So welcome everybody. It is Wednesday, May 12, it's 2pm Eastern 1pm Central. Welcome to the this week's version of the national fellow online lecture series. Reminder, this is sponsored by the education and fellowship committees through am SSM. The remember the the point of these lectures is really to serve as an adjunct to your programs educational programming. We want to provide our fellows, as well as other trainees with direct access to educational experiences from top MSM members in a variety of formats and really to assist in preparation for the CAQ for our soon to be graduated fellows as well as for those of you who are taking the recertification July or November. Just as a reminder, please mute your devices microphone, you can submit questions to the chat function clean your name and program if you wish I will try to monitor that throughout Dr Dugan's talk. After the, the talk is over, Andy Meyer will send out an evaluation, which will also be available on MSM collaborate. And with that, I like to introduce today's speaker and talk title. Today we're going to have Dr Sheila Duke and I'll do again, out of rush. She's going to be speaking on pelvic floor dysfunction. Very briefly, this does not do her justice, but she's a current professor and the interim chair for the Department of Physical Medicine rehabilitation at the Russian University Medical Center Chicago. Dr Dugan teaches medical students and musculoskeletal and pelvic health, and really mentors the capstone projects. She's a co founder for the rush program for abdominal pelvic health. She's published numerous book chapters and articles and lectures nationally prior to medical school she was a physical therapist and both orthopedic and neurological rehabilitation so she, she really has a wealth of information to offer, not just to our fellows but to everyone who's listening today on this, this particular topic. With that, I'll let Dr Dugan, take over and let her upload and share her slides. Okay. Let's see if I can get this right. Okay, here I am. So it's great to be here today let me put this on from the beginning that right. So I'm here to talk about my favorite topic, the pelvic floor, but just want to say, you're in a wonderful area of medical care, and I use the analogy of sports medicine a lot when I'm talking to my pelvic floor patients, you know, be it that they're you know, an older woman with urinary incontinence or an older male after prostate cancer, there's kind of sports specific steps that you want to have people be able to do before they're ready to kind of take the pelvic floor on the road, if you will. So, I hope that today's talk will make you understand how much you already know about the pelvic floor. Get rid of some of the trepidation that you might have about asking around bowel, bladder and sexual function, because of course we take care of human beings not just athletes and they all have bowel, bladder and sexual function issues that add to their quality of life and impair their performance in their given sport. So welcome to today's talk, it's going to be very clinically focused, because again I want to kind of reduce any stigma you have about the pelvic floor needing to be a separate entity that only certain people take care of. I have no disclosures for today's talk. I hope you understand the role of pelvic floor muscle dysfunction and pain and impairments that you're seeing every day in your sports medicine clinic. Recognize appropriate healthcare providers, and how they're trained, so you have teammates that you can work with to evaluate and treat pelvic floor muscles. Lastly, because of this area we want to make sure that there's an informed consent, and that you use pictures or models if you are providing pelvic floor care that shows the patient exactly what muscles we're talking about and how they can be palpated externally and internally. You can also consider having a chaperone. So we're going to be talking today about so much about sexual assault in the pelvic floor which is a place that I've worked with others in the AM SSM. But just a reminder if you're a traveling physician that you do not think about using a hotel room with a bed as a place to examine an athlete that you be sure to rent a separate space where you can have an exam table, and you might also plan to have someone come in pairs at least to come to the exam room, and certainly for the internal part of the exam that's something that can be done one on one between the provider and the athlete. treatment plan, like any other sports medicine treatment plan includes a defined course specific outcomes and timelines. And if we think back to some of the heinous sports related sexual misconduct that we've heard about. We need to know that we're doing medical care and if includes pelvic floor muscles because of the history of the physical exam, and you have a treatment plan you have expected outcomes and a defined course, and then we change directions if it's not helping the individual rather than prolonged care that is then inappropriate. So, let's get started. What are the pelvic floor muscles their muscles that attach internally to the pelvic bones. They are a support structure for your abdominal and pelvic organs and they also have specialized outlets. spine and limbs which is why our athletes especially who do repetitive high force activities have have to use their pelvic floors which may become tight and ineffective dysfunction can present in many ways it can present with pain and or urinary defecatory or sexual organ issues. So these are some corroborating questions and information that might help you to put the pelvic floor on your differential diagnosis, the pelvic floor muscles are integrated into lower extremity in the trunk. So I often would say if you presented a shoulder case, and all you did was talk about the gun and humoral joint, and didn't mention the scapula thoracic area of the proximal core muscle attachments, you pretty much be left out of the sports medicine fellowship, and somehow we're allowed to