Ali had an accident while riding her bike. Someone crashed into her, causing her to fall. A week after the accident, she started experiencing pain in the vulva and the surrounding area near the vaginal opening (vulvodynia). A year after the accident, the pain had become so severe that she could no longer sit comfortably, nor could she ride her bike. She feared sexual intercourse or penetration due to the pain and was unable to wear tight pants without feeling discomfort. Standing for long periods was also uncomfortable, and she reported experiencing metatarsalgia, which caused pain in her feet and legs. She also noticed that every time she lifted something heavy while engaging her abdominal muscles, she felt pain in the vaginal area.
Clinical Examination Findings
- Weak pelvic floor strength upon assessment.
- Muscle coordination issues in the pelvic floor, with minimal perineal pressure and difficulty relaxing the pelvic floor muscles.
- Increased muscle tone in the pelvic floor, piriformis muscle, obturator internus, and the muscles of the urogenital triangle (with more significant restriction on the right side than the left).
- An active trigger point internally on the left obturator internus.
- Moderate to severe connective tissue restrictions in the suprapubic area, pelvis, inner thigh, hamstrings, gluteal muscles, and lower back (with the right side more restricted than the left).
- Postural deviations, including left shoulder elevation and anterior rotation of the right innominate bone when standing.
Assessment
Ali found me after realizing that her previous physiotherapy treatment was not progressing. She had read an article about connective tissue and wondered whether its restrictions were contributing to her symptoms—an aspect that had not been addressed in her current physiotherapy program.
Indeed, connective tissue restrictions played a role in Ali’s painful symptoms. However, considering that abdominal strengthening and back stretches worsened her pain while spinal mobilization from a chiropractor provided relief, and given the mechanism of her injury, I suspected that her symptoms originated from spinal nerve involvement and that the connective tissue restrictions were a result of this dysfunction. The pudendal nerve, which can cause vulvar pain, can make diagnosis confusing, as multiple nerves interact in the pelvic region.
Peripheral Nerve Involvement in the Pelvic Area
As Ali fell off her bike, she positioned her leg in a way that could have irritated the genital branch of the genitofemoral nerve, which was indeed one of the nerves contributing to her pain. However, many other nerves were likely involved in her painful symptoms as well.
Another significant factor in her pain was her posture. With any injury, the body adapts its posture to avoid pain. Ali had been moving uncomfortably for over a year before coming to see me. Each time she sat in an awkward position, it further contributed to her overall posture and connective tissue restrictions, which in turn irritated the nerves, creating a vicious cycle of pain and dysfunction.
By the time Ali came to me, her pain had become chronic, raising the question: what came first—nerve irritation or connective tissue dysfunction? Either way, I knew that improving one would benefit the other. That’s why we worked on restoring her connective tissue mobility and managing her pain to address nerve discomfort. Additionally, I believed that her pelvic floor contributed to the pain cycle, as she reported experiencing pain when lifting weights. When the pelvic floor muscles are recruited incorrectly during weightlifting, they struggle to contract and relax effectively. This leads to motor control deficits, meaning the pelvic floor muscles were not providing dynamic support during lifting, were not relaxing at rest, and were found to be weak during clinical testing.
My Goals:
Short-term Goals:
- Develop the skill of mindful relaxation.
- Reduce connective tissue restrictions by 30%.
Long-term Goals:
- Reduce the initially increased muscle tone to the minimum possible.
- Return to sexual activity with minimal or no pain.
- Be able to sit for at least one hour on soft surfaces without pain.
Treatment Plan
I explained to Ali that I was unsure of the primary factor causing her painful symptoms. We started with weekly sessions, focusing on the connective tissue restrictions on the right side of her body, particularly in the vulva, suprapubic area, bony pelvis, and posterior pelvis. I also recommended that she use a pelvic wand to further address myofascial restrictions.
The goal of my therapeutic approach was to improve her quality of life by reducing symptoms, nerve irritation, and pain. Although I suggested that she consult a pain management specialist, Ali was convinced that her connective tissue was the root of the problem and was hesitant to see another specialist. She decided to stick with my approach, with the option of seeking pain management if her symptoms did not improve.
Key Milestones in the Treatment Process
One month after starting therapy, Ali’s mobility restrictions had improved. After each session, she felt much better for about two days and could sit at the table to eat for more than ten minutes. After eight weeks of treatment, she could sit for 40 minutes and had started wearing the underwear she used to wear before her injury without discomfort. Her pain had changed in sensation, suggesting that the nerves were beginning to calm down. The areas where she felt symptoms were smaller. She reported feeling 40–50% better and was ready to attempt sexual intercourse. One week after the first month of treatment, she told me that, for the first time in a long while, she had spent an entire day without pain and was even able to watch a movie without getting up!
Since healing is never a straight path and often involves setbacks, Ali experienced a relapse when she decided to wear sandals without proper support. This affected her posture and triggered nerve sensitivity, as her abdominal muscles were still weak. Her symptoms flared up for almost a month while we tried different strategies to bring her back on track. Eventually, Ali swore she would never wear unsupported sandals again.
For the next two months, I saw Ali once every two weeks while she continued her strengthening program. Nine months after her initial evaluation, she was doing exceptionally well. She was much stronger, and her connective tissue restrictions had significantly improved. She could sit for long periods, drive, and watch a movie without discomfort. She was becoming increasingly functional and remained consistent with her Pilates exercises, which contributed to her strength. The only lingering issue was a slight tightness in her hamstrings and legs. At this point, we decided to conclude our sessions.
Every time I check in with Ali, I encourage her to continue her journey of strength. I am grateful that she no longer experiences vulvar or vaginal pain and that she continues to progress toward her goals, using the tools she learned to maintain her improvements without the risk of relapse.
Three Key Takeaways for People Experiencing Chronic Pain:
- Don’t give up. Recovery doesn’t happen overnight. Sometimes, it becomes a new way of life.
- The patient’s goals and desires shape the treatment and its success.
- Don’t be discouraged by flare-ups or symptom relapses. Even specialists can’t always predict when and why a setback will occur. The healing process is a long journey, but with dedication and hard work, we become stronger than before.
