3/19/2014 Objectives Pelvic Dysfunction Throughout the Life Span  Pelvic anatomy review and how it pertains to pelvic symptoms appropriate for physical therapy referral  Physical therapy approaches to treat pelvic dysfunction for: pediatric patient, teenage patient, adult female  Discussion of prolapse and physical therapy Susan Dunn, P.T.  Discussion of pudendal neuralgia and physical therapy approach Dunn Physical Therapy, PLLC  Dyspareunia, Vulvodynia, vaginismus, anismus approach for physical therapy KCNPNM 2014  Lab to demonstrate and practice techniques to evaluate patients appropriate for physical therapy referral. Differential diagnosis techniques P l i Diagnoses Pelvic Di Child (age 5-puberty) • • • • • • • • • Dyspareunia Muscle Atrophy Interstitial Cystitis Constipation Abdominal pain Vaginal Stenosis Incontinence Pubic Symphysis Pain Pelvic Organ Prolapse • Piriformis Syndrome • Diastasis Recti • • • • • • • • • • • Vestibulodynia Vulvar Vestibulitis Vaginismus/anismus Levator ani syndrome Pudendal Neuralgia Iliopsoas Syndrome Episiotomy pain Coccydynia Obturator Internus Syndrome Post Operative pain Sciatica Teenage patient  Enuresis  Dysparuenia  Encopresis  Endometriosis pain  Dysmenorrhea  Sports/Activity related pelvic pain (developmental/overuse/misuse)  OAB  Pelvic pain  Urinary incontinence (stress/urge/mixed)  Constipation  Giggle incontinence  Bowel/Bladder Retention  Constipation Giggle Incontinence  Pelvic pain as a result of scoliosis  OAB  Lower abdominal pain due to musculoskeletal causes  Vulvodynia (BCP, sports, smoking, stress, etc)  1 3/19/2014 20-40 year old patients 40+ female patient  All of the above and…….  All of the above and……  Post partum pelvic pain  Menopausal pelvic pain  Oncology related pain  Pelvic Organ Prolapse  Dyspareunia  Post-operative POP surgeries  UI/FI/constipation/OAB/Retention  Joint replacement and post-op pelvic symptoms  Pudendal nerve diagnoses  Diastasis recti  Post operative pelvic pain  Sports/Activity related pelvic pain (overuse/misuse) ANATOMY OF THE PELVIC FLOOR The Bony Pelvis  False Pelvis  True Pelvis  Pubis  Il Ileum  Ischium  Sacrum  Coccyx Viscera and the endopelvic fascia  Viscera are often thought of as being supported by the pelvic floor, but are actually a part of it. Through connections to the pelvis by such structures as the cardinal and uterosacral ligaments and the pubocervical fascia the viscera play an important role in forming the pelvic floor. (DeLancey)  Anterior compartment is divided by the genital tract at the point where it passes through the urogenital hiatus where the organs pass thru the pelvic floor. 2 3/19/2014 Endopelvic fascia Superficial Pelvic Floor Muscles Forms a continuous sheet-like mesentery extending from the uterine artery at the cephalic point to where the vagina fuses with the levator ani muscles below below.  Parametrium = uterine attachments  Paracolpium = vaginal attachments  Urogenital Triangle Superficial Layer Muscle Origin  Superficial Transverse Perineal  Bulbocavernosis ( (Bulbospongiosis) p g )  Ischiocavernosis Levator Ani Muscles Insertion Action  Levator ani + superior fascia and inferior fascia Ischiocavernosis Ischial Tuberosity Aponeurosis of crus clitoris Erection of clitoris Bulbocavernosis Perineal body Fascia of corpus cavernosum Vaginal sphincter & clitoral erection Superficial Transverse perineal Ischial tuberosity and ramus Perineal body Fixes the perineal body Pelvic Diaphragm = Levator ani cont. Levator ani cont. The levator ani has constant activity similar to postural muscles. This constant action eliminates any opening within the pelvic floor through which prolapse can occur and forms a relatively horizontal shelf on which the pelvic organs are supported.  Interaction between the PF ms and supportive ligaments is critical to pelvic organ support. As long as the l.a. ms functions properly the pelvic floor is closed and the ligaments and fascia are under no tension. The fascia simply act to stabilize the organs in their position above the l.a. ms.  