talk about the hip or the pelvis or the lumbar spine without mentioning the pelvic floor muscles, which to me is pretty ridiculous, and hopefully that's changing. And as we'll talk about today there are special ways to be trained and to care for the pelvic floor so not to say that you're all going to be doing that in your practice but you certainly need to have partners in your community that can do this assessment, otherwise your differential diagnosis is going to be limited and you're going to fail to be successful in treating patients adequately. They do work, the pelvic floor muscles do work in series with back and hip muscles, they function as a key core stabilizer. So, problems above or below the pelvic floor can root themselves in dysfunctional pelvic floor behavior so you know you might find that prior to a pelvic pain the person had a distal limb they had a stress fracture. They were in a boot, they had knee surgery. So really thinking about this kind of kinetic chain as well as when you think about the history of present illness what got somebody to where they are, you know, did they have a limb injury and then they started to perform with compensatory patterns which then turned on their pelvic floor to the point of now pain and dysfunction. Pelvic floor muscles are constantly working so they support the viscera and they maintain continents, and they basically contract to maintain closure of the pelvic floor, and they do this even in increasing abdominal pressure like weightlifters or somebody, or bending a jump off of in a track meet or off of a beam, and they actually have to be relaxed to allow urination defecation. So I'm not going to have a lot of time to talk today about the patients I get referred from urology and colorectal surgery and urology, they're really have trouble urinating completely or being able to have a bowel movement. But again, this idea that they have to relax in order to urinate or defecate can become a dysfunction as well. Acute pelvic pain has many causes as you all know, I was talking to my friend Heidi Prather last night and she gave me this great analogy that she uses that the, the organs are the fruit, and the pelvic floor is the basket. So I typically tell my patients that there's the organ doctors and then I'm the container doctor. I'm the person responsible for muscles that attach to the pelvis from above and below. I'm responsible for how these muscles are functioning correctly. Acute pelvic pain can of course come from visceral sources. And we do see athletes who have problems like endometriosis. We see people that have, you know, kidney stones and so I'm sure you've all seen visceral pain in your, in your training years. And then there's kind of somatic sources which is putting together the muscles of the pelvic floor, abdomen, back, and the proximal lower extremities as well as bones, joints, and all the parts of joints like ligament and cartilage. And then there's also neuropathic sources, lumbar nerve roots, the predendal nerve is a local peripheral nerve, there's other local peripheral nerves, the ilioinguinal, the genitofemoral nerve. So this is all things that you have learned in your, in your training and so please don't, please remember to bring all that forth as you're listening to a patient and how they got to where they are because sometimes there's the intersection of visceral and somatic sources. As in any other parts of sports medicine, careful listing of symptoms, the nature and the onset will start to give you some good ideas around somatic versus visceral, around a local nociceptor versus a referred pattern. Was there an acute versus a chronic injury? You can use things like the pain scale and the visual analog in order to at least get a starting point for how the athlete marks or feels about their pain or their performance right now. If you can have somebody point to the location of pain, it's really helpful again to think about a local nociceptor and assessment of other organ systems, especially for the pelvic floor is important bowel and urinary habits. Is there pain related to their menses? And is there a history of sexual trauma? Now, again, I put this on here because just like having a grade four tear with a, with a vaginal delivery causes trauma and scarring to the pelvic floor muscles. We know that a history of sexual trauma can also set people up for abnormal muscle behavior. And I have become more and more comfortable. And I find that it's more and more important for me to ask a simple question like, has anybody ever put something into your vagina or rectum without your permission? So this is a way to, you can further say, because there's literature that would say that this has happened to you, that your muscles will perform abnormally and can lead to pain and problems such as, you know, urinary pooping and sexual dysfunction. So again, has anybody ever put something in your vagina or rectum against your permission? Obviously the right genitals, depending on the patient's genital sex. It allows the floor to be opened. And it also, like I find in my clinic, it also gives people a moment to stop and listen and think about it because if it hasn't happened to them, it could have happened to somebody else on their team or in their family who has revealed that they've had been victims of sexual assault or sexual trauma. So please try to get comfortable. You could work on this by asking, you know, practicing this when you're in clinic with each other, just to make sure that you're able to bring that important part of information forward. Certainly we would ask, what is your pregnancy history? What about deliveries? Have you ever had any surgeries? So again, these are important facts you need to know for the pelvic floor function. Obviously neurological symptoms are important and as in any part of the body, they make us start thinking about a peripheral versus a proximal neurological source. And then pervious or previous injuries or surgeries are also helpful to understand tissue changes or, you know, changes in