The lumbar sacral nerve plexus can be divided into the direction the nerves travel, either anterior or posterior. This post will focus on anterior hip nerves. I remember writing about the brachial plexus over and over in physical therapy school, but only a few times for the lumbosacral plexus. Patients frequently report anterior hip and pubic pain and can often have signs and symptoms of nerve entrapment. This article orients the reader to links between signs and symptoms and examination to help appropriately diagnosis specific nerves in the athletic population.
The obturator, femoral and lateral femoral cutaneous are more commonly entrapped in sports injuries. Although the three nerves that travel together through the inguinal canal (ilioinguinal, iliohypogastric, and genitofemoral) are less common, however surgery can create nerve entrapment sequelae.
There are a few places where the obturator nerve can become squished. Typically, as it leaves the obturator canal which presents at medial thigh pain, and then again in the fascia of the adductors which presents as pain with abduction. The challenge is to differentiate between the nerve and adductor strain. Obturator nerve entrapment will test positive with passive hip abduction and extension, but negative resisted hip adduction.
The femoral nerve can become entrapped in a kind of compartment syndrome as it goes between the psoas and iliacus. This can lead to compression to the neurovascular bundle with resultant swelling, edema, and ischemia. Signs of femoral nerve compression include anterior thigh numbness and paresthesias. Occasionally, this can also include the saphenous nerve with symptoms continuing along medial knee to foot. Femoral nerve entrapment can create quadricep muscle weakness and atrophy, with diminished or absent patella tendon reflexes. Symptoms are reproduced with hip extension and knee flexion thereby elongating the femoral nerve.
The lateral femoral cutaneous (LFC) nerve is sensory. Diagnosed as meralgia paresthetica, the LFC nerve is typically entrapped where it penetrates under the inguinal ligament just medial to the anterior superior iliac spine (ASIS). Symptoms include numbness, tingling, hypersensitivity to touch, burning along outer thigh along the iliotibial band. The LFC nerve can often be compressed by wearing heavy belts (scuba divers, construction belts, etc). Special tests that indicate LFC are pelvic compression in side lying with involved side up to slack the inguinal ligament and Tinels sign.
Anterior hip pain is fairly common in pelvic floor patients. Differential diagnosis and treatment of these anterior nerves can allow patients to return to full daily function. To learn manual assessment and treatment techhniques for the lumbar nerves, consider attending Lumbar Nerve Manual Assessment and Treatment.
Martin R, Martin HD, Kivlan BR. Nerve Entrapment In The Hip Region: Current Concepts Review. Int J Sports Phys Ther. 2017 Dec;12(7):1163-1173.
I recently assisted at a Pelvic Floor Level 2B course which has been updated with recent research, new sections, and less repetition from Pelvic Floor Level 1. In the course they mentioned this article which sparked a lively discussion and I had to learn more. It is rare to see a study with a large number of participants in pelvic health and especially with a vaginismus diagnosis.
Vaginismus is defined as a genito-pelvic pain/penetration disorder along with dyspareunia under the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders; Fifth Edition) in which penetration is often impossible due to pain and fear. Vaginismus is both a physical and psychological disorder as it exhibits both muscle spasms and fear/anxiety of penetration. Symptoms vary by severity. Common presentation is an inability or discomfort to insert/remove a tampon, pain with penetration, and complaints of “hitting a wall” in attempted penetration; and inability to participate in gynecological exams.
The authors of this study evaluated the severity of vaginismus. The penetrative history was used in addition to presentation at pelvic exam, and then given a level. There are 2 grading systems, Lamont and Pacik, that indicate the level of fear and anxiety about being touched. They found that those with severe vaginismus were Lamont levels 3 and 4, and Pacik level 5. For example, a Pacik Level 5 includes Lamont grade 4 “generalized retreat: buttocks lift up; thighs close, patient retreats” plus a visceral reaction such as “palpitations, hyperventilation, sweating, severe trembling, uncontrollable shaking, screaming, hysteria, wanting to jump off the table, a feeling of going unconscious, nausea, vomiting and even a desire to attack the doctor”.
241 patients participated in this study, with a mean duration of 7.8 years. 70% of participants were a Lamont level 4 or Pacik level 5 at baseline. The authors looked at previous treatments tried and coping strategies; 74% had tried lube, 73% had tried dilators, 50% had tried Kegels, 28% had tried physical therapy, 3% had tried a surgical vestibulectomy. The full table 2 is in the article. Most participants had a mean of at least 4 failed treatments.
The aim was to help these women to achieve pain free intercourse after treatment. In order to tolerate the treatment, many were sedated with midazolam before the Q-tip test, and more sedation given as needed. The treatment lasted for about 30 minutes and consisted of:
If the patient consented, her partner could be present during the procedure and was allowed to palpate the level of spasm with gloved digit and was educated on dilator insertion. The authors noted that many partners had a ‘profound’ experience.