When   Levator ani divided into:  Pubovisceral muscles: pubococcygeus and puborectalis  Iliococcygeus muscle: arises from arcus tendineus levator ani and forms a horizontal shelf that organs rest on. the pelvic floor muscle relaxes or is damaged the pelvic floor opens and the vagina lies between the high abdominal pressure and low atmospheric h i pressure. Th The li ligaments are stressed d and will eventually fail. 3 3/19/2014 Pelvic Diaphragm MUSCLE ORIGIN INSERTION ACTION Pubococcygeus Dorsal surface of pubic bone & fascia of Obturator Anococcygeal & perineal body Supports pelvic viscera Pubovaginalis Medial & anterior Perineal body pubic arcuate ligament Puborectalis Posterior pubic arcuate ligament Anococcygeal Elevates and constricts the anal body,lateral walls canal of rectum and anus Iliococcygeus Dorsal surface of pubic bone Anococcygeal body and coccyx Supports pelvic viscera Coccygeus (Ischiococcygeus ) Ischial spine, sacrospinous ligament Caudal part of sacrum and coccyx Flexes coccyx, stabilizes sacroiliac joint, supports pelvic viscera Muscles of the Pelvic Floor Pelvic Diaphragm – -Levator ani complex: Puborectalis Pubovaginalis Iliococcygeus - Coccygeus  Obturator Internus  Piriformis  Sphincter of vagina and urethra Coccygeus  Borders the pelvic diaphragm posteriorly  Sometimes called ischiococcygeus given its attachments.  Arises from the ischial spine and expands to insert on the lateral borders of the lower two sacral and upper two coccygeal segments.  Externally it blends with the sacrospinous ligament which forms the inferior limit of the greater sciatic foramen.  Can form a continuous plane with the iliococcygeus.  Innervation – 4th and 5th sacral ventral rami Nerve Supply to Genitalia Ilioinguinal nerve L1 mons pubis and labia majora  Genital branch of the g genitofemoral nerve ((L1-2))  Perineal branch of the femoral cutaneous nerve (L2-3)  Perineal nerve (termination of the pudendal nerve) S2-3-4   Affects both men and women of the population  single most common indication for referral to women's health services, accounting for 20% of all outpatient appointments  $881.5 million spent per year on outpatient management in the USA alone  7-24% 4 3/19/2014  Objective:  Medical History:        Pain location and description  Changes in bowel and/or bladder function  Pain with voiding or BM  Sexual Dysfunction  Influence of the menstrual cycle  Clothing irritation  Current Exercise Routine  Myofascial y Trigger gg Points   Mobilize/Stabilize Thoracic spine, Lumbar spine and SI Joints LLD, Postural abnormalities Muscle imbalance Connective Tissue Mobilization, Dry Needling  Surrounding the bony pelvis  Anterior, medial, lateral and posterior thighs  Abdomen, low back, buttocks  Nerve Mobilization  Seating Adaptations/Work Modifications Spine, pelvis, hips  Address Connective Tissue Restrictions and MTrPs  Strength, alignment, mobility  Connective Tissue Pain increases/decreases with…. Address Structure and Biomechanics    Subjective:   thought to be related and unrelated Structure and Biomechanics Etiology •Infection/inflammation •Psychosomatic – h/o sexual trauma; background of religious orthodoxy •Post-op P t complication li ti •Neural alterations/neural tension •Musculoskeletal causes •Cross communication between somatic and visceral structures • • • • • • • • • Subcutaneous Panninculosis in circumferential thigh, abdomen, groin, gluteal folds  Seen in over 90% of patients with urogenital pelvic pain  Common: Piriformis, Gluteus med/max, HS Adverse Neural Tension  The nervous system is a continuous elastic structure that moves and is vulnerable to unwanted fixation. Changes in one area have repercussions in another.  Pudendal, Sciatic Pelvic Floor Dysfunction Dyspareunia Muscle Atrophy Interstitial Cystitis Constipation Abdominal pain Vaginal Stenosis Incontinence Pubic Symphysis Pain Pelvic Organ Prolapse • Piriformis Syndrome • Diastasis Recti • • • • • • • • • • • Vestibulodynia Vulvar Vestibulitis Vaginismus/anismus Levator ani syndrome g Pudendal Neuralgia Iliopsoas Syndrome Episiotomy pain Coccydynia Obturator Internus Syndrome Post Operative pain Sciatica Etiology • Trigger (possibly infection/inflammation) – breakdown in CT – proliferating nerve fibers penetrate the basal membrane & reach the surface epithelium – reduced sensory pain threshold = allodynia • Allodynia triggers