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Athletic Related Pelvic Pain

Nolana Newton PT, DPT, OCS

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Athletic Related Pelvic Pain

Objectives:

Identify common causes of pelvic pain in athletes

Identify contributing factors that lead to pelvic pain in athletes

Recognize common patterns to correct to decrease pelvic pain

in athletes

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What do we know…

• Athletic groin pain – incidence rate of 3-23% in the physically active

population

• Groin injuries can represent up to 5% of all soccer injuries (Kerbal et al.)

• In runners – hip, pelvis and groin injury rate: 3.3% to 11.5%

• Incidence of upper leg injury in runners: 3.4% -38%

• Prevalence of urinary incontinence in female collegiate athletes 28%

(Nygaard et al.)

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What do we know…

Groin injuries are reported in men > women

Pelvic floor dysfunction is reported in women > men

Definitions vary and pelvic pain is much less reported in literature

Symptoms can be diffuse and insidious

When it is diagnosed it is commonly present with more than one condition

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Types of Pelvic Pain

Osteitis Pubis

Athletic Pubalgia / Sports Hernia

Core Muscle Injury

Vaginal or Rectal Pain

Groin, hip, or Pelvic Girdle Pain

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Osteitis Pubis

Characterized by pain / tenderness of pubic symphysis

Overuse syndrome

Found in athletes who do a lot of kicking, turning, twisting,

cutting, pivoting, sprinting

Soccer, distance running, rugby, and hockey

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Athletic Pubalgia vs Sports Hernia vs Core Muscle Injury

• Athletic Pubalgia/ Sports hernia: strain or tear of any soft tissue in the lower

abdomen or groin

• Core Muscle Injury : Usually refer specifically to tears in the abdominal

muscles at the attachment to the pelvis. Men > women and 94% of unknown

cause, 6% trauma

Structures Involved:

• Abdominal wall

• Adductors

• Hip flexors

• Pubic bone

• Pelvic floor musculature

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Who is the driver?

• Podschun et al. described high hamstring pain with a non-relaxing

pelvic floor

• Coady et al. reports on the link between pelvic floor and intra-articular

hip disorders. Vulvar pain may be linked to effect of FAI on pelvic

muscles and nerves

• Referred pain from lumbopelvic, sciatic n, glut max or piriformis can

mimic hamstring pain

• Interdependence of lumbopelvic and lower extremity kinematics

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Why is this important?

Pelvic Floor pain often goes unreported

When it is reported there is often a significant lag between onset

of symptoms and diagnoses.

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Screening questions

• Urinary symptoms

• Anorectal symptoms

• Neuromuscular symptoms

• Other areas of pain: low back, hip, thoracic spine, LE

• Childbirth, pregnancy, changes in training or activity

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Physical Therapy Assessment

Standing:

Posture assessment

Palpation of landmarks

Active lumbar ROM

Pelvic girdle tests

Standing functional tests

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Physical Therapy Assessment

Sitting:

Seated thoracic rotation

LE MMT

LE neuro screen

Hip ROM

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Physical Therapy Assessment

Supine

Breathing coordination

Coordination of PFM/TA

ASLR and PSLR

Abdominal integrity

LE MMT

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Physical Therapy Assessment

Sidelying

Specific PFM Assessment

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Planes of Movement

www.nasm.org

Functional Tests:

First level:

Forward bending, backward bending and standing rotation DL

Standing march

SL stance – ability to stand on one leg but transitioning from one leg to the other

DL squat

2nd level:

Side step to SLB

SL squat

Squat to jump

ASLR

Glut bridge – SL bridge out

Treatment focus:

1. What reproduces symptoms

2. What movements reproduce symptoms

3. What planes of movement are they having difficulty controlling

4. What planes of movement are primarily affected

Physical Therapy Pelvic Health Treatment:

• Address local impairments then move out

• Address PF tissue density first

• Address understanding of the contract vs relax cycle (motor control of PF)

• Within motor control address ability to breath correctly and coordinate with PF

• Also coordination of PF with abdominals – specifically TA

• Now we can progress strengthening and functional stability!