how things are aligned. Again, as in any sports medicine exam, observation is very important on the physical exam, altered posture, gait, seated position, facial expression. You already know a lot about a patient's situation before they even open their mouth. If you watch them come into the room, or if you've roomed them, if you notice how they're sitting, if you take a look at their facial expression, and for that matter, how other people around them, how's the trainer chatting with them? Is there a coach with them? Is there a family member? We'll go right to sort of the somatic exam. So the musculoexcell examination is really important and really starts with palpation. And you use your bony landmarks that you've been taught about for lumbar and hip and sacroiliac patient pain. And laying hands on a patient is also really important because it gives you a lot of information. And obviously you first ask permission and say that, now I'm going to have you undress and I'm going to lay my hands on you in order to feel different muscles, bony prominences, and make sure that you get consent for that. I think we sometimes forget that that's important. And if somebody has been the victim of trauma, laying of the hands could be triggering for them. Anyhow, there's certainly myofascial pain that's pretty common in certain muscles around the pelvis, the glutes, the piriformis, the adductors, and the psoas. And today you're going to also think, well, now what is deep to the piriformis and what other area do I need to think about laying hands on or referring the patient to a pelvic floor provider who could do so, which would be the obturator and ternus muscle, which is of course just the next layer down from glute, piriformis, and then obturator. The abdominal exam is also really important, especially when we have an overlay of pain, which causes breathing disorders or urinary or fecal issues, which cause bloating or bladder pain. So again, you know, pull out of your hat, your abdominal exam. I think that many physicians don't know how to do an abdominal exam and people end up in the ER with a right lower quadrant pain that really could be a psoas problem. And they get all kinds of testing and lab work and nobody really lays hands on the patient. And being able to distinguish a musculoskeletal and intra-abdominal process is important, especially when you're traveling with the team. The pelvic floor examination, I have this really old slide here, these pictures on the right. Just like any other exam, there's observation, there's going to be special testing, there's going to be a neurological exam. And again, orienting the patient to all this before you ever get to this part of the exam is going to be really important. Are there scars? In a multiparous person, women, is there prolapse, meaning that the tissue has lost some of its integrity? In a patient with prostate cancer, is there scarring around the rectum? So again, I know we see athletes of all ages. Neurological function, like any other part of the body, includes sensation and motor testing. So again, you can pretty much tell a patient who's read about their pudendal nerve pretty quickly in the office that your pudendal nerve is working because you have intact sensation and you have the ability to recruit your pelvic floor muscles. And there is some detail here that LACOC is a physical therapy scoring system. And you can also check reflexes over here on the far right. You can do a perianal swab and look for a contraction of the rectum. And again, depending on your version of sports medicine and if you're traveling with teens and do you have to think about spinal injury, it's good to be confident with your examination of reflexes around the perineum. The musculoskeletal or pelvic floor bimanual examination is not the bimanual examination you learned as a family medicine or in your OB rotations. It's really to feel the muscles where they originate and where they insert. And thankfully, just like other parts of the body, the anatomists have named things well so the puborectalis muscle starts on one pubic rami, goes around and lassoes the rectum and attaches to the other pubic rami. So you can become very proficient in understanding muscles where they begin and where they end. You can also ask the patient to do a motion so that that muscle will be contracted. So for instance, if you're doing an examination in the vagina and you are putting your finger on the obturator and ternus muscle, again, deep to the glutes, to the piriformis, the obturator and ternus, a frequent pain generator, you can ask the patient to abduct their hip and resist abduction to feel the obturator and ternus muscle there on the lateral side of the pelvis. Most of these muscles begin at the pubic bone and go all the way back to the sacrum and coccyx. So if a patient has pain that's both anterior and posterior, if they mentioned any tailbone pain, if they're having trouble with defecating, you also want to think about a rectal exam and sort of demonstrate to yourself and the patient why you may be having the symptoms you're having and then also what we need to do to treat the muscle. So we sometimes fail pelvic therapy by treating only the vaginal aspects if it's a female and not looking at the rectal exam. And also if you have a coccydynia and your X-ray is normal, patients still have pain because of tightening of the coccygeus muscles, right and left, or the alignment of the sacrococcyx joint. So it's really important to have proficiency in the rectal exam as well. Again, there are superficial muscles that really aren't typically palpated unless there's some top bands that are present. So in this picture on the top, we have some of those superficial muscles. This is the muscles of the female pelvic floor. So the bulbocavernosis and the ischiocavernosis are sort of in this triangular area versus the male pelvic floor where these muscles are up on the penis and do things like cause erection of the penis and cause ejaculation of the penis. And again, having a picture and