Yeast the Inflammation Beast

 

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Fiona McMahon DPT, PT

You are what you eat. Trash in equals trash out. You can’t exercise yourself away from an unhealthy diet. These adages are often on my mind as I make my food choices because of the myriad health professionals who have taken time to come to our practice to tell us how we can improve our own and our patients’ health by taking more time to look at what we are consuming in our diet. Lately, many of these clinicians have been focusing on candida overgrowth and diet, which can contribute to pain and inflammation conditions.

What we eat can directly affect the bacterial and fungal makeup of the gut, AKA the gut microbiome. The gut requires a certain level of good bacteria to help us digest what we eat. Over time a poor gut microbiome can affect how efficiently the gut works. The function of the gut goes beyond just digesting food but also is vitally important for the production of neurotransmitters, which help to spread messages within the brain and throughout the whole body.  The microbiome also plays an important role in our hormones and immune system. When the microbiome of the gut is not balanced, it is called dysbiosis.

One of the most common culprits in gut microbiota dysbiosis is candida, (Yeast!). Candida is a naturally occurring inhabitant of the body and when it’s at appropriate levels, it doesn’t tend to be noticed, but anyone who has experienced a yeast infection knows that if this little guy is allowed to go unchecked, it can do a lot to make you miserable. Besides plaguing women with itching, burning vulvas, a yeast overgrowth may cause many other ailments.

Science has pointed to the role candida can play in contributing to chronic and inflammatory conditions. In one study by Kumamoto in 2011, candida overgrowth was associated with delayed healing of inflammatory lesions and was associated with pro-inflammatory cytokines (chemicals) and increased incidence of inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

Yeast overgrowth can also affect the bladder along with over colonization of Saccharomyces (another form of fungus). In fact, yeast and Saccharomyces were found to be higher in women during a flare of interstitial cystitis than when their symptoms were low.

Yeast is not the only organism that can get out of balance and affect our bodies in harmful ways. There are many other players that can get out of balance. Some signs of an altered gut microbiome is a history of allergies, eczema, or repeated fungal infection.

 

What to do?

It all seems pretty dire, right. How do you control who is colonizing your gut, when you barely have enough time to make it to the gym after work? There are a few simple steps you can start with.

Avoid antibiotics, unless your doctor thinks you need them.

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The medical community has become a lot more aware of the dangers of over-prescribing antibiotics from their perspective, but it is important to keep in mind that a powerful antibiotic can wipe out good bacteria and bad bacteria in one fell swoop. If the good guys in your gut are reduced, the bad bacteria have a better chance of taking over. Take antibiotics only when recommended. Keep in mind antibiotics will not help treat viruses like the flu, they can only treat bacterial infections.

Modify your diet

close-up-cooking-cuisine-629093.jpgIncrease your consumption of good fats (omega 3’s) to help reduce inflammation.

Food high in omega 3’s includes flax and hemp seed/oils, fish (the fishier the fish, usually means more omega 3’s, for example, herring is higher in omega 3 than a milder fish like snapper). Also, reduce your consumption of processed foods which can increase inflammation levels and eliminate simple sugars and fried foods. If this is only minimally successful, try a gluten and dairy free diet.  

If simple changes are not helping consider seeing a professional

Find a naturopath, functional or integrated MD, or nutritionist who can investigate more fully whether or not you have SIBO (Small intestinal bacterial overgrowth), candida overgrowth, or other gut microbiome disorder. Or perhaps you are lacking certain ingredients, vitamins or mineral.  These professionals can tailor a diet and medication regimen to help return your gut microbiome to tip-top shape.

fiona2018

Fiona McMahon is currently seeing patients at our Midtown Location

 

If you have questions about orthopedic, pelvic, or sports physical therapy, BBPT is offering free phone consults to those living in the greater NYC area for a limited amount of time!

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

 

 

Sources:

Kamamoto C. Inflammation and gastrointestinal candida colonization. Cur Opin Microbiol. 2011;14(40): 386-391

World AIDS Day

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Today, December 1st, 2018, is World AIDS Day. World Aids Day has been held on the first of every December since 1988. World AIDS Day works to spread awareness of the disease and to remind the general public that AIDS and HIV still must be taken seriously and that there is still a lot of work to do in order to prevent the transmission of new cases, as well as to better care for those who are infected with the disease.