A nurse worked with the couple for about two hours in the recovery room to help them be more comfortable moving the dilator in and out with minimal-to-no pain as the numbing agent lasts 6-8 hours. Three participants were treated each time and consented to meet each other. Patients were discharged with #4 dilator in place and asked to keep in until the next day. They were given Ibuprofen and sleeping aids as needed.
Participants return with partners and progress up to larger sizes (#5 and #6). They participate in group counseling with the primary researcher Dr. Pacik. This lasted about 5 hours; and consisted of education of dilator progression, returning to intercourse and lubricants. If participants wished to have private counseling instead that was granted. Many exchanged contact information. They were encouraged to continue seeing their healthcare clinicians as indicated; sex therapists, physical therapists, psychologists.
- 2 hours of dilator per day. Either in 1 sitting or 1 hour of dilator work x2 per day
- Progress to bigger sizes until #5 or #6 is comfortable
- 1 hour of dilator use per day and continue toward larger sizes
- 15-30 minutes of dilator use per day
- 10-15 minutes of dilator use per day or every other day
During the counseling session post-procedure, the recommendations for returning to intercourse included:
71% of participants achieved pain-free coitus 5 weeks after the procedure. 2.5% could not achieve coitus within one-year period although they could use #5 or #6 dilators. The participants were given a validated outcome tool, the Female Sexual Function Index (FSFI), before and after the procedure and at 1-month, 3-months, 6-months, and 1-year; with significant improvement at each interval. The patients were followed for one year, and often remained in contact with the authors for much longer ranging from 16-months to 9-years.
The authors propose that use of dilators at the time of botox and post procedure counseling and support help participants ‘break through’, whereas previous treatment may not be as multidimensional and limit efficacy. Botox lasts 2-4 months and allowed for dilation progression.
Initially after reading this article the treatment seemed a little drastic to me, but then I considered the women with this level of vaginismus are often not coming into my clinic. They may need this level of structure, consistently, and multidimensional treatment as half measures have failed them. I am so glad they were persistent and found the help they needed.
Pacik, P., Geletta, S. Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Sex Med 2017;5:e114-e123
Pelvic pain is a common diagnosis that we see as pelvic floor therapists. Pelvic pain is pain located in the lower abdomen, but above pubic symphysis, and is associated with various causes; myofascial pain, neuropathies, endometriosis, painful bladder, and irritable bowel syndromes. A common symptom of pelvic pain is deep dyspareunia or pain with deep vaginal penetration. Vulvar pain is different, as it is below pubic symphysis, and has several sub-classifications. These sub-classifications can often be confusing. The National Vulvodynia Association has a free online education that explains the different sub-types very succinctly. This article focuses on provoked vestibulodynia, which is the most commonly studied.
PVD or Provoked Vestibulodynia often has superficial dyspareunia which can negatively affect sexual functioning, which can lead to changes in psychological function and quality of life. Women with PVD often complain of greater pain during and after intercourse, pain catastrophization, and allodynia when compared to women with superficial dyspareunia but without PVD. These symptoms indicate central nervous system upregulation or sensitivity. This study sought to investigate the impact of these symptoms.
Pelvic pain encompassed a variety of complaints: “dysmenorrhea, deep dyspareunia, dyschezia, chronic pelvic pain, back pain, or diagnosed or suspected endometriosis”. Participants were excluded if postmenopausal or if self reported never sexually active.
One hundred twenty nine participants were divided into those with pelvic pain and PVD (43), and those with pelvic pain alone (87). For this study PVD was diagnosed as superficial dyspareunia (>4/10) and positive Q-tip test with a fixed pressure of 30g. Those with did not meet this criteria were considered to have pelvic pain alone.
The two groups were compared for superficial and deep sexual discomfort severity, sexual quality of life; fear avoidance, feelings of guilt, frustration, etc, physical examination of trigger points along abdominal wall (positive Carnett test), and numeric pain scale of various painful lumbo-pelvic regions.
Of the 129 participants notable findings in both the two groups include 31% had confirmed endometriosis, 40% suspected of endometriosis, and in the remaining 18% had no confirmed or suspected endometriosis. The authors found that the pelvic pain + PVD group had significantly more superficial dyspareunia (p=<.001) and deep dyspareunia (p=.001) which was rated >7/10 for both. This group was also had greater (3x more likely to have) depression symptoms, greater anxiety, and catastrophizing, and was more likely to have painful bladder syndrome than the pelvic pain alone group. There were no differences between the two groups for irritable bowel syndrome or abdominal wall tenderness.