showing a patient why they're having erectile dysfunction is it can be really relieving to your athlete who thinks, why has my hip pain or my pelvic pain now started to get in the way of sexual function and is this in my head? So again, what you're, no pun intended, is this in my brain that these things can go along if these are untreated. So rather than thinking, oh geez, now the patient is really getting into their minds, understand that the anatomy is such that these different layers of muscles will start to have dysfunction one after the other. This is the levator ani, the sling of muscles. Again, I like Heidi Prather's analogy of this is the basket around the fruit and around the openings that allow things to exit normally or not so normally. And you know, does your athlete have a longstanding history of constipation and now suddenly they're having pelvic pain, but nobody's putting the two together. So again, this is just another demonstration of muscles where they originate and where they insert. I don't think there'll be on your test, you'll have to label any muscles, but just remembering that there are superficial and deep pelvic floor muscles and that the levator ani is one name that puts the three separate slings of muscles together into one name. This has shown up as colorectal surgeons talking about levator ani syndrome. In gynecology, they might call something vaginismus, which means that the muscles aren't relaxing. And as we all know, coccidinia simply means pain near the tailbone, but we can be a lot more specific and elegant with our diagnosis and treatment. So again, this is a little more detail about the obturator internus and the coccigeus, again, two that I think you're commonly going to be thinking about or even seeing, and maybe it's seen you and you haven't seen it. So the pelvic floor examination does include an internal exam, and I took this old drawing that I found, which is about as inaccurate of a picture as you can have. So because of the element of internal assessment and the possibility of people being traumatized, either in the community by a sexual assault, sadly, even in the sports medicine community, or even by a previous provider who has not asked, is it okay with you? Is this uncomfortable? Do you need me to stop? But rather has rushed through things for a patient. It's really important for you to understand that eye-to-eye contact is really going to be important, and that you've already prepped the patient for this part of the exam. You've already asked about having a chaperone with them. And if you are a male provider, and even myself as a female provider, letting them know that a chaperone is available, but I would definitely have a chaperone with you if you are a male provider with a female patient, and vice versa, probably true. Okay, so let's move on. So again, the neurovascular examination is really important, like in any part of the body. Again, understanding is the sensation intact? Can they do an active contraction? The patient must be oriented to the both external and internal exam. And I know when I gave my talk at the AMSSM meeting, that someone was asking about, is there a way externally, and even with the patient clothed, that you could start to figure out whether the pelvic floor is involved? And I would say that if the patient is in this lithotomy position, or the hook-lying position, where they're laying on their back with their knees bent up, you can palpate the ischial tuberosities on each side externally, through however many layers of clothing or uniform is needed. And then if you just take your finger, just hook it medial to the ischial tuberosity on each side. So if you went distally, you'd get hamstring. If you come medially and sort of press in that space between ischial tube and rectum, that's going to be a nice place externally to palpate the external pelvic floor, and to look for symmetry or asymmetry in terms of tenderness, and how much pressure that you're feeling. Now, when we learn to do this work, it's usually through special coursework, which is a tactile coursework, hands-on. The American Physical Therapy Association has classes as well as at some of the AANEM, or the AAPMNR meeting I've taught classes before, as well for folks to learn manual skills. Some, in gynecology, they talk about using a cotton tip swab to sort of see about allodynia. And I think that's probably because OB-GYNs don't typically think about neuropathic pain like we do in sports medicine or rehab. So you can take a cotton tip swab or just lightly palpate with your own finger as the examiner to see if there is not only sensation, but either a bad feeling, an allodynia, or a change in sensation where a light touch is perceived as a terrible pain or a sharp pain. And you can also, again, palpate these external attachments of the local muscles. For the internal exam, it's a single digit insertion around the introitus. So again, just like there's coccydynia, there's other things like vestibulodynia, where a patient's vestibule becomes extremely uncomfortable for uncertain reason, or there's something also called vulvodynia, where again, that's another description. Vulva is the non-hairy skin around the opening of a woman's vagina that includes the labia minora and labia majora that can again become hypersensitive a la kind of a complex regional pain sort of presentation. You can ask, again, the patient to use their muscle like bearing down as if to stop the flow of urine and palpating laterally. You can again have the patient AB duck their knee against resistance so that you're actually using this internal hip AB ductor. And again, we consider the rectal exam probably in sideline as long as you can make eye-to-eye contact with the patient. So again, the most common thing that we find in the pelvic floor is myofascial pain, but other potential causes of pain in this area could be trochanteric bursitis, referred pain from the lumbosacral spine of the SI joint, hip joint pathology, some kind of stress fracture, acute fracture. So again, you, and