Adhesions: The Source of Pelvic Pain?
May is Pelvic Pain Awareness Month and an important topic as it affects 25% of women, many seeking answers and treatment at our clinic. Chronic pelvic pain is described as "nonclinical pain of at least six months duration that appears in locations such as the pelvis, anterior abdominal wall, lower back or buttocks and that is serious enough to cause disability or lead to medical care" according to the American College of Obstetricians and Gynecologists (ACOG). In addition to physical pain, women can also experience sleep dysfunction, depression, anxiety and negative effects on relationships and ability to work. Clinically, we see it manifest as symptoms of menstrual cramps, hip and sacroiliac dysfunction, infertility and/or bladder, bowel or sexual dysfunction. It is important to rule out medical reasons for pelvic pain. Click here to learn more.
If there is one thing that is overlooked when it comes to pain and dysfunction in the pelvis, it is adhesions. In addition to causing pain, adhesions can disrupt core function and act as a strait jacket around muscles and nerves of the abdominal and lumbopelvic region. Adhesions are fascial restrictions; think stiff knee after surgery or a scar across a knuckle. In order to understand how adhesions disrupt function, it is important to understand what fascia is.
Recently, medical researchers claim to have discovered a new organ they are calling the interstitium. What they are describing is fascia, the fluid-filled matrix of connective tissue throughout the body that serves as an envelope around blood vessels, nerves, muscles and organs that drains into the lymphatic system. Think of fascia as the white, slippery connective tissue in chicken or roast beef. Fascia is made up of collagen, elastin and ground substance (a gelatinous watery substance in between the collagen and elastin protein fibers). During the healing process, the ground substance dehydrates and shrivels up like a raisin while collagen lays down more collagen in a process called collagen cross-linking. The healing process occurs anytime there is an inflammatory event:
irritable bowel, inflammatory bowel disease
According to WebMD, the risk for developing adhesions is 93% after an abdominal surgery. The incidence of adhesions following gynecological surgery is cumulative with each surgery. One study of autopsy investigators found a 90% incidence of adhesions with multiple surgeries, 70% incidence of adhesions in women with gynecological surgery, 50% incidence after appendectomy and more than 20% incidence in patients with no history of surgery. This might explain why adhesions occur in athletes who fall repeatedly during sports or individuals with gut inflammation. Often problems develop over time as the body learns to compensate. What starts as piriformis syndrome or hip bursitis can lead to pelvic floor tightness and fascial restrictions that can disrupt normal urinary and bowel patterns, menstruation, intimacy and/or core muscle function.
The pelvis is unique with more than 35 muscles attaching to it, each wrapped in a layer of fascia, making it more susceptible to adhesions than any other part of the body. Adhesions are more common in females, the right side of the body where there are big organs (i.e. liver) and in certain individuals due the the unique genetic make-up of collagen and elastin.
Adhesions are painful due to nerve fibers known as nociceptors inside fascia, causing sensations such as burning, pulling and deep cramping. They can adhere around nerves and disrupt nervous and digestive system function and cause even more pain or lack of sensation to an area. Adhesions also increase the risk for small bowel obstruction (SBO), a potential life-threatening condition where stool is unable to pass through the system. Adhesions disrupt neurological since the brain receives altered information from tightness in the periphery. Think of the brain as a general and the nerves bringing information back to the general (brain) as the reconnaissance team. If the information going to the general is altered, the information coming back to the troops will be inaccurate or distorted. This describes what happens in perpetual holding patterns as muscles and fascia contract to protect vital organs and areas of the body.
In addition, the belly or gut brain has an influence on fascia and why we believe it is important to address inflammation in the digestive system. The gut brain has more than 100 million neurons and as many as 9 times as many neurons in the body come from the enteric nervous system than from the brain itself; in other words, from the bottom-up rather than top-down. Many of the neurons in the gut are mechanoreceptors that when stimulated can trigger neuroendocrine changes, including the production of serotonin, the neurotransmitter involved with mood and behavior, and histamine, a substance involved in the inflammatory process. Experts now claim that 90% of serotonin is produced in the gut-brain. A healthy gut is essential for a healthy mind, and of course, a healthy core.
Adhesions that develop around the organs (viscera) can disrupt a number of functions, including normal organ mobility. Organs are dynamic and move with each breath and as digestion occurs throughout the day. There can be fascial restrictions around the bladder, intestines, diaphragm, kidneys, ovaries, uterus, tailbone, pelvic floor, prostate (males) and nerves. Here are some examples of how adhesions can disrupt function:
1. BLADDER - The bladder is like a water balloon that takes up more space as it fills with urine to expand upwardly. If the fascia around it is restricted, the bladder cannot hold as much urine, which can result in frequent urination, urethritis (pain or burning in the urethra), urgency to void or nocturia (nighttime voiding). Many patients are surprised that after only one or two sessions of visceral mobilization, they are able to sleep through the night. Some women have this problem for 10 plus years and assumed it was “normal.”