This research is consistent with other research findings. The authors explore various causes of the findings including; cross- sensitization - where there may be cross talk of nerve signals from viscera to viscera and viscera to muscular structures that converge in the spinal cord. The authors note that the poor relationship between PVD and irritable bowel and PVD and abdominal wall tenderness limit that theory. They explore the psychological symptoms may be a consequence of pelvic pain or it may be that having anxiety/depression may make women more sensitive to developing pelvic pain and PVD. This sounds like a little chicken or egg theory. The authors suggest that those with PVD and pelvic pain may benefit from a more intensive multi-disciplinary approach including; “medical, surgical, psychological, or physical therapy approaches”.
Bao, C., Noga, H, Allaire, C. et al. “Provoked Vestibulodynia in Women with Pelvic Pain” Sex Med 2019; 1-8
Pelvic pain can often involve adverse neural tension. The hip and pelvic nerves wrap around like spaghetti, making diagnosis and treatment difficult. Is the pain driver boney, capsular, muscle or neurovascular? Luckily, impingement and labral tears are fairly easy to diagnosis. Nerve entrapment can be a little bit tricky to diagnosis and treat. Part of being a good pelvic floor physical therapist is appropriately diagnosing and then partnering with patients to treat symptoms, pain, and movement dysfunction.
The authors of this study focused on hip, so this blog focuses on sciatic and pudendal nerve entrapment in the athletic population. Nerve entrapment occurs when the normal slide and glide is limited. That can be from any structure in the pelvis and hip region that cause strain or compression on the nerves in the area. Often patient’s descriptions of pain can be the first sign with complaints of ‘burning’, ‘sharp’, or changes in sensation. Evaluation for changes in reflexes and motor function are helpful. Other signs of nerve entrapment are tenderness to palpation and reproduction of pain with movements that elongate the nerve. Medical management to confirm diagnosis include nerve blocks, and diagnostic imaging, and nerve conduction velocity tests.
Specific locations of pain can help determine where the nerve is being squished. The sciatic nerve (L4-S3) can be entrapped as it passes between the piriformis and deep hip rotators. This often presents with a history of trauma to the gluteal area and limited sitting tolerance (>30 minutes). As the sciatic nerve moves down it can have ischiofemoral impingement, when the nerve gets compressed between lateral ischial tuberosity and greater trochanter at level of quadratus femoris muscle. This will often present as pain during mid- to terminal-stance during walking. Then, once the sciatic nerve clears the pelvis it can become entrapped by the proximal hamstring. There can be hamstring trauma in the history, and possible partial avulsion or thickening of the hamstring may entrap the sciatic nerve.
The pudendal nerve (S2-S4) can become entrapped in several areas and symptoms often include pain medial to the ischium and can include genital regions for all genders, perineum, and peri-rectal regions. The most common areas consist of the space between the posterior pelvic ligaments (sacrospinous and sacrotuberous) and the obturator internus muscle. History often includes bike riding, and a common complaint is pain with sitting, except a toilet seat.
Differential diagnosis for posterior nerves physical examination can include the following tests:
Consertative treatment including physical therapy can be helpful. Manual therapy including nerve glides and soft tissue mobilization. Nerve mobilizations require anatomical nerve pathway knowledge. Mobilizing the nerves is thought to improve blood flow within and around the nerve, decrease adhesions, and also may affect central sensitivity. Soft tissue mobilization is geared towards positively affecting scar tissue and encouraging movement that may be restricting neural movement.
Therapeutic exercises for strengthening and stretching are also helpful, however use caution to avoid aggressive stretching as it may aggravate nerves. Exercises to promote load transfer through the pelvis and lower extremities can be helpful. The authors also suggest lower extremity passive PNF (proprioceptive neurofacilitation) diagonal movements. The authors also suggest aerobic conditioning, cognitive behavioral therapy, and for the chronic pelvic pain population, pelvic floor muscle training that does not provoke symptoms.
When conservative treatment including injections produces limited results, surgical treatments are often the next step. Often surgeries where the nerves are decompressed, neurolysis, or removed, neurectomy can be helpful.
To learn more nerve assessment and treatment techniques, join Nari Clemons, PT, PRPC in her course Sacral Nerve Manual Assessment and Treatment in Tampa, FL this December 6-8, 2019!
Martin R, Martin HD1, Kivlan BR 2.Nerve Entrapment In The Hip Region: Current Concepts Review.Int J Sports Phys Ther. 2017 Dec;12(7):1163-1173.
