The Intersection of Orthopaedics and Pelvic Health
By Danielle Santora
PT, DPT, OCS
As a child and an adolescent, if you were to ask me what I wanted to be when I grew up, I would have most definitely replied by saying a professional student. Seriously. I loved taking notes, studying and most of all, I loved learning new information.
Knowing this, it’s probably not surprising that I decided to pursue physical therapy after undergrad. Physical therapy school is usually an additional three years after undergrad, and I was excited to further my education. Once in physical therapy school, I was most drawn to orthopaedics. I liked that it felt like a puzzle. A specific diagnosis could be driven by various different factors based on the individual, and it was up to the collaborative efforts of the PT and patient to determine those factors, and come up with a solution.
I was introduced to the pelvic floor towards the end of physical therapy school, much the same as most physical therapy students are, which was for a few hours in my “Special Topics” class. It was presented to us as a specialty within orthopedics. We were taught the most basic concepts, and then told the rest was “to be continued…”. If we wanted to learn more, we’d have to take additional courses. My interest was instantly piqued. How could I effectively treat patients when it appeared that there was vital information regarding the pelvis that might not be readily available to the average physical therapist?
I decided to begin my professional career in orthopedics, gain more knowledge and experience, and then take the appropriate courses and find the best mentorship before transitioning to pelvic health.
My interest in the pelvic floor was renewed a few years into my practice, following a personal experience with pelvic floor physical therapy (more on that later). Not only did I want to learn more, but I finally felt ready to apply my orthopedic knowledge and experience to this new field. I eventually made the transition, and I have not looked back since. I have learned, and continue to learn, so many new things from my studies, my colleagues, and especially my patients. I am so grateful that I have found my niche that allows me to fulfill my goal of being a lifelong student.
Now let’s discuss the ways in which my beginnings in orthopedics have shaped the way I practice as a pelvic floor physical therapist, and how my transition into the world of pelvic health has changed the way I treat currently. I hope it helps answer questions for practitioners who are thinking of transitioning to pelvic health, as well as for patients who are curious about what pelvic floor physical therapy entails, and what it can offer them.
Quick disclaimer: The below is my personal experience as both an orthopedic and a pelvic floor physical therapist. Each physical therapist practices differently, and the interventions they employ will vary greatly based on the practitioner, setting, and patient. There is not a correct or incorrect way to practice PT.
What I’ve taken from my orthopaedic experience to my pelvic floor practice:
1. I am still looking at the body in its entirety
In orthopedics, it is common for PTs to take a “full-body” approach when treating patients, as it is well-accepted that dysfunction in one area of the body, may contribute to pain or dysfunction in another area of the body. We call this “regional interdependence”. For example, a patient who complains of knee pain when weight training may benefit from hip strengthening to improve the dynamic alignment of their lower extremity when performing a squat.
Despite the fact that pelvic floor physical therapists are specialists, the pelvic floor does not function in isolation, and we also treat based on the concept of regional interdependence. For example, stiffness in the foot can impact a person’s ability to absorb force and subsequently contribute to urinary incontinence. In this case, if you were to solely strengthen the pelvic floor, it is likely that the patient would improve, but perhaps not enough to return to running.
Regional interdependence as it relates to the pelvic floor was the final push for me to transition to pelvic health. When I sought out pelvic floor PT for complaints of pelvic pain, I was shocked that the therapists I worked with suggested I work on upper back mobility and my squat form. As a physical therapist, these were deficits I had already identified in myself but had put on the back -burner (PTs admittedly do not always take their own advice). This experience helped me to begin to bridge the gap that exists between pelvic floor physical therapy and orthopedics. It simultaneously gave me confidence in my already existing knowledge and practice, while pushing me to want to learn more.
2. I am still prescribing both traditional PT exercises and functional exercises when appropriate
While the pelvic floor has a reputation for being mysterious, it really is just a group of muscles, and the normal rules of rehab still apply. Strengthen what is weak, lengthen what is overactive, and train what is uncoordinated. Over time, I have found ways to incorporate a lot of the exercises from my previous practice into my current treatment plans, although often with a different focus or intention.
For example, I still use weighted squats and deadlifts to teach lifting mechanics and pressure management to people that are postpartum and individuals with pelvic organ prolapse. I frequently incorporate standing rows and other exercises traditionally used for posture training into my sessions, as changes in the natural curvature of the spine and/or the tilt of the pelvis can contribute to changes in the length and tension of the pelvic floor muscles. Additionally, research has shown that improving hip strength can also increase pelvic floor muscle strength – so yes, I will still occasionally prescribe clamshells. And these are just a few ways in which I have been able to carry over some of my favorite exercises into pelvic health.
3. I still place great importance on the PT-patient relationship
Just as important as the education and interventions we provide, is our relationship with the patient. In fact, research has shown that a strong physical therapist-patient relationship wherein the patient is an active participant in their plan of care, may improve pain levels in those with chronic pain. In both settings I have worked in, I have tried to facilitate trusting relationships with my patients by actively listening to their stories, providing reassurance and encouragement, collaborating with them to determine which interventions are best suited for them, and determining goals that are important to them.