What is AIDS/HIV?

AIDS (acquired immunodeficiency syndrome), is caused by a virus called human immunodeficiency virus (HIV). HIV can be treated in order to prevent AIDS, however, there is currently no cure for HIV.

HIV causes AIDS by attacking the immune cells of a person’s body, which can leave a person vulnerable to infections that otherwise would not have made them sick. These infections are referred to as opportunistic infections, an opportunistic infection is a signal that someone’s HIV may have progressed into AIDS.

As we said earlier, HIV doesn’t always have to progress to AIDS. Antiretroviral therapy (ART)  can work to help keep the immune system healthy, as well as lower the risk of transmitting the virus to others. People on ART have dramatically improved lifespans. It is imperative to get on ART as soon as possible to lessen the effects the HIV virus has on your immune system.

HIV Testing

1 in 7 people infected with HIV does not know they have the virus. Testing is necessary to start treatment and reduce the harm done to your immune system as well as the risk of transmission to others.

According to HIV.gov, you should be tested if:

  • “you a man who has had sex with another man
  •  you had sex—anal or vaginal—with an HIV-positive partner
  •  you had more than one sex partner
  • you injected drugs and shared needles or works (for example, water or cotton) with others
  •  you exchanged sex for drugs or money
  •  you been diagnosed with, or sought treatment for, another sexually transmitted disease
  •  you been diagnosed with or treated for hepatitis or tuberculosis (TB)
  • you had sex with someone who could answer “yes” to any of the above questions or someone whose sexual history you don’t know?

Taken directly from HIV.gov, click here to learn more

 

HIV/ AIDS and Physical Therapy

Physical Therapists do not treat AIDS or HIV, rather, they can treat some the symptoms of AIDS/HIV and HIV/AIDS treatment, to allow patients to live as fully and independently as possible. Both the disease itself and the treatment for it have effects like increasing fatigue, decreasing strength and endurance, and increased pain. Physical therapy can help by tailoring programs to help with pain, ability to perform everyday tasks, improve heart health, balance, endurance, strength, and flexibility.

You can mark today by doing a number of things:

Wear a red ribbon to spread awareness

Donate to groups that work to help people living with AIDS and help to prevent its transmission:

United Nations (UN AIDS)

https://donations.unaids.org/

UNICEF

https://www.unicefusa.org/donate/support-unicefs-hivaids-programs

 

Resources:

HIV/Screening:

National HIV Testing database: https://gettested.cdc.gov/

A Holiday Gift for You! BBPT is Offering Free Consults for People Living in the Greater NYC Area!

Group Serious 2

Any persistent pain or chronic back or pelvic pain can be tough. It is tough to have and often times it can be extremely isolating. Many of our patients have to go through a number of clinicians before they even get a diagnosis of pelvic floor dysfunction. If you are reading this blog, you probably have some questions about pelvic floor dysfunction and if physical therapy is right for you.

We are here to help. If you are living in the Greater New York Area and have some questions about orthopedic, sports or pelvic floor dysfunction and if physical therapy is right for you, I encourage you to call our office. For a limited period of time, we are offering free 15-minute phone consults with our licensed physical therapists to patients in the greater New York Area. For those of you living outside this area, a fee may apply to the consult but can be applied towards payment for a PT visit if you chose to visit us. Don’t miss this opportunity to learn more about your pelvic floor and what PT can do for you.

The Physical Therapists at Beyond Basics also treat orthopedic (sport and joint injuries), pediatric pelvic floor dysfunction and orthopedic injury, and much more. Give us a call to discuss how PT can help with any one of these issues!

All the best,

Beyond Basics Physical Therapy

212-354-2622 (42nd Street Location)

212-267-0240 (William Street Location)

Marathon Training: Two Perspectives

sneaker.pngAs we creep closer and closer towards marathon weekend, our very own Tina Cardenia PT, DPT, CFMT and Victoria LaManna (Vicky) PT, DPT, CLT, PRPC were kind enough to share their stories about preparing for the 2018 New York City Marathon. Vicky will be running her first marathon on November 4th, 2018 in order to raise money for Multiple Sclerosis Research. Tina was gracious enough to volunteer her expertise in orthopedic physical therapy to help Vicky have the best run possible for a great cause. If you are interested in donating to support MS research, please donate here and read more about their stories below. If you are interested in hearing more about our orthopedic and sports program here at Beyond Basics Physical Therapy, give us a call at 212-354-2622.