a change in sensory transmission of pain – CNS changes with decreased pain threshold in trunk/upper extremity • Frequently coexisting hypertonicity or spasms in pelvic floor vaginismus 5 3/19/2014 Anismus Vaginismus •Common female psychosexual dysfunction •Involves involuntary contraction of vaginal musculature making gp penetration difficult or impossible p •Classified as primary or secondary • Dyssynergic defecation • Failure of normal relaxation of pelvic floor during attempted defecation • Can C occur iin b both th children hild and d adults d lt b butt iis more common in women • Can have psychogenic or mechanical causes • Often a history of constipation and/or incontinence Dyspareunia Vulvodynia • Painful sexual intercourse due to medical or psychological causes. These symptoms are significantly more common on women than men affecting up to 20% of all women at some point in their life life. • Defined by the international Society for the Study of Vulvovaginal Diseases (ISSVD): Vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. • Patients can be further classified by the anatomical site of pain ie hemivulvodynia, clitorodynia, Vestibulodynia (previously know as vulval Vestibulitis) • Symptoms are also classified as provoked or unprovoked • (British Joural of Dermatology, “Guidelines for the management of vulvodynia, Mandal et al, 16, 2010) Vulval pain related to specific disorder (ISSVD) Atrophic Vaginitis  Infectious  Shrinkage in length and diameter of vagina  Inflammatory (lichen planus/sclerosus, glandular, etc)  Loss of elasticity  Neoplastic  Epithelial thinning and subsequent loss of vaginal rugae  Neurological (pudendal neuralgia, spinal compression, etc)  Erythema  Petechial hemorrhages  Palor/Dryness/itching/irritation/burning  Vaginal blood flow reduced/decreased lubrication (Johnston et al, J Obstet Gynaecol Can 2004;26;503-15) 6 3/19/2014 Treatment Other Than Physical Therapy • • • • Sexual therapy – individual and couple Systematic desensitization – relaxation techniques Hypnotherapy Botox injections Physical Therapy Intervention • • • • • • • • Orthopedic evaluation Perineal ultrasound Vaginal dilators Electrical modalities Manual therapy Therapeutic exercise Dietary and behavioral modifications Self care/home management skills Electrical Stimulation Pudendal afferent to pudendal efferent (striated ms. contraction) t ti ) Pudendal afferent to hypogastric (inhibits bladder) Pudendal to pelvic n. reflex (inhibits bladder) 7 3/19/2014 Perineal Ultrasound Decrease soft tissue tension Increase blood flow Decrease hypertrophy/scar tissue Not appropriate for all patient types and contra-indicated for some diagnoses. Vaginal Dilators Protocol varies depending on diagnosis Common diagnoses that are appropriate for vaginal dilators: Dyspareunia, constipation, vaginal stenosis, muscle hypertonicity 10 minute break TYPES OF PROLAPSE PROLAPSE Can effect up to 50% of females over age 50 Cystocele Cystocele-- Bladder Urethrocele Urethrocele--urethra Rectocele Rectocele-- rectum prolapse prolapse--uterus Enterocele Enterocele-- small bowel Sigmoidocele Sigmoidocele--turning inside outward of the descending colon Uterine 8 3/19/2014 STAGES OF PROLAPSE URETHRAL/ BLADDER DESCENT SYMPTOMS OF PROLAPSE Low back pain pain-- caused by stretching of the uterosacral ligament Hip and lower abdomen pain, leg fatigue Feeling g of “falling g out” or heaviness Cystocele Cystocele-- UI, post void dribble Urethrocele Urethrocele-- unusual spray Recurrent bladder infections Penetration can be painful secondary to stresses on the US ligament THOSE AT RISK FOR PROLAPSE        Those who have had previous hysterectomyhysterectomy- increases risk of incontinence by 40% secondary to scarring urethra, loss of support of bladder, injury to plexus/nerves Menopause-- because estrogen helps to close everything off and fluff the Menopause tissues up. Obesity weight loss Obesity, Parity, increases with increase in number of vaginal deliveries History of strainingstraining- diarrhea/ constipation lifesytle issues Those with hypermobilityhypermobility- more correlation CT relaxation than strength of pelvic floor Scars affecting the abdominal wall CONSERVATIVE TREATMENT