Often pelvic floor therapists see men for post-prostatectomy urinary leakage. However, at least for me, that quickly led to seeing male patients for pelvic pain and sexual dysfunction. Male sexual dysfunction is a broad category and can consist of erectile dysfunction (ED), ejaculation disorders including premature ejaculation (PE), and low libido -- often there is a pelvic floor muscle (PFM) dysfunction component. Conservative treatment frequently consists of pharmacological and lifestyle changes for this population.
In normal sexual function, the male superficial pelvic floor musculature (bulbocavernosus and ischiocavernosus) work together to create increased intracavernosus pressure by limiting venous return, resulting in an erection. Ejaculation is created by rhythmic contractions of the bulbocavernosus muscle.
The authors of this systematic review were curious if pelvic floor muscle training was effective for treating erectile dysfunction and premature ejaculation diagnoses, and if so to determine whether there is a treatment protocol. Ten studies were found that met the inclusion criteria, five that focused on ED and five that focused on PE. In total, there were 668 participants ranging in age from 30-59 years old. Studies were excluded if participants were post-prostatectomy and/or had a neurological diagnosis. The intervention was a pelvic floor program, and pelvic floor muscle contractions were either taught or supervised. Studies also included supportive treatment including biofeedback, lifestyle changes, and electrical stimulation.
The studies focused on erectile dysfunction listed a combination of hormonal, psychogenic, arteriogenic, and venogenic causes. The pelvic floor training ranged from 5-20 visits over 3-4 months and included a home exercise program. Pelvic floor training was similar in all studies and consisted of maximal quick contractions over one second and submaximal endurance holds over 6-10 seconds. Compliance to home exercise program was not assessed. Between 35% and 47% of participants reported a full resolution of symptoms. Subjective improvements were supported by improved maximal anal pressure and intracavernosus pressure. One study used the International Index of Erectile Function (IIEF) and showed significant improvement (p<0.05).
The studies focused on premature ejaculation noted participants had either lifelong or secondary PE. The pelvic floor training in these studies ranged from 12-20 sessions over 1-3 months. All studies used electrical stimulation as part of the pelvic floor muscle training. Four studies also used biofeedback. Only one study listed a home exercise program but did not report on compliance. The pelvic floor muscle training was compared to nothing in three studies, and to a selective serotonin reuptake inhibitor (SSRI) in the other two studies. Patient reported full resolution of symptoms was 55-83% in two studies, and there was a significant improvement in delay in heterosexual penetrative ejaculation (p<0.05) in three studies.
For both erectile dysfunction and premature ejaculation, pelvic floor muscle exercise prescription was 2-3 times per week with pelvic floor muscle contractions both maximal quick contractions and submaximal endurance holds. Significant results were shown with participants who were taught pelvic floor muscle contractions through a combination of verbal and physical means (typically biofeedback). Specific verbal cues were not reported. The authors suggest that electrical stimulation was helpful for training recruitment patterns; however, there was not a significant difference in outcomes for those with ED when using electrical stimulation. The authors suggest that pelvic floor muscle training can be part of a conservative treatment. It may be used with oral pharmacology for quick results, and may be beneficial with electrical stimulation and biofeedback, though more research is indicated.
If you are interested in learning more about treating male patients, consider attending Male Pelvic Floor: Function, Dysfunction, and Treatment!
Myers, C., Smith, M. “Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review” Physiotherapy 105 (2019) 235–243
I recently found this article from the Psychology Research and Behavior Management Journal. I found myself curious about how other healthcare disciplines treat a diagnosis that often presents in conjunction with pelvic floor dysfunction. Irritable bowel syndrome, or IBS, affects nearly 35 million Americans. It is considered a ‘functional’ condition meaning that symptoms occur without structural or biochemical pathology. There is often a stigma with functional diagnosis that the symptoms are “all in their heads”, and while there are many theories about what predisposes individuals to IBS, the experts now think of IBS as a “disorder of gut brain interaction”. Generally, there are 3 subtypes of IBS where people note either constipation dominant, diarrhea dominant or mixed. In order to be diagnosed an individual must report abdominal pain at least 1 day per week in the last 3 months which is related to stooling and a change in frequency or form. Other symptoms that are common are bloating, nausea, incomplete emptying, and urgency.
The author suggests a biopsychosocial framework to help understand IBS. An interdependent relationship between biology (gut microbiota, inflammation, genes), behavior (symptom avoidance, behaviors), cognitive processes (“brain-gut dysregulation, visceral anxiety, coping skills”), and environment (trauma, stress). The brain-gut connection by a variety of nerve pathways is how the brain and gut communicate in either direction; top down or bottom up. Stress and trauma can dysregulate gut function and can contribute to IBS symptoms.
