Myofascial Pain

Myofascial pain is a condition in which pain originates from shortened, tense and restricted muscles and fascia (otherwise known as connective tissue.) Myofascial pain is very common across many chronic pain conditions. In people with chronic pelvic pain, studies estimate that at least 50%, and possibly up to 90% of people have musculoskeletal dysfunction contributing to their pain symptoms.

Despite the fact that myofascial pain affects such a large proportion of people with pelvic pain, it is one of the most overlooked diagnoses in this population. The majority of people with conditions like endometriosis, vulvodynia, irritable bowel syndrome, or bladder pain syndrome/interstitial cystitis will ALSO have some component of myofascial pelvic pain.

Let’s talk about the pelvic floor and its surrounding structures. Our pelvic region is comprised of organs, muscles, ligaments, fascia, tendons, joints, blood vessels, nerves and skin. In order for our pelvic floor to work at its best it is important for these structures to work harmoniously and fluidly together.

It is helpful to understand a bit more about how the pelvic floor muscles, organs, fascia and the bony pelvis normally work together in order to understand myofascial pelvic pain. The bony pelvis is shaped like a bowl, and the pelvic floor muscles form a web or sling along the base and sides of the bowl. The muscles help to support all of the pelvic organs, including the bladder, rectum, and the vaginal and uterus in women. Our pelvic floor not only supports our pelvic organs but also provides control for bowel and bladder function, acts as a pump to drain blood and lymphatic fluid and assists with sexual function.  The pelvic floor muscles work together with the abdominal wall and back muscles, as well as the spine and hips.

When we have good fascial mobility our organs can function at their best without restriction as they are meant to move fluidly with breathing and body movement. Our fascia is like a spider web that connects all parts of our body. We have different types of fascia, superficial just under the skin, deep covering muscles, bones, nerves and blood vessels and fascia that surrounds the organs, spinal cord and brain (dura is a tube covering our brain and spinal cord and has attachments on the inside of our skull to the tailbone or coccyx at the end of the spinal column - otherwise known as our craniosacral system). Our craniosacral system should move freely without restriction.

The pelvic musculature is the floor of your core. It moves in synchrony with your diaphragm muscle as you breath. As you breathe in, your pelvic floor musculature descends or goes downwards towards the floor. This happens due to air is filling up in your lungs putting more pressure on your abdominal and pelvic floor regions.  During exhalation or breathing out you will feel a rise in your pelvic floor.  As air exits your lungs you will then reduce the pressure on your abdomen and pelvic floor.  We also need to understand that movement above and below the pelvic floor can impact this region. If your diaphragm muscle is in spasm this can contribute to pelvic floor dysfunction as well as how you walk as these forces/imbalances can translate all the way up to your pelvic floor.

Pelvic myofascial pain, often referred to as pelvic floor muscle pain or levator ani syndrome, is pain resulting from shortened, tense and restricted muscles and fascia in the pelvis. This can include the vagina, groin, lower abdomen, low back, hips, gluteals, and sacroiliac areas. This type of pain can be episodic (ie associated with menstruation or a specific activity such as sexual intercourse or penetration) or it can occur spontaneously.

Symptoms of myofascial pain can vary depending on which muscles are involved and on the degree of tension or overuse. But people with myofascial pelvic pain frequently report pelvic cramping, heaviness, aching, throbbing, or pressure. Many people also report episodes of sharp or shooting pain. Pain may be present in the middle, or on either side of the pelvis, and location may fluctuate from day to day. Some people report pain in their lower abdomen, hips, low back, or pain that radiates down their legs.

The pattern of pain symptoms can also vary quite a bit, but many people with myofascial pain report that pain worsens throughout the day or with activities, such as standing or driving for long periods. Many people have exacerbations of pain related to menstrual periods, intercourse, bowel movements, urination, or having a full bladder. Pain can last for hours or days after an aggravating episode.

Many people who have pelvic myofascial pain, especially when it is left untreated, often report depression, anxiety, feelings of helplessness about their pain. When sexual function is affected by pelvic myofascial pain, many people negatively impact on their intimate relationships.

It is important to note that there is often overlap between symptoms of myofascial pelvic pain and other pelvic pain conditions, like endometriosis, vulvodynia, irritable bowel syndrome, and bladder pain syndrome. Because the pelvic floor muscles are connected to and support the function of the pelvic organs, and because the pelvic floor muscles and pelvic organs share many sensory nerve pathways, it can be challenging to distinguish between pain originating in the pelvic organs verses the muscles based on symptoms alone.

Myofascial pelvic pain can happen because of a musculoskeletal issue or can happen in response to another pelvic pain condition. Examples of primary musculoskeletal causes include injuries to the pelvic floor muscles during childbirth, abdominal wall muscles during surgery, or back muscles and spine resulting from a car accident. However, most people with myofascial pelvic pain do not have a history of these types of injuries. Rather, it seems more common that myofascial pelvic pain begins slowly, sometimes in response to another pelvic pain condition, such as dysmenorrhea, bladder pain syndrome/interstitial cystitis, or vulvodynia.

Patients with myofascial pain often have tender, contracted bands or painful nodules, called trigger points, within a muscle. Trigger points don’t just act locally – many patients experience intense systemic symptoms when trigger points are activated, such as sweating or a racing heart beat. While we don’t understand exactly why myofascial pain or trigger points develop, we believe that the process involves abnormally active communication between a nerve and a muscle. A muscle that contains these trigger points can become shortened, weak, and constantly painful over time.