CONSERVATIVE TREATMENTS PFMT has been found to be effective in reversing pelvic organ prolapse by one stage. Studies by Bo in 2010 in the American Journal of obstetrics and Gynecology (n=55) 1X a week for 3 months, 2X a month for 3 months, lifestyle advice 6 months later: 74% reported p decreased symptoms, y p , 19% improved p byy one stage g Stupp et al in 2011 In the International Urogynocology Journal  (n=21) 7 appts over 14 weeks, 12 week HEP with phone calls every 2 weeks from PT, lifestyle advice 61% at least1 stage improvement, at baseline 81% felt a bulge, postpost-intervention only 9.5% Need for more research with uniform parameters 9 3/19/2014 CASE STUDY 58 year old female presenting to clinic following surgical procedure for prolapse repair. PMHX: delivered 2 large babies(8.5#) 33 and 36 years prior via CC-section. Pt. is morbidly obese, has lost greater than 10% BM X 2 each time with the symptoms of prolapse neccessitating surgery. C/o’s prolapse symptoms, UI with cough, urge incontinence, fear of weight loss and it’s effect on her pelvic floor Observation: large abdominal scar midline abdomen from midline umbillicus to mons pubis, pedulous abdomen with large crease Palpation: scar tissue restriction upward mobility, taut band at midline CASE STUDY CASE STUDY          Pt. was seen for 13 visits over 8 weeks. Treatment included soft tissue mobilization for scar mobility, lifestyle advice behavioral modification for urge incontinence, biofeedback training for PFMT and Pilates based exercises in clinic and home program. S Symptoms t att D/C D/C: Pt. has been able to lose weight, reports decreased fear of weight loss, reports no bulge in vagina, Is no longer wearing protection for UI No longer feels the taut band of scar tissue pulling downward. Improvement in both resting baseline (m. tone) and endurance on EMG Has returned to wellness program including cardiovascular and strength exercises OBESITY EFFECT ON PROLAPSE Kudish et al 2009 in Obsteteric Gynecology published a study about obesity and it’s effect on POP. 10% weight loss did not have a positive impact on POP. They did report an increase in urethrocele folllowing 10% weight loss.  Their conclusions: fat may play a role in pelvic organ support and the damage done by childbirth and obesity might take more time to regress following weight loss or is irreversible.   Clinical implications: avoid weight gain and prevent obesity CASE STUDY SOURCES Swift S E, Pound T, Dias J K 2001 CaseCase- Control study of etiologic factors in the development of severe pelvic organ prolapse. International Urogynecology Journal and Pelvic Floor Dysfunction 12(3):187--192 12(3):187 Kudish B I, Iglesia C B, Sokol R J, Cochrane B, Richter H E, Larson J Hendrix S L, Howard B V 2009 Effect of weight change on natural history of Pelvic Organ Prolapse. Obstetrical Gynecology 113(1): 8181-88 Stupp L, Paula A, Resende M, Oliveira E, Castro RA, Batista M J, Girao C, Sartori M G F 2011 Pelvic Floor muscle training for tretment of pelvic organ prolapse: an assessorassessor-blinded randomised controlled trial. International Urogynecology Journal and Pelvic Floor Dysfunction 22:1233--1239 22:1233 Braekken IH, Majida M, Engh ME, Bo K 2010 Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessorassessor-blinded,randomised, controlled trial.Am J Obstet Gynecol. 203(2):170.e1--7 203(2):170.e1 10 3/19/2014 SOURCES  Bo K, Berghmans B, Morkved S, Van Kampen M eds 2007 Evidenced--Based Physical Therapy for the Pelvic floor Evidenced Bridging Science and Clinical Practice. Butterworth Heinmann Elsevier Pub. Benson T J, ed 2000 Urogynecology and Reconstructive Pelvic Surgery Vol V of Atlas of Clinical Gynecology. McGraw Hill  Smith R, etal.2006 Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy 52: 11 11--16.   