Stress affects the autonomic nervous system that contributes to sympathetic (fight/flight) and parasympathetic (rest/digest). Patients with IBS may have dysfunction with autonomic nervous system regulation. Symptoms of dysregulated gut function can present as visceral hypersensitivity, visceral sensitivity, and visceral anxiety. Visceral hypersensitivity is explained as an upregulation of nerve pathways. The author sites studies that note that IBS patients have a lower pain tolerance to rectal balloon distention than healthy controls. Visceral sensitivity is another sign of upregulation where IBS patients have a greater emotional arousal to visceral stimulation and are less able to downregulate pain. The author notes that the IBS population show particular patterns of anxiety with visceral anxiety and catastrophizing. Visceral anxiety is described hypervigilance to bowel movements and fear avoidance of situational symptoms. For example, fear of not knowing where the bathroom is located.
Cognitive behavioral therapy (CBT) has been shown to be an effective treatment to decrease the impact of IBS symptoms. CBT is focused on modifying behaviors and challenging dysfunctional beliefs. CBT can be presented in a variety of ways, however most include techniques consisting of education of how behaviors and physiology interplay for example the gut and stress response; relaxation strategies, usually diaphragmatic breathing and progressive relaxation; cognitive restructuring to help individuals see the relationship between thought patterns and stress responses; problem-solving skills with shift to emotion focused strategies (“acceptance, diaphragmatic breathing, cognitive restructuring, exercise, social support”) instead of problem focused strategies, and finally exposure techniques to help the individual slowly face fear avoidance behaviors. So much of the techniques are similar to what pelvic floor therapists try to educate our patients in. It is reassuring to me that through we may be different disciplines we are on the same team are moving towards the same goal. The author recommends a 10 session treatment duration, and notes that may be a barrier for some. Integrated practice with other healthcare professionals is also recommended. The more we can know about what our other team members are doing to help support patients the more effective we all are.
Kinsinger, Sarah W. “Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights” Psychology research and behavior management vol. 10 231-237. 19 Jul. 2017, doi:10.2147/PRBM. S120817
Pain demands an answer. Treating persistent pain is a challenge for everyone; providers and patients. Pain neuroscience has changed drastically since I was in physical therapy school. This update comes from the International Spine and Pain Institute headed by the lead author Adriaan Louw, PT, PhD. If you are interested in reading more about persistent pain, I suggest reading the article in its entirety.
This article brings together several comorbidities that pelvic physical therapists often encounter; fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and chronic Lyme disease. The authors argue that all of these syndromes have many common symptoms and might be dependent on the provider that the individual goes to as to which diagnosis the individual receives. Often, once an individual has a diagnosis, he or she (more often she) then identifies with this label. The authors reason that once medical pathologies have been ruled out, then a more holistic, biopsychosocial approach may create better outcomes.
Pain neuroscience education is a way to explain pain to patients, often with analogies, with a focus on neurobiology and neurophysiology as it relates to that individuals pain experience. To be able to educate our patients, we as providers, must be able to understand neuromatrix, output, and threat. Moseley states “[p]ain is a multiple system output activated by an individual’s specific pain neuromatrix. The neuromatrix is activated whenever the brain perceives a threat”. If that sounds like gibberish, consider watching this TEDx talk by Lorimer Moseley on YouTube (the snake bite story is a favorite of mine):
What is a neuromatrix? Essentially, it is a pain map in the brain; a network of neurons spread throughout the brain, none of which deal specifically with pain processing. The way I visualize it is to think about what goes on when you think of your grandmother. There isn’t a grandmother center in the brain, but there are sights and smells (sensory), feelings (emotional awareness), and memories that all come up when you think about her. When we are overwhelmed with pain, those regions become taxed and the individual may have difficulty concentrating, sleeping, and/or may lose his/her temper more easily. Just as each person’s grandmother is different so is a person’s pain and the neuromatrix is affected by past experiences and beliefs.
Pain is an output. It is a response to a threat. When a person is exposed to a threatening situation, biological systems like the sympathetic nervous system, endocrine system, immune system, gastrointestinal system, and motor response system are activated. When a stress response occurs, these systems are either heightened or suppressed to help cope, thanks to the chemicals epinephrine and cortisol.
What is a threat? Threats can take a variety of forms; accidents, falls, diseases, surgeries, emotional trauma, etc. Tissues are influenced by how the individual thinks and feels, in addition to social and environmental factors. The authors propose that when individuals live with chronic pain, their body reacts as though they are under a constant threat. With this constant threat the system reacts and continues to react, and the nervous system is not allowed to return to baseline levels. This can create a patient presentation with immunodeficiency, GI sensitivity, poor motor control, and more. This sounds like most patients who walk into my clinic. The authors suggest that one system may be affected more and that can influence what the patient is diagnosed with even though the underlying biology is the same for many conditions. There are theories for why that happens; genetics, biological memory, or it could be the lens of the provider that the patient sees. There is a table in the article that shows symptoms, diagnosis, and current best evidence treatment for the conditions of fybromyalgia, chronic fatique syndrome, irritable bowel syndrome, and chronic Lyme disease which is worth a look. The treatments all work to calm the central nervous system.
