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Getting to the bottom of things
This month I would like to discuss the pelvic floor, an area of our anatomy that is critical to the body's musculoskeletal balance and health, yet commonly neglected and poorly understood by many physicians. The pelvic floor may be neglected partly because its mechanics are subtle.
Patients with pelvic floor imbalances are usually unaware that a mechanical problem is present, even though they may have unexplained pain in the low back, coccyx or legs. And yes, neural therapy may be a key to unlocking some of the puzzles behind these pain conditions.
Coccydynia‐A pain in the tailbone
The structure most likely to manifest musculoskeletal pain in this area is the coccyx. The grand Latin name for this painful condition is coccydynia or coccygodynia. Often coccydynia is triggered by direct trauma to the coccyx‐but the puzzle is, why does the acute pain become chronic?
There are a number of possible reasons why acute coccydynia becomes chronic or why chronic coccydynia appears with no apparent cause. Most of these reasons have little to do with the coccyx itself.
One way of looking at this question is to see that the coccyx is located more or less in the middle of the pelvic floor. Imbalances of the pelvic floor muscles will therefore put chronic strain on the sacro‐coccygeal joint and make it irritable and painful.
In turn, muscle imbalances of the pelvic floor do not occur in isolation and are always associated with mechanical disturbance (somatic dysfunction) of the pelvic ring. Therefore, manipulation of the pelvis is often a part of coccydynia treatment.
Examining the pelvic floor
Mobility of the coccyx should be assessed directly by grasping it (through the rectum) between the index finger and the thumb. If moving the coccyx in one direction increases the pain, moving it in the opposite direction, and holding it there for a minute or so, will sometimes provide considerable relief. (A release or softening of the tissues is felt at a certain point.)
The pelvic floor muscles can also be examined directly by positioning the fully clothed patient supine with hips and knees flexed and feet on the examining table. The examining hand comes underneath the leg, around the buttock so that the second to fifth fingertips gently probe the pelvic floor muscles. With pelvic floor muscle imbalance, the right side is usually tighter than the left. Gently pushing the tighter side cephalad and holding it until a release is felt will often balance the pelvic floor.
Should you suspect an interference field?
How about non‐mechanical disturbance in this region? What about interference fields? The pelvic floor itself (like the scalp) rarely harbors interference fields. Occasionally, one can be found in a Bartholin cyst (or its scar) or in the urethra. More common by far are interference fields in the anus and the pre‐coccygeal ganglion.
Anus interference fields usually result from present or past local difficulties, e.g., fissures, fistulas, or painful hemorrhoids. Treatment is a ring of quaddles a couple of inches away from the anus, followed by a small intravenous bolus of dilute procaine.
Pre‐coccygeal ganglion interference fields usually develop after trauma to the coccyx or in association with other interference fields in the pelvis or pelvic floor. They should be looked for especially in conjunction with anal interference fields. Treatment is by injection (see page 192 of Neural Therapy: Applied Neurophysiology and Other Topics) or by use of the TensCam device available from Charles Crosby, DO, of Orlando, Florida at 407‐823‐9502.
Pelvic floor interference fields may be silent locally and cause pain in the low back, legs, or even farther afield. They should be suspected particularly with inner‐thigh pain or bilateral knee pain. And pelvic floor interference fields are almost certainly present when pelvic ring and leg mechanics are in perfect balance, yet pain persists.
Robert F. Kidd, MD, CM