While this therapeutic alliance is of the utmost importance no matter the physical therapy setting, it is especially important in pelvic health, as those who seek out pelvic floor physical therapy often have seen many providers in the medical system, and may have long and complicated histories. My time spent in orthopedics helped me to build my listening skills and refine the way in which I communicate with patients, giving me the confidence to approach more sensitive topics, such as bowel, bladder, and sexual function.
How my practice has changed and evolved since becoming a pelvic floor PT
1. I’ve had to look beyond the musculoskeletal system
In orthopedics, we primarily deal with the musculoskeletal system, which provides our bodies with form, stability, and movement. As the name suggests, it is comprised of muscles and the skeleton (including cartilage, tendon, ligament, and connective tissue). As I mentioned above, pelvic floor physical therapy is technically an extension of orthopedics. As such, pelvic floor physical therapists are proficient at treating all of the above-mentioned structures throughout the body, especially at the level of the pelvis. However, based on the diagnoses we encounter, we need a working knowledge of additional systems of the body. When I first started to treat the pelvic floor, I had to crack open my dusty anatomy books, and re-familiarize myself with different organs, functions, and concepts, the most prevalent of which were:
- The urinary system, as coordination of the pelvic floor muscles is necessary for both urination and urinary continence
- The gastrointestinal system, and its role in defecation, fecal continence, abdominal pain/bloating, and constipation
- The reproductive system, as it relates to menstruation, menopause, pregnancy/postpartum states, and sexual function
Working with multiple systems has allowed me to broaden my approach to care, and to treat in a way that is more holistic. Not only am I educating my patients regarding exercise, posture, and body mechanics, but also about sleep, diet, nutrition, and stress management. I have a greater working knowledge of medications and their effects/side effects, surgeries, and different testing procedures.
2. I am treating areas I had previously not been qualified (or comfortable enough) to treat
When I decided to transition to pelvic floor physical therapy, I knew that I would quite literally be taking on new territory. One of the most obvious ways in which pelvic floor physical therapy differs from traditional orthopedic physical therapy is that we have the ability to assess and treat the pelvic floor muscles both externally and internally. For those of you who are not familiar with pelvic floor physical therapy, a therapist with advanced training can use one gloved finger to assess and [if necessary] treat the pelvic floor. This is done only with the patient’s consent. This aspect of care was totally new to me, and I am grateful to the PTs who mentored me, to help me develop a gentle touch and a greater sense of confidence when treating such a sensitive area.
To my surprise, another area I found myself regularly treating was the abdomen. Previously, I had thought of the abdomen only as it relates to core stability. While I spent a lot of time strengthening my patients’ core, I was totally overlooking the mobility of the abdomen. The abdomen is made up of the abdominal wall, and within the abdomen are the viscera, or organs. The abdominal wall is composed of skin, muscle, and fascia (connective tissue), and the viscera are connected to the abdominal wall and one another via fascial connections. Restrictions in the abdomen due to surgery and/or chronic inflammation can affect the organs’ function, the muscles’ ability to contract or relax, and even the mechanics of the entire trunk. For example, as the bladder fills, it expands into the abdominal cavity, displacing the small intestine. If the small intestine has restrictions and is unable to move freely, this may limit the bladder’s ability to fill. In theory, this may be a contributing factor to urinary frequency. Additionally, restriction in the small intestine can limit the range of motion of our trunk, as the small intestine moves over the top of the bladder during forward bending. While the small intestine may not be the first thing I assess when someone complains of difficulty bending over to tie their shoes, it is something I definitely keep in mind! And while I do still help patients strengthen their abdominals when necessary, I only do so when the abdominal wall is free of restriction.
3. I have added surprising tools to my PT toolbox
As mentioned above, I came into pelvic floor physical therapy with a knowledge of muscles and a plethora of exercises/stretches to treat those muscles. While I had anticipated adding a few more pelvic-floor-specific techniques to my repertoire, I was surprised to find that some of the most useful techniques I learned were those geared toward treating the nervous system. In short, if we are in a state of chronic stress due to work, finances, or interpersonal relationships, we are frequently activating our sympathetic nervous system (i.e. your “fight flight” response). Over time, this frequent activation of our sympathetic nervous system may affect our health and our bodies, contributing to pain, and tight and tender muscles. If a person is experiencing pain in a particular part of their body, and their nervous system is “up-regulated”, treating the muscles is often not enough. This patient’s plan of care must include interventions aimed at “down-regulating” their nervous system. Examples of down-regulation techniques include breathing, vagus nerve stimulation, humming, and mindfulness. Diaphragmatic breathing is a technique I employ with almost every patient I encounter, and it is an intervention I wish I utilized more frequently with patients when I was ortho-based.
In summary, while there is no “correct” journey to becoming a pelvic floor physical therapist, I am grateful for the experiences and knowledge I gained from working in ortho first. It has no doubt shaped who I am as a clinician today. That being said, I am equally as grateful to have made the transition to pelvic health. Since doing so, I’ve improved my hands-on skills, discovered new interventions, and learned to treat in a more holistic way. Every patient teaches me something new, and each day is a learning experience. I look forward to continuing my journey as a life-long student, as I continue to add new tools to my PT toolbox.
Danielle Santora is a pelvic PT at Beyond Basics in New York City. Her experience in orthopaedics heavily influences her treatment style. She believes in using an approach that marries manual therapy, functional movement, and postural awareness to partner with the patient to help them find relief from pain, regain control over their health, and to achieve the goals that are important to them.
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