**Please be aware that in this blog there is mention of sexual assault. Though there are no specific details, please take care if you are easily triggered by this topic.**
Pain around the low back, hips and glutes can be so hard to diagnose and treat. It’s so frustrating to many providers when a patient is referred to us with a generalized diagnosis of “Low Back Pain.” I enjoy a puzzle and have seen a LOT of different issues, but I can definitely understand the frustration. I think it is always more important to focus on the patient’s frustrations and how their pain is affecting their daily lives instead of my own frustrations of trying to solve the puzzle.
I will never forget the time when I had a kidney infection but was initially feeling low back pain. At this point, I was a new PT and thought it was just from lifting on patients and maybe overdoing certain activities. I stretched, did some core stabilizing exercises and used a tennis ball in attempts to decrease the pain but it kept getting worse. Granted, if a patient had told me these symptoms, I would have immediately seen red flags, but it’s hard to see those on yourself when you have a physically demanding job and are a caregiver (i.e., you put others before yourself). Needless to say, I ended up absolutely miserable with a fever and overwhelmed with exhaustion when I asked my mom to bring me to the doctor. Within 2 minutes he diagnosed me with a kidney infection, was given antibiotics and was out of work for a couple of days to convalesce. I am one of those people who easily acquire urinary tract infections but do not realize that I have one until it has reached or is about to reach my kidneys. Is this more information than you wanted to know about me? Probably.
At any rate, I state that example to show how diagnoses like “Low Back Pain” can arrive anywhere from a muscle spasming bending to spit out your toothpaste in the bathroom sink to cancer. That’s a broad scale, huh? Let’s go over a couple of examples where pain is stemming from the pelvic floor and not necessarily at the site of where the pain is coming from.
Hip Pain
I once had a woman come see me for left hip pain. She was a runner with a teenage son and worked mostly sitting at a desk for 8-10 hours a day. As I do with all my patients, I looked at her feet and hip alignment. It was definitely off to where her lower body looked like it was turned to the right and her upper body was trying to make up for that and rotated to the left. The fact that she was only having hip pain was surprising to me. I worked on correcting her alignment, this involved feet, the entire spine, addressing hip tightness and giving her visual feedback in a mirror of what “normal” feels like as she had adapted to that posture. Over the next 4 treatment sessions, her pain improved temporarily but would never go away and the left hip would always want to tighten back up again. I broached the subject with her of an internal pelvic exam as some of the hip rotators are located deep in the pelvic floor. She stated she would think about it but wanted to keep trying external. I totally understood that and wanted that to be a decision mutually made and not me trying to override her autonomy. Within two more sessions and things staying the same, she said she was ready to try an internal assessment and release if needed. I assessed her internal pelvic floor and immediately found two tight muscles affecting her hip mobility and also found a trigger point that recreated her pain. After a trigger point release to that muscle, her pain completely went away and the mobility of her left hip and overall posture was improved overall.
Migraines/Headaches
Headaches and migraines come in all shapes and sizes and triggers. I was once treating a woman for low back pain after her personal trainer decided on her first session to have her do 100 lunges while carrying 10lb dumbbells. Yeah…that’s a story for another day but I told her that she needed to find a different trainer. This woman, unfortunately, had a history of assault (which is very common with many of my patients as 1 in 3 women experience some type of sexual assault in their lifetime). I recall that we were approaching the holidays, which were a trigger of her assault for her, and she started to experience migraines. As I do with all of my patients, I looked at the entire systems (muscular, nervous system, skeletal, etc.) to see where I needed to focus my attention to help her. We did have a safe conversation about her assault and she was still willing to have me assess her pelvic floor to see if it was triggering her migraines. The trigger point was around her coccyx (tailbone) at the coccygeus muscle. It helped bring down the intensity of her migraine and I spent less than 10 minutes on the release of the muscles before working on her neck and viscera to help balance her nervous system from that “fight or flight” to more “rest and regulation.” Now, I did not cure her migraine’s trigger. That is something for her to work in mental health therapy, but it brought to light how she can help control the manifestation of her trigger. That’s empowering in a time where you feel very little power.
Ankle Pain
Another patient of mine would come in on and off for right ankle pain, to the point where she had almost convinced that she sprained it but there was no bruising or swelling and no trauma to warrant a sprain. Her standing posture wasn’t really enlightening because she nearly refused to put weight on that right leg. Laying down, however, her right hip was higher than the left and the right hip was in spasm. I palpated around her right ankle and there was no pain to touch, no swelling, no bruising. There wasn’t anything wrong with her ankle, per se. I checked the alignment of her pubic bones and noted that the right side was higher than the left and there was a gap. She also nearly jumped off the table when I palpated her there. Since there was no trauma, I asked where she was in her menstrual cycle. She answered that she felt like it has been coming on for a week and feels bloated but her period had yet to arrive. I palpated her uterus and it was full but also rotated to the right. Since there are ligaments that attach from the uterus to the sacrum, I palpated her sacrum, which was also rotated and painful. After doing some visceral work to help the uterus get into better alignment, manual therapy to improve the sacrum, lumbar spine and R hip alignment, she was able to stand on her right leg with 80% reported reduced pain and not limp when walking. I gave her some gentle stretches to help hold her hip and sacrum in alignment until her period comes. I got a text the next morning stating that her period finally came. She had also remembered that when she was younger, she fell off of a horse one time and ended up severing the ligaments on one side of her sacrum that attaches to the uterus. I then educated her that this pain might reoccur since it directly involves the uterus on a monthly basis. Again, helping my patients understand their bodies so they can address their issues and at least give it an identity is so empowering and is better than them spending hours spiraling down a Dr. Google rabbit hole.
Thank you so much for hanging in there for this blog post. I know it was long but I hope you found it interesting and can have another perspective on where the pain is versus where it is coming from!
Kathleen Neal, PT, DPT