Nerve Roots: S2, S3, S4  50% sensory, 20% motor and 30% autonomic 11 3/19/2014  Pain in the perineal region due to insult of the pudendal nerve  4% of pelvic pain patients; 1% of the general population  7 women for every 3 men  MOI: Traction, Compression, Surgical Insult, Visceral-somatic interaction Difficulty voiding/ Having a bowel movement Erectile dysfunction Inability to orgasm/pain with orgasm  Location: Perineum, proximal thigh, buttocks, scrotum, testes, penis, vagina, clitoris, vulva  Unilateral or bilateral (depending on type and location of insult)) Usuallyy unilateral  Superficial pain, burning, numbness  Worse with sitting  Progressive throughout the day  Will not wake at night  Decreased when sitting on toilet seat  Traction  Compression  Surgical  Constipation,  Cycl Cycling, g, Childbirth, strenuous squatting Horseback o sebac riding, d g, p prolonged olo ged ssitting tt g  Hysterectomies,  Common  corrective sx for prolapse etiology for nerve entrapment Visceral-Somatic Interaction  Chronic bladder infections, yeast infections, bacterial prostatitis 12 3/19/2014  Childbirth, Constipation, Strenuous Squatting  “Cyclist’s Syndrome”  Hysterectomy, Correction of prolapse, Orthopedic  Chronic bladder infections, yeast infections, bacterial prostatitis 13 3/19/2014  Primarily clinical   “Diagnosis of Exclusion” – lack of evidence of organic disease with diagnostic testing; Other possibilities have been ruled out  Nantes Criteria - 2008  Benson J, Griffis K: Pudendal Neuralgia, a severe pain syndrome. Am J Obstet Gynecol 2005;192:1663-8.  Tu F, Hellman K,Backonja M: Gynecological Management of Neuropathic Pain. Am J Obstet Gynecol 2011;205(5):435-443.  Chiarioni G, Asteria C, Whitehead W: Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options. World J Gastroenterol 2011 October 28;17(40)4447-4455.  Hibner M, Desai N, Robertson LJ, Nour M: Pudendal Neuralgia. J Min Inv Gynecol. 2010; 17(2):148-153.  Stav K, Dwyer P, Roberts L: Pudendal Neuralgia Fact or Fiction? Obstet Gynecol Surv 2009; 64(3):190-199.  M h kk Mahakkanukrauh k h P, Surin S i P, Vaidhayakarn V idh k P. Anatomical A i l study d off the h Pudendal P d d l Nerve N adjacent dj to the h sacrospinous i li ligament. Clinical Cli i l Anatomy 2005;18:200-205.  Robert R, Prat-Pradal D, Labat JJ, Bensignor M, Raoul S, Rebai R, Leborgne J. Anatomic basis for chronic perineal pain: the role of the pudendal nerve. Surg Radiol Anat 1998;20:93-98.  Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health. 2006 Jul 6;6:177.  Wise, D, Anderson R. A Headache in the Pelvis. Occidental, CA: National Center for Pelvic Pain Research, 6th edition. 2011  Rummer E, Prendergast S. De-Mystifying Pudendal Neuralgia as a Source of Pelvic Pain: A Physical Therapist’s Approach.  Inclusion Criteria:  Pain in the area innervated by the Pudendal Nerve  Pain more severe with sitting  Pain does not awaken patients from sleep  Pain with no objective sensory impairment  Pain relieved by diagnostic pudendal block Complementary Criteria:  Pain characteristics of burning, shooting, stabbing  Sensation of a foreign body in the rectum or vagina – “sitting on a golf ball”  Triggered by BM  Primarily unilateral  Tenderness on or around the ischial spine LAB Helping the clinician assess for musculoskeletal referral Differential Diagnosis – Visceral vs. Musculoskeletal Visceral Pain Referral and Special Tests 14 3/19/2014 Gastrointestinal Pain Patterns • Referred pain may be the only type of pain that is felt when the visceral organs are involved • Visceral pain is usually referred to a cutaneous surface Stopka, Christine, Zambito, Kimberly. The Prof Journal for Athletic Trainers and Therapists. Jan 1999. Stomach Pain •Pain in the midline upper abdomen and inferior to the xiphoid process •Referred pain to the back (T6-10), right shoulder/upper trapezius and lateral border of the right scapula Small Intestine •Pain in the middle abdomen around the umbilicus •Pain may refer to the back around the L3/4 disc space Large Intestine and Colon Pancreas a in the e middle dd e lower o e abdo e that a iss poo oca ed •Pain abdomen poorlyy localized •Pain can be referred to the sacrum •Epigastric Epigastric and Left upper Quadrant pain that radiates into the left upper lumbar region/thoracic spine and sometimes into the Left shoulder •Acute Pancreatitis: Increased pain with walking and lying supine, Decreased with sitting and leaning forward •Bluish discoloration in the periumbilical area •Pain relief after defecation or passing gas 15 3/19/2014 Spleen • Kehr’s Sign: Left shoulder pain related to serious abdominal injury. i j