2. COLON aka LARGE INTESTINE - Think of the large intestine as a tunnel that serves as the medium to move stool through. If the tunnel has scar tissue around it and the opening is constricted, it can lead to small stools or a backup of stool or constipation. The cecum (beginning of the colon on the right side) and the sigmoid (end of the colon on the left side) runs parallel and is attached to the hip flexor on each side. An individual can have persistent hip flexor tightness if the adhesions around the colon are not mobilized.
3. SMALL INTESTINE - The small intestine is about 20 feet of convoluted tube that sits directly on top of the bladder. If stool stays there longer, it exerts downward pressure on the bladder, leading to unnecessary bloating, pain, urinary frequency or organ prolapse. The ileo-cecal valve also can be restricted, which is responsible for the muscle tone and peristalsis of stool within the colon. If it is stuck, it can slow colon transit time and contribute to constipation or pain when stool is attempting to pass through the system.
4. TAILBONE - If the tailbone or coccyx is restricted, the muscles that attach to it (pelvic floor) are restricted and can interfere with penetration, ability to sit and/or bladder or bowel function. Adhesions around the tailbone can be the result of a trauma to the tailbone, such as a fall, chronic constipation or adhesions from the abdomen that involve the pelvic girdle.
5. PERIPHERAL NERVES - The nervi nervorum is the fascial sheath that encases nerves and can shorten its natural glide around structures. A restriction around the sciatic nerve can cause pain with sitting, muscle tightness in the hamstrings and legs. Restrictions in the obturator nerve can cause tightness or pain in the groin and inner thigh. The pudendal nerve can become entrapped in many structures, including the pelvic floor and can cause pelvic floor tightness and saddle pain.
6. KIDNEYS. The fascia around the kidneys (renal fascia) can become restricted and cause hip flexor tightness, shallow breathing or decreased endurance, since the kidney normally moves up and down with each breath. If exhalation is restricted, the pelvic floor piston (the diaphragm and pelvic floor move up and down together in sync) cannot work and a person can have pain or lack of endurance with exercise.
7. UTERUS - Each month histamine is released during the menstrual cycle triggering inflammation. In addition, as the uterus sheds its lining and menstruation occurs, menstrual cramping can be severe if structures around the uterus are restricted. Many of the women and female athletes we treat reduce and even completely abolish menstrual pain, even if they came in for other reasons. Fertility can also be affected by adhesions around the ovaries, Fallopian tubes, uterus and ligaments.
8- MUSCLE SYNDROMES - Many individuals have persistent hip flexor tightness and pain that is often relieved with mobilization of the renal fascia and respiratory diaphragm. The pelvic floor muscles remain tight if the fascia known as the urogenital diaphragm is restricted. In addition, hamstring and hip flexibility can be improved by addressing the adhesions around the peripheral nerves.
You might be asking yourself, what is wrong with scar tissue and why can’t I just have it surgically removed? The problem with surgery is that adhesions or collagen cross-links develop in the normal process of healing from surgery. The only way to alter fascia is to physically load the tissue in all three fascial planes, either through manual therapy or specific exercise or movement. It is important to note that scar tissue will not go away on its own! If fascia is not restored to normal mobility, the core muscles will never be able to function as they were designed to. The fascia around the organs is continuous with the fascia that envelopes the muscles in the lumpopelvic region, including the thighs. Contracting core muscles can actually reproduce the symptoms or tug on the fascia more, perpetuating the problem, hence the “catch 22” that so many individuals are in.
At Healthy Core, we use several techniques to address adhesions in the pelvic region. Our goal is to change the information going TO the brain in order to change the brain's response to the tissues. According to Lorimer Moseley, an international researcher on pain science, "to reduce pain, we need to reduce credible evidence of danger and increase credible evidence of safety." This is an important concept in healing since pain is the "opinion of the brain". Visceral mobilization is laborious and time consuming, requiring one-on-one attention and is performed by a highly skilled provider on the abdomen, thighs and even internally (vaginally or rectally) to address restrictions around the tailbone, urethra or pelvic floor. In the United States, physical therapists are one of the only providers that can perform internal treatment, although this varies from state to state. Instrument assisted soft tissue mobilization involves the use of a tool (we use the Edge and Stickon tools) to stimulate the mechanoreceptors in the fascia. The thoracic spine and area between the shoulder blades responds effectively using this tool to reduce the fight or flight response through the sympathetic nervous system, since autonomic system neurons are located in this region. Kinesiotape has gained a lot of attention since new research has helped us understand why taping works. It has a decompression effect to separate the layers of fascia as confirmed by ultrasound studies and furthermore through brain MRIs, where sensorimotor areas light up in response to taping the skin. Taping the skin is like taping the brain to improve muscular control for movement and stability.
Getting help from the right provider is essential to healing pelvic pain resulting from adhesions. If you have had medical screening and no answers for your pain, musculoskeletal dysfunction and adhesions may be to blame. Do your research and ask questions before scheduling an appointment to ensure you will be in good hands (pun intended).
Schleip R et al. 2012. Fascia - The Tensional Network of the Human Body. Churchill Livingstone.
Callaghan et al. Effects of Patellar Taping on Brain Activity during Knee Joint Proprioception Tests Using Functional Magnetic Resonance Imaging.