From the Runner’s Perspective

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Victoria LaManna (Vicky) PT, DPT, CLT, PRPC

This year I am participating in my first ever marathon in the NYC Marathon for Team TischMS. Truly, this is my first ever 5k, Half Marathon, or Full Marathon. I am traditionally an anaerobic, (short bursts energy) exerciser. I have played soccer, dabbled in Muay Thai kickboxing, yoga, and weight lifting for exercise. The mind-body challenge of running a marathon (and doing it all for a great cause!) appealed to me. But where to start?

Luckily, I am in a profession that specializes in exercise, injury screening, and prevention, as well as injury rehabilitation. One of my co-workers has also run a few marathons and pointed me in the right direction for a training schedule. To further help ensure success in my training process, I also started physical therapy and made sure I got on my co-worker Tina’s super busy schedule.

vicky.pngShe first tested my core strength, checked hip mobility and strength, as well as spine and rib cage mobility. All areas that are important for efficient running. Tina found that I had poor core-first responses to outside forces, meaning that every time my foot hit the ground while running, my core was not firing to connect my lower extremities to my trunk. This could definitely be why I was experiencing right low back pain with running, and it could actually lead to further injury and result in not being able to RUN at all! Tina also found limitations in my breathing, rib cage, and thoracic mobility. Other than back pain, my first main complaint a few weeks into training was that I could not breathe. While you could chalk that up to poor conditioning, it was something that was felt immediately in runs – as if I just did not have the capacity to take a breath in. This is where we started our treatment – rib cage and thoracic spine mobility.

From there, Tina continued treating based on observation of my running pattern. She continued to work on hip, spine mobility and core control based on what she saw was insufficient in my running. My breathing improved greatly, as well as my mobility. I began to run completely pain-free with ease.

About 2 months away from Marathon Day, I injured my right foot trying to complete a 16-mile training run. I was unable to walk without pain and was limping around the office. Tina quickly observed that I had a bone in my foot and ankle that were compressed and out of alignment. Her work to align my foot and ankle, working all the way up again through my hip and trunk helped me to get back to pain-free running.

I am all set to run the NYC Marathon Sunday, November 4th! I am incredibly thankful to Tina for helping me to get through my training pain-free, manage an injury along the way, and quickly get me back on track for race day. And I am thankful for Team TISCH for allowing me the opportunity to join their team and support a great cause that affects many men and women.

Are you training for a marathon? Looking to improve your running form? OR even improve your golf swing? I would highly recommend seeing a physical therapist for an injury prevention screen for any and all sports, recreation or exercise. Setting yourself up for optimal movement and mechanics will enhance your activity, as well as reduce the risk of injury. It worked for me!!

 

From the Therapist’s Perspective:

Tina Cardenia PT, DPT, CFMT

Tina head shot

Victoria LaManna is such an inspiration. She volunteered to run the NYC marathon this year with little to no running experience and I was lucky enough to help prepare her! I have been working with Victoria for the past 6 months and I am amazed by how far she has come and how much she has already accomplished. Each week during our PT sessions there were a couple of things that I would look at to monitor her progress. I would observe her running, assess her core with tests called the Lumbar Protective Mechanism* and the Elbow Flexion Test*, her standing posture, her single leg stance, double leg squat, single leg squat, her glut and hamstring strength and how it connects to her trunk, and trunk rotation range of motion.

I saw that Vicky’s main limitations when I was observing her run were her limited trunk rotation towards the right, poor landing control on both of her legs especially her right one, and running with her feet turned out. One of the main things I looked for when observing Vicky run is the force transfer through her body from her feet to her trunk, and how the force translates through the rest of her body. It looked as though the force transfer wasn’t as efficient as I would have liked and this repetitive stress through her back and legs could potentially lead to injury.

tina and vickyVicky’s limitation with trunk rotation correlated to one of her complaints of having difficulty breathing during her runs. It seemed as though she was only able to get a good breath through only one side of her body. Upon examination, I found that she was limited into rib cage expansion especially on the right side. After some rib mobilization and breathing inhalation retraining and working thoracic spine rotation Victoria was able to rotate more symmetrically and reported an increased ease of breath with running.