then visceral referral, which you're going to be thinking about when you hear the history. In a visceral referral pattern, you may not be able to find a nociceptor in the muscle of the pelvic floor or in any of these other regions. But I guess I put this up to show you that every pelvic floor exam includes a hip, a pelvis, and a lumbar exam. So it's a bit of what I was taught as a physical therapist, kind of a quarter exam. You want to examine all the things in the kinetic chain for that painful part of the body. So as I'm ruling in a pelvic floor dysfunction, I'm also ruling out, this is not a radiculopathy, this is not a labral tear, this is not a sacroiliac joint dysfunction, so that as I'm doing the exam, I'm today talking about the pelvic floor exam, but it's going to be part of a complete examination of the lumbar pelvic hip area. Uh-oh, the screen's showing Ellen. I paused my screen share, I don't know why. Should I come back out and come back in? I think I will. Sorry about that. All right. Is my computer acting up? Oh, rats. Oh, here we go. Okay, so just like in any part of the body, trigger points are a main pain generator. They're superficial local areas of hyperesthesia that cause sharp pain and cause a pattern of referred pain, just like in the upper trap, referral to the arm, same thing here. An active trigger point prevents elongation of the muscle, so then it gets perpetuated because it's gonna change the link tension curve of the muscle and it's gonna reduce its ability to function well. Thankfully, it responds to soft tissue techniques and really in studies, this is the most common and overlooked cause of pelvic pain. And I met a male patient today who has been through this crazy workup, colonoscopy, sigmoid. He's had this test called an anorectal manometry where we put a balloon and try to get a person to expel the balloon. There's also a test where you basically get contrast put into your rectum and you have to defecate it out. And nobody examined the patient who's got tight pelvic floor muscles and probably if we treat his myofascial pain, his constipation will get better. So make sure, we examine patients and if you are worried that there's a pelvic floor problem, if it's on your list, if you don't do the exam, make sure you refer to somebody who can do the examination. One time I went to a PT office and they said, oh, I told my patient, if you don't get better, I'm going to send you over to that PMNR doctor who's going to put a finger in your rectum. I said, first of all, why are you selling it that way? Secondly, I'm glad you're thinking if he's not getting better that you need to broaden your diagnosis, but you could also pull out your anatomy book and show the patient, here's another set of muscles that could be part of the problem. So let's not perpetuate that something about the pelvic floor examination is inappropriate or terribly painful or awful. It's just part of what we need to do when patients present with a certain history and physical exam and certain types of injuries. So the levator ani or that set of three muscles is a real common place to have trigger points. The obturator internus being one of those members that's very common and then also the piriformis. So again, these layers, am I pressing externally? Am I on glute? Am I on piriformis? Am I an obturator internus? Hard to know when you're pressing internally, you're pretty certain you're on the obturator internus. In women, most commonly the referral patterns go to the vagina, the perineum, the rectum, the bladder, and there can be associated problems with lubrication. So dyspareunia, feeling of rectal fullness, problems when somebody goes to the bathroom. So please listen carefully for those types of complaints. It isn't mandatory, but it's not uncommon. And there can be referral patterns up to the abdomen, to the buttock, to the thighs. And again, one of the things on the exam that you're asking somebody whenever you're palpating a trigger point is, is that hurt here? And is it referring anywhere? And many times you're going to be able to cause the patients presenting symptoms, which of course is something I will document. There's a trigger point located X and it's causing the patients referring symptoms of, or presenting symptoms of Y, whether this is in the cervical region, whether this is lumbar, whether this is a glute that's referring down the lateral leg to the knee, same thing in the pelvic floor. The levator ani muscle can also refer pain to the sacrococcyx region. Obturator internus can also go to the anal region. So again, think about this when you have patients with these proximal hip and pelvic things that are not getting better with your typical diagnoses that we like to give. Again, why are these muscles are set up for this? Because they support the organs, they provide stability. They're constantly working to prevent incontinence. They have other actions like sexual function. They're affected by psychological stress and they're really part of this kinetic chain. So they're at risk, especially when core muscles are weak, or as I mentioned earlier, if you've had some kind of distal lower limb injury and you started to make these compensatory patterns. And again, as much as we know about myofascial pain, we're learning more and more. This year's American Academy of PM&R, there was some elegant studies brought forth by physiatrists that work at the NIH, taking a look at these centrally maintained pain mechanisms. Even the idea that if you have a right-sided adductor muscle strain, that the feedback into the spinal cord can cause some spillover into the bladder or into the bowel. So there's all of that sort of central nervous system upregulation, local inflammation. Somebody gets a little bit of an infection and then what was a minor problem becomes a major problem. Again, we talked about local trauma. The person that I presented at the annual meeting was a cross-country college athlete who had been sexually assaulted and hadn't really told anybody until I asked her, which