keep the conversation going! Special thanks to my world-wide pelvic health team! It’s so fun collaborating with such a great group!

Have you heard anything else about the body that does not seem to be right? Ask here and we’ll do our best to answer! Physical therapists out there—what are your other favorite myths to de-bunk? Let’s all work to spread accurate knowledge—knowledge really is power! Have a great Wednesday!

~ Jessica

A Pain in the Tail…bone (Part 2: Treatment)

“Due to the dearth of research available and the low levels of evidence in the published studies that were located we are unable to recommend the most effective conservative intervention for the treatment of coccydynia. Additional research is needed regarding the treatment for this painful condition.” 

This statement comes from a 2013 systematic review on conservative treatments for coccydynia… isn’t it so encouraging? We discussed what coccyx pain meant, the causes, and the examination approach last week in Part 1 of “A pain in the tail…bone.”  Today’s post will take a close look at my approach for treating people with tailbone pain and what we do know in the current research. Unfortunately, as you see from the comment above, research for the best treatment for tailbone pain is significantly lacking…so we’ll have to rely on my clinical experience as well as the knowledge from courses I have attended and practitioners I have collaborated with in the past.

So, what should treatment for tailbone pain include?

1. Pain reducing strategies: Day one of treatment should always include recommendations for reducing pain by changing some basic daily habits. Typically, this includes:

  • Cold packs/hot packs: Basic, I know, but they feel good and can help a sore coccyx feel better after a long day. I prefer ice, but others prefer heat. I recommend using for about 10-15 minutes, a few times per day or as needed. Recent recommendations always include using cold/heat as needed.
  • Alignment, & Cushions when needed: Alignment, especially in sitting, is very important for reducing pressure on the tailbone in the initial phase of treatment. Slumpy postures actually put more pressure against the tailbone and neutral postures distribute weight to the bony parts of our pelvis more evenly. Along with this, firm comfortable chairs tend to support a more neutral posture, but cushy couches or chairs usually promote a more slumped posture. As I mentioned in my previous post, many people with tailbone pain tend to develop a side-twisted sitting posture. It makes sense– they’re trying to unweight the tailbone–but over time, this “wonky” sitting can lead to low back pain, and that’s not fun for anyone! So, we need to learn to sit up comfortably, and a good tailbone cushion can be a helpful tool for that. Note: Donut cushions don’t tend to help as much with tailbone pain unless the pain is totally referred from the pelvic floor musces. These unweight the perineum due to the center cut-out, but they don’t unweight the coccyx.  A cushion that has a back cut-out, like the ones pictured tend to be more helpful.
  • Coccyx cushion from Amazon.com

    Aylio Seat Cushion
  • Body Scanning or “Check-ins”: Many people with tailbone pain will clench muscles around the tailbone as a protective strategy–usually the glutes and the pelvic floor to be precise. As we discussed previously, these muscles can refer to the coccyx, so it is important that we decrease this hypervigilant clenching pattern. I typically recommend scanning the body, or checking-in, a few times a day to feel if muscles are clenched hart or relaxed. If you feel any clenching, try to drop the muscles and allow them to let go.
  • Pelvic Floor Drops: As mentioned previously, many people with coccyx pain have tender and over-contracting pelvic floor muscles. Pelvic floor drops are exercises that encourage a completely relaxed pelvic floor. Typically, these pair well with breathing exercises as functional diaphragm use can encourage appropriate pelvic floor relaxation.
  • Stretches: My favorite stretch for someone with coccyx pain is what I call “The frog.” This stretch not only helps to stretch out the buttock muscles, but also is a position of optimal relaxation for the pelvic floor! This is often done with a person lying on their back with knees pulled up to chest and held open. Alternatively, a wide kneed child’s pose can also promote relaxation for the muscles. Other stretches to open the pelvic or stretch the muscles around the pelvis can also be helpful–but this one is my go-to on day 1.
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Photo by Mark Zamora on Unsplash. Arms can be reached out in front. You can also place a pillow underneath you while you lean forward if that is more comfortable

2. Manual Therapy Techniques: The goal of manual therapy should be to decrease soft tissue sensitivity/pain and to improve the mobility of the coccyx, SI joint and low back if indicated. Typically we do the following:

