During a pelvic muscle assessment, patients who have pelvic pain or other dysfunction that includes pelvic floor muscle tenderness will often ask the pelvic rehabilitation practitioner the following question: "Doesn't everyone have tenderness if you push on the muscles like that?" The answer should be "no," and we have research to support this claim. While it may seem incredibly simple to a pelvic rehabilitation provider that a "healthy muscle does not hurt" and that in order to optimize muscle function, the length-tension curve should be optimized, this knowledge is not universally understood by most patients. Tenderness, especially if severe or if the intensity of the discomfort inhibits a healthy muscle contraction, can be eased so that a patient can learn to appropriately contract and relax the pelvic floor muscles.
While logical to rehabilitation providers, the concept that healthy muscles are typically devoid of significant tenderness must be well-established if we wish patients, providers, and payor sources to join in our belief that diminishing such tenderness can be a marker of progress. (Of course we keep in mind that function trumps tenderness, especially when a person has no functional limitations despite presenting with muscle tension or tenderness.) Researchers have aided our profession in establishing that significant muscle tenderness is not present in young, healthy, asymptomatic patients.
In research published last year, Kavvadias and colleagues assessed pelvic floor muscle tenderness in 17 asymptomatic, nulliparous female volunteers (mean age 21.5 years with results indicating low overall pain scores. The authors also aimed to examine inter-rater and test-retest reliability of specific muscle tenderness testing using a visual analog scale (VAS) and a muscle examination method recommended by the International Continence Society (ICS) over 2 testing sessions. This study used a cut-off score of 3 or less on the 0-10 VAS to determine clinically non-significant pain. Inter-rater and test-retest reliability was reported as good to excellent for palpation to the posterior levator ani, obturator internus, piriformis muscle, and for pelvic muscle contraction, yet found to be poor to fair for pelvic floor muscle tone and anterior levator ani palpation. Resulting scores on the VAS were less than 3 for all muscles tested, leading the investigators to conclude that in nulliparous women aged 18-30 who have no lower urinary tract (LUT) symptoms or history of back or pelvic pain, tenderness "…should be considered an uncommon finding."
While this research is in moderate contrast to some research cited in the report, the authors point out that the exclusion criteria and the ages of the women were more narrow in their studied population. Other authors such as Montenegro et al. (2010) have also reported a low prevalence of pelvic muscle tenderness in healthy volunteers (4.2%) whereas Tu et al. reported a high prevalence of tenderness (75%) in women who present with chronic pelvic pain. For male patients, Hetrick et al. concluded that patients with chronic pelvic pain syndrome, or CPPS, have more pain and tension in pelvic and abdominal muscles than men without pain.
The value of research that establishes markers of health in tissues relating to function cannot be underestimated within the realm of pelvic rehabilitation. If we propose or document that reducing tender points, tension and muscle dysfunction is valuable for our patients, research that creates a baseline of non tenderness in patient populations is needed. The research from Kavvadias and colleagues assists our cause, as we can put this information together with other valuable modes of intervention to address pelvic muscle dysfunction within a holistic model of care. If you are interested in discussing further research about pelvic muscle tension, tenderness, and muscle releases, check out faculty member Ramona Horton's Myofascial Release for Pelvic Dysfunction, taking place next in Dayton, Ohio, this June.