was part of her presenting problem. There's other posture and biomechanical abnormalities that we see every day. We see internal rotation of the hip, leg length discrepancies, people that seem to have pelvic malalignment that comes and goes. We heard some great talks at the meeting, too, about some of these hip pathologies. And then, of course, don't forget pelvic organ pathology and the visceral somatic reflex. So if somebody has endometriosis, that endometrial tissue is sending messages to hip and abdominal muscles for constant guarding. And then, of course, this wind-up phenomenon with persistent inflammatory metabolites, not to mention a wind-up when you're not able to perform well. And this is important to our athletes. It's maybe part of their being at school and that's part of their identity. So there's also that sort of wind-up of the, this isn't going to get better and what am I supposed to do next with our athletes? So lastly, I want to, again, reiterate a pelvic floor treatment plan, like any treatment plan, includes tissue diagnosis, a defined course, specific outcomes, and a timeline that's based on clinical reasoning. And we have an athlete who's had months or years of chronic pain, wherever it is. We're not going to make them better immediately, but if we've completely missed a set of tissue that's part of the problem, then we can bring forth the idea that we should be able to change and we should be able to impact your function. So for instance, if your pelvic floor is chronically tight, you really can't fire your gluteus medius. It's almost like if I was trying to fire my biceps, but my triceps would not let go, my biceps isn't going to work. So again, if we're going over and over again, doing the same hip abductor strengthening and it's not changing, then kind of reconsider, is the antagonist muscle not able to relax all the way? So the treatment of myofascial pain in the pelvis is very successful. There's a large literature of pelvic floor physical therapy. The physical therapist in the pelvic floor region is also going to be thoughtful around posture, gait, range of motion of the spine, pelvic instability, lower extremity strength and mobility. Obviously, we're going to take a look at sports specific movement patterns. When during your performance, do things start to go south on you? And these other contributing factors could be causing the pelvic floor dysfunction or it may be an acute injury like you're on the beam and you injure your pelvic floor muscle. But these other instabilities and lower extremity abnormalities will just mean that the course of treatment will take longer. They also will do the internal vaginal exam and then they'll be starting to treat these pelvic floor muscles. Again, giving the patient the option if it's too uncomfortable, if you're not ready for this or if it's bringing up anything negative, if you had a triggering event, then we can always stop and discontinue. Some of our patients don't even get an internal exam when they first come in for a visit because they have this concern and maybe they have or have not yet revealed some type of trauma, but even without trauma, this is a very personal part of the body. People think I'll read about my pelvic floor and I'll go home and just do a hundred Kegel exercises every day. So if you had a, I don't know, a biceps injury and you thought the way to fix it is by actively contracting it a hundred times a day, it would end up going the wrong direction. So we really only focus on strengthening once we've been able to normalize the muscle tone and normalize the length of the muscle and the behavior of the muscle. And then like in any other area, we'd start with laying down and doing some strengthening and then maybe half kneel or standing or jumping or landing as is needed by the patient's functionality. In the course of pelvic therapy, if it's not going well or the muscle doesn't seem to be able to relax, sometimes the patient is sent back for some trigger point injections. Sometimes we do this right ahead of a physical therapy appointment in order to kind of allow the patient to tolerate, the athlete to tolerate the treatment and make for a more specific outcome of improved muscle function. Here we go. Other things to consider as in any myofascial patient, acupuncture, oral medications, if again, it's a prolonged course and the patient has these grooved abnormal movement patterns, we sometimes get into tricyclics or anti-seizure meds. The medications that are FDA approved for fibromyalgia, we use off-label for local myofascial pain. If you can get some muscles to relax and then they recur with their tension, you can even go as far as a Botox as another way to prevent contraction of the muscle. And again, contracted muscles with intense myofascial pain are thought to diminish blood supply, cause local ischemia. This may also then add into that local pain producing substances being peripherally deposited. So we've got this kind of way to break that cycle. Like in any other part of the body or any other athlete, acute flares are well treated by ice, heat, local massage. And again, since anxiety can literally cause your sphincters to tighten, understanding the role of anxiety that's playing in your pain or your performance problem is also something important to clue the athlete into. Okay, I put a few, just a few references, but there is a huge literature on pelvic floor and rehabilitation of the pelvic floor. I have Janet Travell's book about myofascial pain and dysfunction and a little bit more about why does myofascial tension cause you to have local pain. But there's lots of things that you can read about to better understand. The only thing I would say as a trainee is it's really important to get out and observe physical therapy. Again, depending on your interest in pelvic floor, my trainees go to the pelvic floor physical therapist here at Rush and are able to observe as long as the patient is comfortable with having another person in the room. And like any other time in the healthcare