  • Soft tissue treatments: This should not be a horribly painful experience! Skilled clinicians can help to improve sensitivity and tender spots in the buttocks, hips, low back muscles and pelvic floor muscles. For the pelvic floor, this can be done externally, vaginally (in women) or rectally. Specifically, the coccygeus, iliococcygeus, pubococcygeus and obturator internus muscles should be evaluated and treated. Sometimes dry needling can be helpful also in reducing soft tissue sensitivity.
  • Coccyx Mobilization: The coccyx can be mobilized some externally with a person in sitting (I use what is called the “closed-drawer technique” here). The best way to mobilize the coccyx is with internal rectal treatments. Internal rectal mobilizations or manipulations can include direct mobilization into flexion or extension, distraction of the coccyx and mobilization into sidebending. The most recent review I found published in 2013 found 3 studies looking at intrarectal manipulation for coccyx pain and all of them did show some improvements in pain for patients…but from a research standpoint, 3 studies is hardly anything and to be honest, the studies weren’t that good. So, we’re stuck with some of my clinical opinion 🙂 I believe intrarectal mobilization can be hugely beneficial for patients! And, I shouldn’t have to say it–but it should always be done by someone trained and skilled in performing it.
  • Lumbar & SI treatment: I highlighted in part 1 that many men and women would tailbone pain often have low back and SI pain as well. In these cases, these areas should be addressed and treated through manual therapy techniques as well as specific exercise recommendations

I often will also use a little bit of taping to help support what I do manually and give my client some input on what I want their bodies to do. I like kinesiotape the best for this and use a few different techniques depending on the person. McConnel tape can also work well.

3. Retrain the Nervous System: Our brain rules– remember, pain is our brain’s alarm system to tell use there is a problem and to protect. A person who has had coccyx pain for a long period of time may develop a sensitized nervous system–and it is so important that this be addressed! So as not to re-invent the wheel, you can read more about it in my previous post reviewing the book, Why Pelvic Pain Hurtsand in my previous post summarizing my presentation to the Atlanta Interstitial Cystitis Support Group. 

Side-note: Pain neuroscience is currently not discussed often enough in the research regarding treatment for coccydynia. I think this is a huge problem–we know that experiencing pain for a long period of time truly impacts the nervous system and we can’t ignore that! This case study showed 2 patients treated for tailbone pain–one was acute, treated immediately and got better quickly. The second had pain for over a year before being treated and did not get as good results– could this “brain retraining” be the missing piece? I think it can’t be ignored.

4. Manage Bowel, Bladder and Sexual Problems: Remember, the pelvic floor muscles attach to the tailbone, so it is so common for people with tailbone pain to notice bowel, bladder or sexual symptoms.  This should always be addressed with good behavioral education and appropriate treatment techniques. I’ll leave it at that…because each one could be a few blog posts in and of themselves.

5. Return to Normal Function: I talk about this in almost every post, but ultimately, our goal is always to get you back to moving, sitting, exercising, etc. as quickly and effectively as we can. As pain decreases, our goal is to retrain the system to function optimally. We do this by retraining proper patterns of muscular activation (yep, diaphragm, pelvic floor, abdominals, low back…with all of the other muscles!), teaching movement with lots of good variation, and a lot of education.

So, that about sums it up… PTs out there, did I miss anything important? I would love to hear from you and start a discussion!

For those of you out there dealing with tailbone pain–please let us know how we can help you better! If you have not tried working with a pelvic physical therapist in the past, I do strongly recommend it!

A Pain in the Tail…bone (Part 1- What is it? How does it happen? How does it feel?)

Let me tell you a little story. Several years ago, I was on my way to a continuing education course in Minneapolis, MN. I arrived to the airport early for my flight and settled in at the gate with a good book waiting for the boarding call. My flight was delayed…and delayed… a one hour wait became a four hour wait. But, I was reading a great book. I believe I got up one time over those four hours. Then I boarded the plane and sat for another 3 hours (finished the book!). Then I had tailbone pain.

Thankfully, in my case, I was headed to a course full of pelvic health practitioners, and I begged one of them to treat my tailbone on the first day. (Yes, it literally went, “Hi, my name is Jessica, will you treat my coccyx?”) She did, and one day later it felt totally better.

The truth is, my story is not a totally uncommon one. I sat in one place for 7 hours straight (likely in a slumped posture)– and my tailbone didn’t like it. I was lucky, because I know about tailbone pain…I was able to get it treated and I got better very quickly. Many people with the same pain will stay in pain for a long time before getting the treatment that helps. So, my goal today is to tell you exactly what tailbone pain is, how it happens, and what it feels like… and then in part 2 to tell you what you can do about it.

First, where exactly is the tailbone? Seems easy, but you’d be surprised how many people don’t actually know where it is.  Several months ago, I received a referral from a PT colleague to treat a nice lady who was having “tailbone pain.” She came into my office and when I asked where her pain was, she pointed directly to the sacrum.  I have had this happen in reverse too where a patient told me his “back hurt” but pointed to his coccyx. So, where is the tailbone? 

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The coccyx (tailbone) refers to the 3-5 fused bones at the very end of the spine. These fused segments attach to the sacrum. To feel your coccyx, slide your fingers down from the sacrum between each cheek of your bottom. You will feel a very small boney structure, and can often feel the tip of the coccyx (which will be very close to the anus!).