Vicky’s lack of control with landing while running meant that she had a lack of eccentric (the motion of an active muscle while it is lengthening) control through her pelvis, causing compression through her back every time she lands. This could explain the low back pain Vicky has been experiencing. To address this, I worked on increasing the mobility and range of motion through her hips, pelvis, and back. I then worked on retraining her body with specific neuromuscular techniques called Proprioceptive Neuromuscular Facilitation (PNF) and specific exercises to help Vicky create a core first strategy with her running. This means, with every step and every movement Vicky is able to initiate with her core muscles first, which prevented her from overusing her bigger muscles which tend to fatigue quickly and can lead to injury and pain.

Vicky was running with her feet turned out causing poor force absorption from her feet up to her body. This style of running can also result in muscle overuse injuries and pain over time. This could have also been contributing to her complaints of shin splints while running. To work on this, I evaluated Vicky’s foot and ankle mobility, her knee tracking with squats, and single leg squats. With knee tracking, I noticed that she went into valgus with both of her knees, but it was worse on her right. Valgus means that her knees were “knocking in” which was an issue of having weak hip strength as well as lack of mobility and flexibility through some of her leg muscles and joints.  I did a lot of manual work to restore good range of motion and mobility and a lot of muscle retraining and drills to train Vicky to use those muscles appropriately and to be able to carry it over into her running.

After all this training and all the hard work that Vicky has been putting into running, Vicky’s running form now looks great! She has much more mobility through her trunk, is able to control her landing much more efficiently and is able to connect her feet for a better push off during running! Even as Vicky increased her mileage, she kept reporting to me how much easier her runs have been feeling, how much easier it was to breathe and how much more ease of motion she had through each run, and I couldn’t be more proud of her hard work!

*The Lumbar Protective Mechanism and the Elbow Flexion Test are special tests that come from the Institute of Physical Art. If you would like to learn more about their approach to PT, click here.

Breast Cancer Awareness Month

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Photo by Miguel Á. Padriñán on Pexels.com

Fiona McMahon, DPT

Have you noticed an increase in the amount of pink on just about everything the last couple of days? The increase of pink everything is because October is Breast Cancer Awareness Month.  Breast Cancer is an extremely common cancer. According to the Nation Breast Cancer Foundation, 1 in 8 women will be diagnosed with breast cancer in their lifetime. Men can also get breast cancer, however, it is much rarer for men to develop breast cancer. Luckily with early detection and treatment of early stage and localized cancer, the 5-year relative survival rate is 100%. That being said, early detection is crucial and it is important to catch breast cancer early to ensure the best possible outcome. Let’s take some time to review the signs of breast cancer and recommended screening protocols.

Signs and Symptoms of Breast Cancer

  • Change of Sensation/ texture of the Breast or Nipples
    • Lumps, change in texture in the breast, nipple, or underarm area
  • Change in appearance of Breast or Nipple
    • Swelling
    • Shrinkage
    • Dimpling
    • Change of nipple orientation
  • Discharge from nipple

Detection

Recommended Screening:

Mammogram

  • Recommended every 1-2 years for women who are 40 years old or older.
  • May be recommended for women who are under 40, but have increased risk of breast cancer.

 

Genetic Testing

For some types of breast cancer, there is a very specific link to a person’s genes and her or his risk of developing breast cancer. BRCA1 and BRCA2 are genes that are responsible for the production of certain tumor-suppressing proteins. In some populations, there are mutations in these genes that disable their tumor-fighting properties. These gene mutations are relatively rare and currently, screening is recommended just for individuals with increased risk of harboring these mutations. According to the National Cancer Institute, individuals who are at higher risk and should consider genetic testing are:

  • Individuals who have a male relative who has developed breast cancer
  • History of BRCA related cancers within family history
  • People of Ashkenazi (Eastern European) Jewish ancestry
  • Breast Cancer diagnosed before age 50 in family
  • Multiple cases of breast cancer in family

Individuals that test positive for BRCA mutations may consider increased screening, prophylactic surgery or chemoprevention.