Appendix – Pain in the shoulder may be increased when patient is supine and legs raised • R LQ pain, well localized but can refer to periumbilical region, right hip hi and/or d/ right i ht testicle t ti l • McBurney’s Point: patient fully supine. Palpate for tenderness halfway between the ASIS and umbilicus • Rebound Tenderness or Blumberg’s Sign: palpate an area away from the area of suspected inflammation. Palpate deeply and slowly, then quickly remove hand. + test= pain or increased pain on the side of the inflammation when the pressure of palpation is released. Hepatic and Biliary Pain Patterns Liver • Splenic rupture • Can also be seen with Ectopic pregnancy • Pain in the Right upper quadrant • Referred pain in the Right upper quadrant, especially after exercise, Right shoulder and Thoracic spine (T7-T10) • Clinically, look for bilateral CTS Urogenital Pain Patterns Bladder/Urethra • Pain suprapubically or lower abdomen • Pain is referred into the general low back 16 3/19/2014 Ureter Kidney • Pain along the costovertebral angle • Pain radiates to the lower abdomen, upper thigh, ipsilateral testis or labium • Unilateral costovertebral tenderness, flank pain, ipsilateral LQ (T11-12)pain, groin pain and shoulder pain, hyperesthesia of T9-10 dermatomes, testicular pain. • Spasm of abdominal musculature • Pain does not decrease with change in position Lower Quadrant Pain Groin Pain Gallbladder • Psoas or obturator abscess, Appendicitis, Peritonitis • Clinical Screening to assess systemic origin • Pain in Right upper quadrant and midepigastrium • Radiating pain into the right shoulder, between scapulae and under the right scapula • Pain increases with inspiration and movement • Pain decreases with trunk flexion • “Hot Rib”: tenderness on the tip of the 10th rib, (right anterior). May also be positive at 11th and 12th ribs. • Murphy’s Sign: patient is asked to inhale while the examiner's fingers are hooked under the right anterior rib cage. The inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed.  Testing for pudendal nerve neural tension at areas of common restriction  Positive Test: reproduces patient’s symptoms, differences from R vs L, test can be altered by movement of distal body part • Heel Tap: passively raise leg on involved side and tap the heel. Pain response= + test • Hop Test: hop on one leg. Pain response= response + test • Iliopsoas Muscle Test: Pt sidelying on uninvolved side, passively extend/hyperextend the involved leg to stretch the psoas • Iliopsoas palpation: patient supine, with hips and knees flexed and supported in a 90 degree position. Palpate 1/3 of the distance between ASIS and umbilicus • Obturator muscle test: patient supine, perform active assisted hip and knee flexion to 90 degrees. Hold at the ankle with support at the knee and move the hip into internal and external rotation. Pain = + test • McBurney’s Point • Rebound Tenderness/Blumberg’s sign Deep Squat  Deep squat position to lengthening the nerve around the ischial spine; Assess for symptoms, and then have the patient extend his/her neck to determine if neural tension needs to be assessed higher up. up 17 3/19/2014 General  The patient is supine and a modified SLR is performed with the examiner at the patient’s opposite flank. Passive femoral internal rotation and adduction are performed in addition to ankle dorsiflexion. The patient is then directed to eccentrically contract the pelvic floor, or “bear down” Pelvic Floor Muscle Palpation At Alcock’s Canal  The patient lies prone with his/her ipsilateral knee flexed to 90 degrees. The examiner will palpate and apply force/traction to the Obturator Internus while passively IR the LE. Mapping of the Hip External Rotators Assessing for Hip Flexor Pathology  Palpation techniques for hip flexors  Pectineus  Iliopsoas  Adductor longus 18 3/19/2014 Q ti Questions……….. How to find and utilize a pelvic pain Physical Therapist      State organizations (KPTA) National Organizations (APTA) National Pelvic Pain Organizations Talk to local P.T.’s and they can normally refer you to the appropriate office. Insurance – these diagnoses are usually covered. Thank You  Dunn Physical Therapy, PLLC  502 502--899 899--9363 19