The authors go on to question the relationship between thyroid function and these conditions as changes in cortisol and the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is fascinating, and confusing. Luckily, the Pelvic Floor Series Capstone course does a great job breaking it down.
Now that this hypothetical patient is in our treatment room what do we do? The authors suggest seeing these conditions for what they are: chronic pain conditions. They recommend that physical therapists see past the label that a patient may have picked up with a previous diagnosis, and keep the following in mind when treating these patients:
These people need the following from their medical providers:
With empathy and understanding therapists can use skills in education, exercise and movement with the intent to improve system function (immune, neural, and endocrine), rather than fixing isolated mechanical deficits.
Louw, Adriaan PT, PhD; Schmidt, Stephen PT ; Zimney, Kory PT, DPT ; Puentedura, Emilio J. PT, DPT, PhD Treat the Patient, Not the Label: A Pain Neuroscience Update.[Editorial] Journal of Women's Health Physical Therapy. 43(2):89-97, April/June 2019.
Leg length discrepancy (LLD) is when there is a noticeable difference in length of one leg to the other. LLD is common and can be found in 70% of the population (Gurney, 2002). LLD can be structural or functional. Structural LLD is when a long bone in the leg is longer or shorter than the other. Structural LLD is often the result of congenital or boney damage of epiphyseal plate. Functional is when there is an apparent LLD from higher in the chain such as scoliosis. Generally as pelvic floor therapists we are orthopedic based therapists. In physical therapy school we learned that a leg length discrepancy had to be >1 cm to be considered significant, and based off of recent research that is still the case. Research in the last few years has focused on whether LLD has an effect on age related changes with osteoarthritis, posture & gait, and pain. Physiopedia suggests differential diagnosis of sacroiliac dysfunction, scoliosis, low back pain, iliotibial band (ITB) syndrome, stress fractures, and pronation. It can often feel like a chicken or egg question.
In the clinic I typically screen for a leg length discrepancy during my initial evaluation. A LLD may be noticed upon observation of gait assessment, standing posture, or part of the pelvic obliquity screen in standing and then in supine.
During gait, a LLD will create bilaterteral gait impairments. Khamis et al did a systematic review of LLD and gait deviations in 2017. They narrowed the search down to 12 articles and found that LLD >1cm was significantly related to gait deviations. These deviations occurred bilaterally, and while initially compensations occurred in the sagittal plane, as the LLD increased so did the gait deviations, and then affected frontal planes of motion as well. Resende et al (2016) agrees that even mild LLD should not be overlooked. They found that the most likely gait deviations were also in the sagittal planes and consisted of rearfoot and ankle dorsiflexion and inversion, knee flexion and adduction, hip adduction and flexion, and pelvic trendelenburg.
The sagittal, or right/left plane, and frontal, or front/back, plane involvement is consistent with the differential diagnosis of sacroiliac dysfunction, low back pain, and pronation. Really, one could justify why a LLD could contribute to pain and dysfunction in most of the lower body. It is reasonable to think that these compensational moments in gait over a long period create boney changes in the lower extremities which may contribute to low back pain.
Clinically, a leg length discrepancy can be assessed directly with a tape measure or indirectly with a shoe lift. Badii (2014) found a higher interrater reliability with the indirect method of a shoe lift as opposed to measuring with a tape measure.
Rannisto et al (2019) looked at leg length discrepancy among meat cutters with low back pain. All participants had been working for 10 years and were greater than 35 years old. Participants needed to have a LLD of 5mm (5mm is 0.5 cm) or more and complain of low back pain of >2/10 on visual analog scale (VAS). They were all given insoles and randomized into 2 groups; the intervention group were given lifts to correct the LLD about 70%; for example a 10mm LLD was corrected to 3 mm. The LLD was measured with a laser ultrasound technique. Participants were followed for 12 months. The intervention group had improvement in low back pain intensity, sciatica intensity, and took less sick time. Possibly the most amazing part is that for those that wore the heel lift at work the compliance was good.
Leg length discrepancy can often be an underlying component contributing to complaints of pain and dysfunction. It may have more of an effect on the populations who stand or walk for most of their work, and I wonder as more people transition to standing desks if we will see more people come into the clinic with a previously undiagnosed LLD.