Mastectomy and Physical Therapy

Mastectomy, removal of the breast is currently the most common treatment for breast cancer. Some women chose to have their breasts reconstructed after their mastectomy and others do not. It is obviously a very personal choice.  Like any surgery, mastectomies require close postoperative care to ensure maximal function and recovery.

You may have read the last sentence, and thought, “What is the function of the breast, besides breastfeeding and for sexual pleasure?” The breast lies in an important intersection in the body. The armpit (axilla) contains bundles of nerves, blood vessels, and lymph vessels that course through it, serving the arm down to the fingers. After a mastectomy, their course can be interrupted by scar tissue, radiation damage (if your treatment included radiation), causing painful conditions such as nerve entrapments, frozen shoulder, and lymphedema, ( a backup of lymph fluid, if left unchecked can cause permanent damage and deformation of the arm).

victoria2016Victoria LaManna, DPT, CLT, is our lymphedema expert. If you have had a mastectomy and are unsure about lymphedema care, she is an excellent resource. She will be able to instruct you in self- care and lymphedema prevention measures. Physical therapy can also help to release scar tissue in the breast and upper arm area, regain strength in the arm, and ultimately improve your function. Visit us, and read up on Victoria’s bio here, as well ask on our website at:  www.beyondbasicspt.com/lymphedema

Sources:

http://www.nationalbreastcancer.org/. Accessed: September 24, 2016

National Cancer Institute. BRCA1 and BRCA2: Cancer Risk and Genetic Testing. https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet#q1. Accessed September 25,2016

http://www.beyondbasicspt.com/lymphedema

Pelvic Health 101 is back! Come to Our First Class on September 20th

On September 20th, at 7pm we will be kicking off our fall semester of pelvic health education class, we call Pelvic Health 101 (PH101). In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health and function of your bowel, bladder, and sexual functioning. We will also be covering how things such as alignment, posture, muscle tone and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes

Pelvic Health 101 Fall 2018

It’s all connected: How pelvic floor dysfunction can contribute to hip pain

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Kaitlyn Parrotte, PT, DPT, OCS, CFMT (practices at our midtown office)

Hip pain can have a significant burden on function and quality of life. While there are many causes, prevailing research shows that hip pain is common in both athletic and older populations (1,2). In athletes, groin pain accounts for 10% of all visits to sports medicine centers, and groin injuries account for up to 6% of all athletic injuries (1). In older adults, a diagnosis like osteoarthritis is common, and is ranked as the eleventh highest contributor of global disability (2). While research often focuses on specific populations of people or diagnoses, when put together, it reveals that general hip pain is a common problem affecting a significant portion of the general population. There are many diagnoses that exist to describe hip pain, with the ultimate goal to develop the most effective course of treatment. Traditionally, when someone with hip pain visits a doctor, a physical examination will be performed, which includes assessing for tenderness, swelling, or redness, and determining the range of motion at the hip joint. The doctor may also recommend imaging, such as an x-ray or MRI, as well as lab tests (3). While this can provide a physician with valuable information, such examinations have the risk of missing causes of pain from nearby structures, such as the pelvic floor.

 

The pelvic floor muscles are three layers of muscles that attach to the lower aspect of each half of the pelvis from side-to-side and from the pubic bone to the tailbone, front-to-back. These muscles support the pelvic organs, as well as contribute to trunk stability, and play a significant role in bowel and bladder control and efficiency, as well as sexual function (4). The muscles that make up the deepest of the pelvic muscles, include the levator ani and coccygeus, as well as the obturator internus on the sides (5). The pelvic floor is interconnected to many key structures in the body, and dysfunction here can affect seemingly unrelated parts of the body. Below are two cases of unresolving hip pain, where assessment and treatment of the pelvic floor helped to promote a return to recreational activities.

 

Case 1: A BICYCLIST

A 32-year-old male professional cyclist came to physical therapy with complaints of pain in his right hip and groin, mainly with prolonged sitting and cycling. This began soon after he suffered severe bruising on his right hip from a fall, with a tear of two hip muscles (tensor fascia lata on the front and gluteus medius on the side). Prior to this, he had a history of multiple leg injuries due to cycling, but had never complained of any pelvic floor issues. Upon examination, decreased hip range of motion was also discovered. Initially, he received ten sessions of “standard physical therapy,” which included stretching, joint mobilization, soft tissue release, dry needling, and exercise.

