Pelvic Floor MSK

A Musculoskeletal Overview

Authors

Affiliations

Nate Yomogida, PT, DPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, PT, DPT

Doctor of Physical Therapy

B.A. in Neuroscience

Reading list

• To read
  • Evidence-based physical therapy for the pelvic floor: bridging science and clinical practice¹
  • Pelvic pain and dysfunction: a differential diagnosis manual²
  • Pelvic Pain Explained: What You Need to Know³
  • A headache in the pelvis: a new understanding and treatment for chronic pelvic pain syndromes⁴
• In progress
  • Fitness for the Pelvic Floor⁵

Function

There are 4 essential functions of the pelvic floor:

1. Supporting organs within the pelvis
2. Bladder & Bowel Control
3. Static and Dynamic stabilization of the pelvic girdle, lumbar spine, and torso
4. Sexual function

Supporting Organs

The pelvic floor must be able to contract strongly and relax in order to have proper bowel and bladder continence and elimination⁵.

The body expells uring or feces in a process known as elimination⁵. To perform elimination, the pelvic floor must be able to relax⁵.

Bladder & Bowel control

Pelvic girdle stabilization

If the pelvic floor is dysfunctional, it will not effectively perform its function to stabilize the pelvic girdle⁵. Over time, this functional pelvic girdle instability can result in issues in the SIJ, lumbar spine, and hips⁵.

The pelvic floor muscles work in conjunction with the pulmonary diaphragm to regulate pressure between the thorax and abdomen⁵.

Sexual Function

The pelvic floor is important for sexual function, during these activities the pelvic floor muscles contract voluntarily or involuntarily⁵.

The pelvic floor is important in sexual function, but oppositely, sexual abuse can damage and cause it to be dysfunctional⁵.

Muscle Function

Although the pelvic floor can be a mystifying and intimidating region, the muscles are no different than the rest of the body. The muscles must:

• Contract⁵
• Relax⁵
• Stretch/Elongate⁵
• Give feedback⁵

Contraction

Inability to properly contract the muscles results in inadequate support for the organs, pelvic girlde, urethra, and/or sphincter⁵.

During lifting, the pelvic floor must be able to contract strongly to provide continence⁵. Without this, the patient may experience incontinence during heavy lifting or sleeping⁵. During coughing, sneezing, running, and jumping thelvic floor must make many quick reactions with each impact to prevent urinary incontinence⁵.

Relaxation

An inability for the pelvic floor muscles to relax can result in low back pain, pain during intercourse, inability to completely empty the bladder, and painful trigger points within the pelvic floor musculature⁵.

Pelvic floor relaxation is important during elimination of stool and urine as well as giving birth⁵.

Stretch

If the pelvic floor musculature is unable to stretch the patient may experience constipation and digestive issues

Bladder Physiology

• 1.1 Basic Bladder neurophysiology⁵.

Layers of the Pelvic Floor

The pelvic floor can be divided into 3 layers of muscles that contract in the sagittal, frontal, and tranverse planes⁵.

1. Parietalis Fascia⁵
3. 1. Sometimes the 3rd layer is divided into 2 sublayers, since the deep transverse perineal muscle lies so deep⁵.

1 Parietalis Fascia

The first layer of the pelvic floor is known as the parietalis fascia (or formally endopelvic fascia)⁵. This layer acts as a “suspensory apparatus” for the organs in the pelvis⁵. This layer is a complex of smooth muscle fibers, ligaments, nerves, blood vessels, and connective tissue which collectively form a “lining”⁵. This lining supports and coveres the bladder, intestine, rectum, uterus^♀, and prostate^♂5. The parietalis fascia connects the interior pelvis to the lower extremity⁵.

Table 1: Periestalis Fascia Muscles

Muscle	Origin	Insertion	Innervation	Action

2 Pelvic diaphragm

3 Urogenital Diaphragm

Etiology

Sexual abuse

Clients who have experienced sexual abuse often have increased tone in their pelvic floor musculature⁵. Increased tone can result in an overflow bladder where urine is constantly dripping⁵.

These clients often present with breathing dysfunction⁵.

Example

Carriere noted that a client who had experienced sexual abuse developed a breathing pattern where should would push her pelvic floor inferiorly during exhalation (instead of superiorly) as a defense mechanism⁵. Over time this resulted in colon problems⁵.

It is essential to listen carefully to these patients and that no treatment, specifically internal treatments, will occur until the therapist and the client agree that is is necessary⁵.

Note

Do not sit higher and look down at the client⁵.

Evaluation of Breathing

Being able to evaluate and restore abdominal breathing is the key to restoring coordination of the abdominal compartment for clients with PFMD⁵.