My biggest clinical pearls from this research is that:
- Heel lifts can be used to diagnose and then for treatment (yay! One less step of getting the tape measure out)
- The heel lift does not have to be perfect. Clinically, I will try a lift and have the person walk, and then we can make a team decision if this lift is enough and feels better
- The gait compensations are consistently adduction and internal rotation throughout the lower body chain. I will continue to work on the opposing muscle groups; lateral rotators, hip extensors and abductors.
Leg Length Discrepancy can be evaluated using various assessments. To learn orthopedic evaluative techniques for patients, consider joining Lila Abbate in her course Advanced Orthopedic Assessment for the Pelvic Health Therapist.
Maziar Badii, A Nicole Wade, David R Collins, Savvakis Nicolaou, B Jacek Kobza, Jacek A Kopec, Comparison of lifts versus tape measure in determining leg length discrepancy; Journal of Rheumatology 2014, 41 (8): 1689-94
Renan A. Resende, Renata N. Kirkwood, Kevin J. Deluzio, Silvia Cabral, Sérgio T. Fonseca. "Biomechanical strategies implemented to compensate for mild leg length discrepancy during gait" Gait & Posture, Volume 46, 2016; 147-153, https://doi.org/10.1016/j.gaitpost.2016.03.012
Sam Khamis, Eli Carmeli, Relationship and significance of gait deviations associated with limb length discrepancy: A systematic review, Gait & Posture, Volume 57, 2017, 115-123, https://doi.org/10.1016/j.gaitpost.2017.05.028
Burke Gurney, Leg length discrepancy, Gait & Posture, Volume 15, Issue 2, 2002, Pages 195-206, https://doi.org/10.1016/S0966-6362(01)00148-5.
Satu Rannisto, Annaleena Okuloff, Jukka Uitti, et al. Correction of leg-length discrepancy among meat cutters with low back pain: a randomized controlled trial. BMC Musculoskeletal Disorders. 2019;(1):1. doi:10.1186/s12891-019-2478-3.
Diagnosing sacroiliac joint (SIJ) dysfunction can be tricky. Therapists need to rule out lumbar spine and the hip, and sometimes there is more than one area causing pain and limiting functional mobility. Typically, ruling in SIJ dysfunction is done by pain provocation tests and load transfer tests. Once the SIJ has been ruled in, then therapists can use a variety of treatments. Often those treatments include therapeutic exercise, joint manipulation, and Kinesio tape. But which intervention is the most effective?
A recent study looked at three physical therapy interventions for treatment for SIJ (sacroiliac joint) dysfunction and assessed which was the most effective (Al-Subahi, M 2017). The authors did a systematic review of the literature. The articles were from 2004-2014, written in English, with male and female participants. This review included a variety of experiment types from randomized control trials to case studies. Of the 1114 studies, only 9 met the inclusion and exclusion criteria. Four of the nine studies used manipulation, three used Kinesio Tape, and the three used exercise. One study did both exercise and manipulation, and was looked at in both interventions. All categories had at least one randomized control trial.
For the manipulation intervention, all studies showed a decrease in pain and disability at follow up. The follow ranged from 3 to 4 days to 8 weeks. Disability was measured using the Oswestry Disability Index. One study did manual high velocity and low amplitude thrust manipulation to lumbar and SIJ manipulation and showed improvement with manipulation to SIJ or SIJ and lumbar. The review did not disclose the type of lumbar manipulation, but did state the SIJ manipulation was a side bend and rotation position with an inferior and lateral force to ASIS (anterior superior iliac spine). Another study did either a SIJ manual high velocity and low amplitude thrust manipulation or a mechanical force with manual assistance. One studied did manipulation and home exercises but did not record exercise interventions. The last study did the same SIJ manual high velocity and low amplitude thrust manipulation as in previous study combined with exercise. The exercises are mentioned below.
For the exercise intervention, the studies did primarily stabilization exercises that were either isometric or isotonic eccentric or concentric. Quick PT school review, in isometric exercises the muscle does not change length, while in isotonic eccentric exercises the muscle is being lengthened under load, and isotonic concentric is the muscle shortening under load. All three studies showed decrease in pain. The first study had 7 participants and combined manipulation and exercise. The exercises consisted of 12% max voluntary contraction and eccentric loading quads in supine with hips at 90 degrees, and concentrically loading hamstrings in prone. The second study was a case study and performed 8 lumbo-pelvic-femoral stabilization exercises for 8 weeks. Fun fact: this case study was written by my Therapeutic Exercise teacher in PT school who did a lot of Postural Restoration based exercises. The last study, had 22 participants and educated and provided exercises on deep abdominal and multifidus muscles and do complete these exercises during functional movements throughout the day. These participants were follow up a year later and had decreased pain compared to laser group.