However, after only minimal improvement, he was referred to a pelvic floor specialist for further evaluation where increased muscle tone and tenderness in multiple pelvic floor muscles (both obturator internus muscles and both iliococcygeus muscles) were discovered. Also, weakness of a pelvic floor contraction was also noted (6). Based on response to treatment, his hip pain decreased significantly from his current treatment of pelvic floor dysfunction, though it was completely missed in the initial testing.

But how does pelvic floor dysfunction contribute to hip pain? The correct treatment was missed because this connection was missed. Consider the anatomy and mechanics of the hip and pelvis. The gentleman described above is a professional cyclist, which means that whenever he is on his bicycle, he must flex (bend) his hip up to 90 degrees. More hip motion does not tend to occur because it would cause the pelvis to become unstable on the small seat (7). When the hip is bent, the femoral head (ball of the ball-and-socket joint) must flex (bend up), abduct (move to the side), and rotate in towards the groin (8). As the pedal is pushed downward, the hip moves into an extension (straightening) position. Although the hip never reaches a fully straightened position when cycling because he is seated, the hip moves through between 40 and 43 degrees of total motion with each cycle of the pedal (7). So, when the hip is moving into that straightened position, that femoral head must extend (move back), adduct (move sideways toward the groin), and rotate out away from the groin. While the movements of ball of the hip are small, as they are occurring with the confines of the socket in the pelvis, it is important to remember what muscles are in close proximity (8).

Besides the extensive list of hip flexors and gluteus muscles, there are several muscles that sit on the inner side of each hip and the bottom layer of the pelvis – the muscles of the pelvic floor. The two muscles that are of the most interest in this case are the obturator internus and the iliococcygeus muscles, as tightness and tenderness were found in each pair. The obturator internus muscle contributes to the walls of the pelvic floor, on each side of the pelvis. and sits on the inner side of the hip joint. The iliococcygeus muscle attaches on one end into the tendinous arch of the obturator fascia, so there is only dense connective tissue joining this muscle and the obturator internus (5).

When the hip is in a bent position the obturator internus muscle abducts the hip, or moves it to the side, away from midline; however, when the hip is extended (straightened) this muscle rotates the hip outward. For the iliococcygeus muscle, its role is one of support for the pelvic contents and lifting for the pelvic floor (5). Considering all these factors, it can be theorized that when the hip is in a bent position at the top of the pedaling cycle the obturator internus is activated through the abduction (sideways) motion of the ball of the hip, and continues to be activated as the hip straightens since the ball is rotating outward. Furthermore, because the iliococcygeus muscle is attached to the obturator internus muscle through a dense strip of connective tissue, it must work harder to help support this obturator muscle throughout the cycling activity. Thus, these muscles have become overused and shortened with regular and intense cycling required of a professional, who likely had some abnormal muscle activation or movement strategies prior to his pain due to previous injuries.

With the specially trained pelvic floor physical therapist, the pelvic floor connective tissue was mobilized internally over two treatment sessions, in addition to the cyclist performing hip stabilizing exercises. After the first session, there was an immediate and significant improvement in hip range of muscle and pelvic floor muscle contraction; furthermore, sitting pain was resolved. After the second session (7 days later) this gentleman was discharged from PT as he was pain free in sitting and cycling. In a follow up call one month after discharge, he was still pain free without altering training (6). This dramatic change occurred because the release of connective tissue in the pelvic floor decreased tension and trigger points in the obturator internus and iliococcygeus muscles. Thus, his hip range of motion and pain were normalized, and he was able to return to competitive cycling without restrictions.

Case 2: A RUNNER

A 45-year-old female was referred to physical therapy by her gynecologist with an initial diagnosis of left hamstring strain, toward the top of the thigh, related to distance running. This woman was an experienced marathon runner, who ran an average of 30-40 miles per week. She presented to her first PT appointment with pain in her left sit bone, with diffuse aching radiating into her left buttock and pubic bone; she stated her pain began about 4 months prior to her first PT session. The mechanism of injury was “pulling a muscle” while trying to avoid falling on a trail run. At that time, she immediately felt pain near her sit bone, but was able to complete her run. Eventually, as her symptoms progressed, she stopped running, and was only able to tolerate about 15 minutes of sitting. By her fourth PT visit, her pain had decreased, but continued mildly with sitting and shifted into her left pubic bone. She also reported a deep ache that could not be touched from the outside. She was referred to a pelvic floor specialist for further evaluation; upon internal assessment of the pelvic floor, significant tenderness and reproduction of the “deep ache” was found in her left levator ani and obturator internus muscles, as well as increased muscle tone. Furthermore, contraction of these muscles was weak, and she presented with poor relaxation of the same muscles. (9).