system where we teach trainees at the bedside, it's not unusual for a patient to be asked, is it okay if the medical student sees you first or what about, this is my fellow, can they start the visit? And certainly if the patient is not comfortable with it, then we would not do that. But, and if it's not just pelvic floor and any chance you get, please do deposit yourself in the physical therapy office and ask to observe what people are doing, understand the rationale and the expected outcomes so that once you're in your practice, you can understand what type of provider you wanna work with. And I also tell my trainees that to have a great sports medicine practice, you have to have great partners in the world of physical therapy and other manual therapy providers. So make that connection now while you have the time and the interest. All right, so that went quicker than I thought and I even talked pretty slow for me. So can we open up for some questions or certain cases? I don't know what's been happening in the chat. So Peter Zhang just wrote, let me just take a look here. One, where can sports doctors get more trained on doing a thorough pelvic floor examination? I'll let you handle that one and I can just read them as we go. Sure, so thanks. I just, interestingly, right before I got on, I had a nice message from a group called Herman and Wallace. So Holly Herman is a pelvic therapist in Boston and Kathy Wallace is a pelvic therapist in Seattle and they have done a good bit of training of pelvic floor physical therapists across the country. And pelvic floor physical therapists can get a special certification from the APTA called the Women's Health Certification, which is sort of a sad thing because when I see a male with pelvic pain and I have to tell him how to find a pelvic floor therapist, I see veterans that come from across the country here to rush to a road home program for military sexual trauma. Anyhow, I send people back to other parts of the country and I tell them, find the APTA Women's Health Locator to find yourself a pelvic therapist. And of course, first question is, do you take care of men also? So anyhow, Herman and Wallace is now offering certification for providers that would like to be certified for pelvic floor, which includes DOs, MDs, chiropractors, and not just physical therapists. So I don't have any conflict of interest recommending Herman and Wallace, but that might be a place to, if you'd like to get a certification, but I would also ask you just to partner with your local pelvic floor physical therapist. And I think that you can at least understand a lot more about what they're doing. I would say in physical medicine or rehab, it's one of the skillsets that my trainees get as part of being a trainee here. So you might also find a physician at your site that would also be able to train you. But great question. The next one is, is there any particular female athletic population or age group that are more at risk for a pelvic floor injury? Well, sure. And it might kind of depend on what type of dysfunction or pain you're talking about. So pelvic pain, I would say just about any athlete, but repetitive, high impact, landing jumps, urinary incontinence, again, we see in high impact volleyball players, gymnasts, cheerleaders. You know, some of the posterior pain, the coccydynia of course is people that are falling a lot, gymnasts, divers, other people that have high impact to their external pelvic floor. But I think when you listen carefully to the history of present illness, there's many different ways that people present to my office. So, you know, don't limit yourself to thinking it's only, you know, types of this type of athlete. If you've ever worked the finish line of a marathon, there's a lot of urinary incontinence going on, at least when I used to work at the Boston Marathon. So, you know, repetitive, high impact stuff for sure, but then odd landings, you know, unexpected parts of someone's routine, you know, landing on the outside of the foot and having to right yourself and doing something in the medial, you know, lower limb near the core, all those things could land you with the pelvic floor dysfunction. And kind of my own question to piggyback on that, if we want to, you know, bring it back to what you said, not just look at the female, but the male athletic population, I would think sports such as ice hockey, rowing, those are just two sports that come to mind, but are there other sports from the male population that one should be aware of if he or she is taking care of an athletic team? Absolutely, I think, you know, hockey and goalies in particular, you kind of get the athletic pubalgia sort of is on the list, but why not the set of muscles just, you know, inferior and a little bit more, I get deeper to the attachment of the adductor or the rectus abdominis or the rectus sheath at the superior aspect of the pubic bone. So absolutely muscles, you know, like in skating even not just the goalie, where you have to repetitively generate force and stop quickly, you know, soccer, lacrosse, anything that's played on an uneven type surface, absolutely, men and women for sure. I think, I'm not sure if you addressed this or not, but Gabby wants to know what resources can you recommend to issue for a home exercise type program for patients where maybe there aren't resources available or there aren't physical therapists that have the expert training that are needed for this dysfunction? Well, Gabby, I think that's a good question, but I also think that non-specific input brings non-specific outcomes. So if you could, the American Physical Therapy Association, the APTA, if you go to their women's health locator, you ought to be able to find a physical therapist somewhere close to even in rural America, because like I said, I'm finding these all the time for my veterans that go home to all over the country. I think that in most cases, it's nice to have a exam and a specific treatment. And there's all kinds of things on the internet around the pelvic