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Anatomical Slings

Posterior oblique sling: Latissimus dorsi, glut max,

thoracolumbar fascia

Anterior oblique sling: Ext oblique, ant abdominal fascia,

contralateral adductors

Longitudinal sling: peronei, biceps femoris, scarotuberous

ligament, thoracolumbar fascia, erector spinae

Lateral sling: glut med/min, TFL, lateral stabilizers of

thoracopelvic region

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zPosterior

Oblique and Anterior

Oblique Sling

Once we are comfortable with pelvic floor ability then we are looking to coordinate

pelvic floor with outer unit muscle patterns

1. Force closure slings: longitudinal sling, posterior sling, ant oblique sling

2. Hip control – glut max, glut med, and hip IR/ER strength

3. Understanding neutral posture – stacking rib cage over pelvis

4. Movement through single plane control (dynamic) – frontal plane, sagittal plane,

transverse plane

5. Multiple plane control

6. Specific sport movement break down in planes

7. Dynamic movement

8. Return to sport progression

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Exercise examples:

Sagittal plane focus:

Easy: abdominal march, bridge

Moderate: bridge march, mini-squat, bird dog

Advanced: SL squat, Forward T

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Frontal plane exercises:

Easy: standing hip abduction

Moderate: sidelying hip abduction at wall; side plank from knee

Advanced: side plank with top leg lifted; side step with band,

lateral T

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Transverse plane exercises:

Easy: hooklying BKFO, sidelying rotation (thoracolumbar)

Moderate: Standing theraband rotation; sunrise/sunset

Advanced: rotational T

z Thank you….

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References

Angoules A. Osteitis pubis in elite athletes: Diagnostic and therapeutic approach. World J

Orthop. 2015 Oct; 6(9): 672-679.

Casey EK et al. Pelvic floor muscle function and urinary incontinence in the female athlete.

Phys Sportsmed. 2017 Nov; 45 (4): 399-407

Calvo-Lobo C et al. Ultrasonography comparison of diaphragm thickness and excursion

between athletes with and without lumbopelvic pain. Phys Ther in Sport. 2019. 37: 128-137.

Coady et al. Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long term

follow up after Hip Arthroscopy. J of Lower Genital Tract Disease. 2015 July; 19(3).

Dos Santos KM et al. Assessment of abdominal and pelvic floor muscle function among

continent and incontinent athletes. Int Urogynecol J. 2019 May; 30 (5): 693-699.

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References

Emami M et al. The activity pattern of the lumbo-pelvic muscles during prone hip extension in athletes with

and without hamstring strain injury. Int J Sports Phys Ther. 2014 June; 9(3): 312-319

Gial Via A et al. Management of osteitis pubis in athletes: rehabilitation and return to training – a review of

most recent literature. OA J Sports Med. 2019: 10: 1-10.

Hentis, Marisa. Successful Outcome of Prolonged postpartum hip pain with focused pelvic healt physical

therapy: A Case Report. Orthop Prac. 2019: 31(2): 84-90.

Lee D. 2011. The Pelvic Girdle. An Integration of Clinical Expertise and Research. Churchill Livinstone

Elsevier.

Louis-Charles, K et al. Pelvic Floor Dysfunction in the Female Athlete. Current Sports Med Reports. 2019

Feb; 18(2):49-52

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References

Kerbel et al. Epidemiology of Hip and Groin Injuries in Collegiate Athletes in the United States. Orthop J Sports

Med. 2018 May: 6(5):

Podschun et al. Differential Diagnosis of Deep Gluteal Pain in a Female Runner with Pelvic Involvement: A

Case Report. Int J Sports Phys Ther. 2013 Aug. 8(4): 462-471.

Rial Rebullido T et al. Pelvic Floor Dysfunction in Female Athletes. Strength and Conditioning J. 2020 Aug; 42

(4): 82-92

Wu JM et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women. Obstet Gynecol.

2014 Jan; 123 (1): 141-148