For the Kinesio tape (Kinesio tape) intervention, the studies did not find that Kinesio tape was not an effective intervention, however the follow up ranged from immediately after applying tape to 4 weeks afterwards. In the first study, a randomized controlled trial with 60 participants, the Kinesio tape was applied in sitting with 25% tension of 4 strips making a star pattern over the point of maximal pain. The Kinesio tape was compared to placebo tape and showed equal improvement in pain and disability. The other two studies applied a different taping technique where the Kinesio tape was applied. One applied the tape over erector spinae and internal oblique muscles bilaterally and in the other study the Kinesio tape was applied with 25% tension over external obliques, a second strip was placed from ASIS to PSIS in side-lying, and then a third strip was placed along rectus abdominis muscle. In this same study the tape was applied for weeks (6x/week for 9 hours/day).
In summary, the authors note that all three interventions help decrease pain and disability in women and men with SIJ dysfunction. The authors suggest that manipulation may be the most effective. Kinesio tape showed no significant difference between placebo tape. Exercise was effective, but less so than manipulation.
This review has a lot of limitations. The variety of experiment types with varying degrees of evidence, small number of participants, and lack of blinding. Most studies had a limited follow up ranging from 3-4 days to 12 months. The outcome measures varied greatly. Most studies had pain scores as the outcome measure, though one study only used inclination meter of anterior pelvic tilt. Use of a consistent objective measure in addition to perceived pain and disability would have helped. Only 1 study did pain provocation tests and that study was a case study whose intervention focused on Kinesio-taping.
As physical therapists we want to provide effective evidence-based practice, and we want to provide individualized compassionate care. It is hard to make a direct line between this study’s recommendations and clinical application based on the numerous limitations. I agree with the authors that manipulation and exercise are bread and butter to physical therapists. I disagree about Kinesio tape not being an effective treatment. Is Kinesio tape going to create boney alignment changes? Likely not. Is Kinesio tape (or any other tape) going to give proprioceptive feedback and possibly help calm sensory pathways? Yes. If a patient likes being taped, and thinks it will help, then I will tape them. Even if taping is just placebo effect; it’s still an effect.
Al-Subahi, M., Alayat, M., Alshehr, M.A., et al. (2017) The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: A systematic review. J Phys. Ther. Sci. 29: 1689-1694.
Recent data suggests that there are about 4 million American women diagnosed with endometriosis, but that 6/10 are not diagnosed. Currently, using the gold standard for diagnosis there are potentially 6 million American woman that may experience the sequelae of endometriosis without having appropriate management or understanding the cause of their symptoms.
The gold standard for endometriosis is laparoscopy either with or without histologic verification of endometrial tissue outside of the uterus. However, there is a poor correlation between disease severity and symptoms. The Agarwal et al study suggests a shift to focus on the patient rather than the lesion and that endometriosis may better be defined as “menstrual cycle dependent, chronic, inflammatory, systemic disease that commonly presents as pelvic pain”. There is often a long delay in symptom appreciation and diagnosis that can range from 4-11 years. The side effects of this delay are to the detriment of the patient; persistent symptoms and effect of quality of life, development of central sensitization, negative effects on patient-physician relationship. If this disease continues to go untreated it may affect fertility and contribute to persistent pelvic pain.
The authors suggest a clinical diagnosis with transvaginal ultrasound for patients presenting with persistent or cyclic pelvic pain, patient history, have symptoms consistent with endometriosis, or other findings suggestive of endometriosis. The intention of using transvaginal ultrasound is to make diagnosis more accessible and limit under diagnosis. It is not intended to minimize laparoscopy as a diagnostic tool or treatment option.
The algorithm for a clinical diagnosis evaluates patient presentation of the following:
Of course, there are differential diagnosis for endometriosis, and those are symptoms of non-cyclical patterns of pain and bladder/bowel dysfunction that would indicate IBS, UTI, IC/PBS. A history of post-operative nerve entrapment of adhesions. Examination positive for pelvic floor spasm, severe allodynia in vulva and pelvic floor, masses such as fibroids. It is important to note that these other diagnoses can coexist with endometriosis and do not rule out possible endometriosis diagnosis.
Hopefully, diagnosing individuals earlier and possibly at a younger age would limit the disease severity and symptoms. This would allow this population to limit the possibility of central sensitization and pain persistence that can affect so much of daily life. Earlier diagnosis may affect infertility and allow this population to make informed decisions about family and career from a place of empowerment.
Agarwal SK, Chapron C, Giudice LC, Laufer MR, Leyland N, Missmer SA,Singh SS, Taylor HS, "Clinical diagnosis of endometriosis: a call to action", American Journal of Obstetrics and Gynecology (2019), doi: https://doi.org/10.1016/j.ajog.2018.12.039.