floor. You might be able to find a urinary incontinence thing. But again, if you strengthen a muscle that's tight and not working well, as long as you let the patient know, you can go home and do these, look up some stuff and do some Kegels, but if you're not getting better, then you need to call me back. I think it's probably important because even though I was a physical therapist, I am not a fan of sending people home with a sheet of exercises, unless I really watched them, that they understand what they're doing and that they can do that with the right quality that I want them to do. So I think when in doubt, try to find a partner who's somewhere in your community that you can use as a referral. Gotcha. And I think we're at time for one or two more questions. The next one is, have you found in anecdotally or in your own practice, musculoskeletal muscle relaxants or things such as SSRIs or duloxetine as an example to be effective for patients who also have concurrent mood disorders, such as general anxiety disorder or anxiolytic issues as well to be effective? Yeah, great question. I think I did not mention, what I use a lot is a suppository, a valium suppository, a diazepam suppository as a way to put muscle relaxant into the pelvis if that's exactly where the pain generator seems to be located. And I use my compounding pharmacy partner here, and not too far from me. And in this case, we can limit how much systemic intake, there will be some systemic uptake as well as local muscle uptake. So if you can work with a compounding pharmacist, that's helpful. And yes, I do feel confident and capable in treating somewhat the aspect of let's say, depressed mood and pain, but I do not feel like I've been trained adequately to understand clinical depression and its treatment or anxiolytics. So I would like to partner with a behavioral health provider, which I do a lot. And I'm really blessed to say there are some great behavioral health folks here at Rush that have always been part of my practice. And so, getting beyond, seizure of membrane stabilizing meds, or maybe SSRIs. Beyond that, I feel like I'm not really within my realm of practice. And as I said before, if I'm gonna be recommending gabapentin or duloxetine to a regional problem, I will tell the patient that the FDA has approved this for fibromyalgia, and I'm using it for a regional myofascial problem. So it's off label, but it has been very helpful in my practice. So again, I think just being direct with your patients about what you are or are not expecting or what's appropriate for how you're using a medication is useful. Good habit to get into. And don't get out of your lane. I've done that, and it's not a good idea, or did that early, and always call in a partner. And I have one more question. So I don't think anything else on the chat. So this is one of my questions, as someone who is probably not very experienced at all in doing pelvic floor examinations, because it wasn't a significant part of my training. I'm sure this holds true for many fellows and sports medicine practitioners. When you suspect pelvic floor dysfunction, but obviously you're not experienced, do you find that your go-to, if you wanna see something, would you go to a 3T MRI with, you'll speak with your collegiate radiologist of I'm looking for X. Would you, if you feel comfortable, go with an ultrasound? If you're trying to look for something, whether it's an enthesopathy, or God forbid, a mass or a tear. I mean, what is your imaging approach? Cause it's a very challenging area. And if you're not an expert, you don't wanna be doing something that's inappropriate. I agree. I think Jason, a lot of times, imaging might be there to rule out something else, right? So you're gonna think, could this be a labral tear? I think the exam, there's a positive, whatever the hip exam seems positive. We've treated the pelvic floor. It's not getting better. So is there something driving the pelvic floor behavior? In terms of ultrasound, I would say that I think in the hands of some of my physical therapy colleagues here, they probably have the most capacity to sort of look at muscle behavior on ultrasound. Many of these things will not show up on any imaging. I mean, unless I guess you do do something like more in the research realm of a particular MRI or thing. So I would say that imaging is typically used to rule out something else and that we really, as physicians, I haven't met a lot of folks that are really using, let's say a vaginal ultrasound, a transvaginal ultrasound to take a look at muscle. But that is something that I do get, I'll get clips from the physical therapist saying, here's the right obturator, here's the left. So it might be a treatment modality more than a, your fingers are gonna, like in many other things where you're getting the test to corroborate what you already know by your exam, trust your exam and trust people that know how to do the exam well. Gotcha. Yeah. Well, we are a little over 50 after the hour, depending on what time zone you're in. I wanna thank Dr. Dugan again for giving a great lecture on a very challenging topic. I believe we only have one or two more lectures left for the online lecture series for the year. So again, thank you to the subcommittee as well as today, Dr. Dugan. Be on the lookout for emails from Andy Meyer for I believe it's one or two more lectures. And we will plan on continuing this again next year, starting in August. So thank you all for attending as well as everyone who is gonna be watching this on the AMSM YouTube channel. Any questions, feel free to reach out to myself or Andy Meyer and please complete the evaluation when it is sent by Andy at your availability. Everyone have a good rest of the day and stay safe. Good luck on your exam, see y'all. Thank you.

3rd Edition, CASE 40

3rd Edition

Obstetrics

pelvic floor dysfunction

sports medicine

pelvic floor musculature

athlete performance

myofascial pain

pelvic floor physical therapy

chronic pain treatment

imaging approaches

behavioral health