The hamstring muscles attach to the sit bone, and in running help to extend the hip and control the knee (10). Due to the location of this woman’s complaints, initial treatments focused on pain management, such as sitting on a wedge or donut to relieve pressure on her sit bone, as well as core strengthening exercises like the plank, and gluteus and hamstring strengthening exercises. Since the patient reported relief of sit bone pain, except with prolonged sitting by her fourth visit, it was logical to directly address the hamstring and gluteus muscles; however, these are not the only muscles in the area of the hip (9).

When this woman was assessed by a pelvic floor specialist, weakness, tightness, and tenderness were discovered in her obturator internus and levator ani muscles on the side of her pain (9). As discussed in the first case, the obturator internus muscle makes up part of the wall of the pelvis and sits just inside of the pelvis, past the hip joint (5). With running, an efficient hip will move between 50 degrees flexion (bending up) and 10 degrees of extension (straightening back) (10). Thus, when the hip is flexing, the obturator internus is likely assisting with abduction of the ball of the hip joint, and when the hip is extending the obturator internus muscle is likely active in outward rotation of the ball (5,8). The levator ani muscles attach from the pubic bone in the front to the back portion of the pelvis, and play an important role in stabilizing the pelvis and the pelvic contents (5). Considering the mechanics of running, the obturator internus and levator ani muscles were likely working hard to promote a good running pattern, and when she tripped on a run, these muscles were overexerted. Then they continued to overwork to compensate for the pain and weakness demonstrated by her hamstring muscles.

In addition to exercises for hamstring and gluteal muscles, internal release of the left levator ani and obturator internus muscles was performed, as well as gentle isometric contractions for strengthening and lengthening of pelvic floor for relaxation. After 7 additional sessions over a 2-month period, this woman’s pain had decreased greatly, she was able to tolerate sitting for more than two hours, she was able to hop on her left leg without pain, and her hip and pelvic floor muscle strength improved. After six months, she had returned to running, and had recently completed a marathon without pain (9).

Conclusion

In summary, augmenting treatment with the addition of direct pelvic floor interventions in each of the above cases significantly improved each person’s remaining symptoms, and allowed them to return to their prior activities without restrictions. This demonstrates the importance of considering the pelvic floor in the diagnosis and treatment of hip pain – these patients both had injuries that were initially missed because the pelvic floor was not considered as a possible cause of hip pain, yet emerging evidence is linking pelvic floor dysfunction to otherwise intuitively unrelated injuries. This also highlights the need for further research in this area to minimize the occurrence of unnecessary procedures and medications, and to ensure that individuals can return to their daily activities with minimal disruption of their quality of life.

If you or someone you know is struggling with unresolving hip pain, make an appointment with a pelvic floor physical therapist today for further assessment. Feel free to contact our midtown office at 212-354-2622 or our downtown office at 212-267-0240, or visit our website (www.beyondbasicsphysicaltherapy.com) for more information! We are offering free phone consultations at both offices for a short period!

Thank you so much for reading our blog.

Katie Parrotte, PT, DPT, OCS, CFMT practices at our Midtown Location

K5 (2)

 

SOURCES

  1. Prather H, Colorado B, Hunt D. 2014. Managing hip pain in the athlete. Physical Medicine and Rehabilitation Clinic of North America, 45(4), 789-812.
  2. Cross M, Smith E, Hoy D, et al. 2014. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Annals of the Rheumatic Diseases, 73(7), 1323-1330.
  3. Osteoarthritis. Retrieved from https://www.mayoclinic.org/diseases-conditions/ osteoarthritis/diagnosis-treatment/drc-20351930.
  4. Continence Foundation of Australia. Pelvic Floor Muscles. Retrieved from: https://www.continence.org.au/pages/how-do-pelvic-floor-muscles-help.html.
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