Several ligaments and muscles attach to the coccyx, including the gluteus maximus and the pelvic floor muscles.  The coccyx does not stay still when we move. In fact, the coccyx moves as we sit and moves again as we stand.

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Now that we got that out of the way, here are a few things to know about coccydynia (tailbone pain): 

-What is it and what are the common symptoms associated with it? Coccydynia translated means “pain in the coccyx,” and that is how coccydynia is defined.  Most people with coccydynia will complain of pain in sitting (especially on hard surfaces), pain in standing for a long period, and pain when moving from sitting to standing or from standing to sitting. Since the pelvic floor muscles attach to the coccyx, many people with coccyx pain will have pelvic floor muscle involvement to some extent and may complain of constipation or pain with bowel movements, changes in urinary frequency/urgency or pain with sexual intercourse. Clinically, I also will often find that people with tailbone pain will begin to have low back pain too– I believe this occurs as people alter sitting positions and “side-sit” to avoid sitting on the tailbone.

-How common is it? The prevalence is actually unknown. Some literature state that it is “uncommon,” but I don’t really think that’s true. I think it’s likely under-reported (as are many things in the pelvis), and I believe the lack of understanding on treatment options contributes to this. Coccydynia seems to affect women more than men (5x more approximately!) and is more common in people with obesity. 

-What causes it? Coccyx pain is typically divided into two categories– traumatic and non-traumatic. Traumatic coccydynia typically occurs either with a backwards fall on the bottom or during childbirth. In these cases, the coccyx can become bruised, dislocated or even fractured. Nontraumatic coccydynia can occur due to prolonged or repetitive sitting on a hard surface (microtrauma), hypomobility or hypermobility of the coccyx (basically, the tailbone isn’t moving properly), degenerative joint or disc disease, and other variations in the structure of the coccyx. In addition, the coccyx can sometimes become painful if a person has overactive pelvic floor muscles as these muscles attach to the coccyx.  Note: Although much less common, coccyx pain can sometimes come from more serious problems like an infection or even cancer. It’s always important to see a skilled health care provider who can help you determine the contributors to your pain. 

-How is coccydynia diagnosed? As I said previously, coccydynia refers to pain in the coccyx, so the best way to diagnose coccyx pain is with a thorough history of the pain and an exam involving touching the coccyx to determine if it is uncomfortable to the person. (This is where some clinicians run into issues…you see, the tailbone is close to the anus, and people don’t always like going there. But it is SO important as a clinician to actually touch the tailbone to help determine why the person is experiencing pain! No one would examine shoulder pain without touching the shoulder! So, please clinicians, palpate the tailbone. Soapbox over.)

I know you would think that most people would “know” if their tailbone was painful…but like we discussed above, many people do not even realize where the tailbone is! Also, it is important to note that tailbone pain can be radicular in nature, meaning that nerves in the area are contributing to the symptoms or it can be “referred pain” meaning that it is coming from a different structure. Some of the muscles that can contribute to tailbone pain are the pelvic floor muscles, the obturator internus ( a deep hip rotator) and the gluteus maximus. I have seen several patients that felt pain in their tailbone that was actually coming from tenderness in these muscles. That’s why an exam with palpation is so important.

– How is the coccyx examined? Examination with a physician typically will include a subjective history, physical exam and may also include some type of diagnostic imaging (x-ray, MRI). Typically, when a person comes into my office seeking physical therapy for coccydynia or tailbone pain, my initial assessment includes the following:

  • A comprehensive history to understand what the person believes is causing the pain, what makes pain better/worse, obstetric history, bladder/bowel history and symptoms, sexual history and symptoms
  • A movement exam– basically taking a person through movements of the spine, sitting, standing, squatting to see how the person moves and what movements (if any) bring on the pain, worsen it, or alleviate it. I also will feel the coccyx in sitting vs. slumping to feel the movement of the coccyx and identify pain.
  • An external assessment of the spine– Mobilizing the segments of the low back, the sacrum and then the coccyx helps me identify which structures may be involved in the person’s discomfort.
  • An external muscle assessment– feeling the muscles of the low back, buttocks, pelvic floor and thighs to see if the muscles are tender and if that tenderness contributes to tailbone pain.
  • An internal assessment of the pelvic floor muscles and coccyx- For patients experiencing significant pain, I will often defer this to the 2nd visit or even later depending on the person. The best way to assess the coccyx is by an internal rectal assessment by a very skilled practitioner. This examination allows a clinician to feel the movement of the coccyx and assess the muscles around the coccyx for tenderness. (Note: examination and treatment should always be a “team” decision. If a person feels uncomfortable with an internal exam and does not wish to have one, the practitioner should respect that and treat the person as well as she can with external approaches)

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How is tailbone pain treated and what can you do NOW to make it better? Stay tuned next week for Part 2… 🙂 

As always, I love to hear from you! Please let me know if you have any questions or comments! Happy Friday!

~ Jessica