While it is possible to have myofascial pain in almost any muscle group, the muscles in the pelvic floor seem especially vulnerable to developing myofascial pain. Pelvic floor muscles have a number of critical functions, including urinary, bowel, and sexual function, and they are also interdependent upon or interconnected with many other muscle groups, such as those in the abdominal wall, back, and legs. If a muscle in one area starts to function incorrectly or develops these painful trigger points, this can place significant strain on neighboring muscle groups and increases the risk that trigger points can develop here as well. Thus, myofascial pain can seem to “spread” over time.

We frequently see pelvic myofascial pain in patients with another medical condition, such as endometriosis, vulvodynia, or painful bladder syndrome. While we consider these to be distinct conditions that warrant their own specific treatments, the fact that they seem to overlap or occur together in many patients is interesting. We suspect that having one of these pelvic pain conditions may predispose patients to developing another “overlapping” pelvic pain condition.

Regardless of why myofascial pain began, once is it present it is important to treat it. Once the muscles have gotten into an abnormal functional pattern, they are likely to continue this abnormal function even if a contributing pain condition, such as endometriosis or irritable bowel syndrome, improves.

Diagnosis of myofascial pain is based on symptoms and a detailed physical exam. Your health care provider will likely ask many questions about location and pattern of pain symptoms, what makes pain worse or better, and about sensitive topics such as urination, bowel movements, and intercourse.

The physical exam to evaluate for myofascial pelvic pain is fairly involved, and typically includes, looking at your posture, how you walk, bend, move, palpation of muscles in your back, abdominal wall, and pelvis, checking alignment of your spine/pelvis, hip and leg flexibility. A pelvic floor examination is helpful to see if you have muscle spasm and trigger points and how well you can contract and more importantly relax your pelvic floor muscles. Not everyone can tolerate a pelvic floor examination due to pain severity but don’t worry there are other ways we can examine your muscles through just observing whether you can contract and relax them. We can also palpate your pelvic floor externally from the outside when an internal examination is not preferred to assess for muscle spasm and tenderness.

There are no blood tests that help to make this diagnosis. Imaging studies are not typically used either, except to rule out other conditions with similar symptoms.

After taking a detailed report from the patient about her pelvic pain, a physician will conduct a series of clinical and laboratory tests and measures to determine what may be causing the patient’s pain. The results of those tests and measures, along with the patient’s history, will enable the physician to develop a medical diagnosis related to the pelvic pain and help identify the other providers that need to be involved with the patient’s care.

The other members of the patient’s healthcare team may include but is not limited to a pelvic health physical therapist, clinical psychologist, sexual therapist, and registered dietician.

Each of these healthcare providers have specific expertise and will conduct additional testing to determine how they can best help the patient. For example, a pelvic health physical therapist will conduct a thorough physical examination to see how a patient moves, how well the pelvic area muscles are working (eg. can the patient contract and relax their pelvic floor muscles?), and develop an individualized plan that incorporates the findings from the clinical examination and the patient’s goals.

The good news is that we have effective treatments for myofascial pain. The most effective and conservative strategy is physical therapy (PT) with a specialty trained physical therapist.

Self-Care

While PT is the most effective option to treat pelvic myofascial pain, there are self-care strategies and behavioral changes that can improve symptoms. These aren’t necessarily a replacement for PT, but can help manage symptoms during pain flares and even decrease the frequency or intensity of pain exacerbations.

The links below provide more information on strategies that tend to be very helpful for many people with pelvic myofascial pain. You may want to talk with your health care provider to identify the self-care approaches that would be best for you.

• Relaxation and Mindfulness
• Physical activity and exercise
• Sleep
• Cognitive and behavioral strategies
• Acupressure

Professional Care

PT with a specialty trained pelvic physical therapist is extremely helpful for many patients with pelvic myofascial pain. Physical therapy sessions should occur in a comfortable, private location. PT often involves:

• Addressing orthopedic issues

  • Posture
  • Correcting your spine and/or pelvic alignment
  • Improve spine/hip mobility and flexibility

• Gentle manual releases to improve mobility of fascia and organs where you are restricted and normalize pelvic floor muscle tone

• Modalities such as ultrasound, cupping, low level laser therapy may be used to break up adhesions, provide myofascial traction/stretch and reduce pain, inflammation

• Your PT will provide an individualized home program based on their examination findings. It is so important to play an active role in your PT by performing your home program and provide feedback to your PT on how it is or is not working so it can be adjusted.

• We are in this together to help you figure out your pain puzzle, but realize what you do at home has the greatest impact. Your home program is key to your success!

Physical therapy takes time (usually 8-12 weeks). You might feel general muscle soreness like you started a new exercise class initially but symptoms should not be more than mild if more you should talk to your PT so they can adjust your treatment

Some patients benefit from use of medications such as muscle relaxants in addition to physical therapy. You should talk to your health care provider to discuss whether these may a good option for you. See Muscle Relaxants for more.

If you do not have an adequate improvement with a course of physical therapy, you may want to discuss whether additional treatments, such as trigger point injections or botox injections into the muscles, may help you make more progress with physical therapy. See Trigger Point Injections for more.

Pelvic myofascial pain should be treated by a physical therapist who has additional specialty training in pelvic floor conditions.

The following national websites can be used to locate a pelvic floor PT near you.

www.aptapelvichealth.org

www.hermanwallace.com

www.pelvicguru.com