Normal breathing

During inhalation:

• Pulmonary diaphragm moves inferiorly⁵
• Abdomen widens⁵
• Pelvic floor relaxes and moves slightly downward⁵

Exhalation

• Abdomen flattens⁵.
• Diaphragm moves superiorly with minimal superior movement of the chest⁵.
• The clavicles should be positioned in an oblique direction from the sternum (superoposterior) which is required for normal breathing⁶.

Assessment

• Place 1 hand on the chest to monitor chest movement
• 1 hand just below the ribcage to feel rib flare during inhalation and flaring in during exhalation⁵.

Faulty Breathing

There are a few key markers to observe to assess breathing:

• Neck muscles
• Loss of Clavicle obliquity
• Epigastric angle
• Upper abdomen crease

Faulty breathing can be observed in standing, sitting, or supine⁵.

Dysfunctional breathing can result in a tight neck muscles which are not relaxed at rest⁵.

For patients who primarily breathe with the accessory muscles in the upper torso will have horizontally oriented clavicles in the frontal plane⁵. As the accessory muscles of inspiration pull the chest upward, this is creating a depressive torque on the SCJ resulting in the clavicle depressing into the horizontal plane⁵.

A very wide epigastric angle >90°⁵.

A deep abdominal crease is also a sign of faulty breathing⁵. This is an evident sign that can be viewed over clothing⁶. The deep crease is observed just superior to the navel⁶. When the patient is in supine, the crease could be up to 3-4 fingers deep⁶.

Usually caused by TrA and internal and external oblique weakness⁵. Tight upper neck muscles and weak trunk muscles are expected⁵.

Note

Clients with these dysfunctions typically have poor posture which should be addressed⁵.

Reversed breathing

Reversed Panting

Dysfunction

Pelvic floor muscular dysfunction (PFMD) is a general term that refers to disorders impacting one or a combination of the 4 functions (supporting organs, B&B, pelvic stabilization, and sexual function)⁵.

This can be caused when:

• Pelvic floor muscles are weak, tight, or torn⁵.
• Ligaments or fascia are stretched or damage⁵.

The result is system that cannot effectively transmit loads through the pelvis⁵. In addition, organ support is impaired, resulting in dysfunction in the lower intestines, bowel, bladder, uterus, vagina, and rectum⁵.

Direct causes

The direct causes of PFMD are unknown, but here are events that can contribute to this problem:

• Traumatic injuries⁵
• Sexual abuse⁵
• Strenuous exercise with improper breathing mechanics⁵
• Childbirth complications⁵

Treatment of Breathing Dysfunction

Traditional Exercises

Kegel Exercises

Kegel exercises were invented by Dr. Kegel when he discovered the pelvic floor’s ability to contract⁵. Originally, kegel exercises were dosed 300x/day during initial treatments and regressed to 80x/day for maintenance⁵.

These exercises, although activating the pelvic floor, were difficult to adhere to for perpetuity and lacked a functional component⁵. In addition, most clients who were treated with Kegel exercises had limited success⁵.

Functional Exercises

When attempting to create “functional” exercises for our clients, we must consider what makes the pelvic floor functional. The pelvic floor functions in synergies with the muscles of the lower extremities, trunk, and movements of the viscera⁵.

Next we must make decisions based on the patient’s goals.

For a client who must lift heavy objects, one should focus on slow-fiber activation over fast-fiber activation⁵.

For a client who struggles with coughing or sneezing, then the fast-fibers should be prioritized⁵.

Clients who have difficulty initiating urination, then breathwork and relaxation would be most beneficial⁵.

Rehab Objectives

1. To achieve sensory awareness of the PFMs⁵
2. Restore coordination of the PFMs with the pulmonary diaphragm⁵
3. Improve coordination of the pelvic floor with surrounding musculature
4. Promote muscle function in different planes of movement⁵
5. Strengthen fast and slow muscle fibers of the pelvic floor⁵
6. Integrate into functional activities⁵

References

1.

Berghmans B, Kampen MV, B^{2} K, Morkved S, eds. Evidence-Based Physical Therapy for the Pelvic Floor: Bridging Science and Clinical Practice. Second edition. Churchill Livingstone; 2015.

2.

Philip PA. Pelvic Pain and Dysfunction: A Differential Diagnosis Manual. Thieme; 2016.

3.

Prendergast SA. Pelvic Pain Explained: What You Need to Know. Rowman & Littlefield Publishers; 2016.

4.

Wise DT, Anderson RU. A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes. New revised, expanded and updated 6. ed. National Center for Pelvic Pain Research; 2012.

5.

Carrière B, Ickes DM. Fitness for the Pelvic Floor. 2nd ed. Thieme; 2024.

6.

Carrière B. Fitness for the Pelvic Floor. Thieme; 2002.