A theraband demo of Pelvic Floor Muscle, Joints and Fascia Pelvic Floor Anatomy A theraband demo of Pelvic Floor Muscle, Joints and Fascia Kathe Wallace, PT Pelvic Resources 5901 Roosevelt Way Suite B Seattle, WA 98105 206 527-2800 KatheWallace.com Clinical Instructor Division of Physical Therapy Dept. of Rehabilitation Medicine, University of WA

Objectives Understand the musculoskeletal connections to the pelvic floor which could contribute to pelvic pain, prolapse and incontinence Review the origins and insertions of the pelvic floor muscles using the 3 layer model. Describe the changes to the pelvic floor muscles with altered pelvic girdle joint alignment in patients presenting for clinical evaluation of pelvic pain and/or pelvic floor dysfunction. Name key pelvic bony landmarks for pelvic floor muscle Describe the accessory muscles of the pelvic floor I’m here today to Review the pelvic floor anatomy and the pelvic girdle with a special model, SO THAT YOU can visualize and identify these muscles during your pelvic floor examination.

The Role of Pelvic Floor Musculature SUPPORT Assists in pelvic/spinal stability Assists in organ support along w/ ligaments & fascia SPHINCTERIC Reinforces urethral closure during ↑ in intra-abdominal pressure Has an inhibitory effect on bladder activity SEXUAL Contributes to sexual arousal and performance Assists in penis and clitoral erection Assists in ejaculation male and female Who got more than this amount of information in PT school? S2-4 but it really does a lot more! These are the classic three from Arnold Kegel in 1950 with some additions from the research that links pelvic floor to pelvic stability. I’ll talk more about all these.

Pelvic Floor Layers- Functional Divisions INTRO AND ANATOMY Pelvic Floor Layers- Functional Divisions Three muscle layers, w/ 3 nerve branches on each side Superficial Perineal Muscles  Superficial Deep Perineal Pouch Pelvic Diaphragm  Deep At the level of the ischial spines Figure 5.76 B. Pudendal nerve in women. © 2008, Herman & Wallace Pelvic Rehabilitation Institute

The Layers of the Pelvic Floor Graphics from Reviving Your Sex Life after Childbirth; Your guide to pain-free and pleasurable sex after the baby, 2014.

The 3 Layers of Pelvic Floor Muscles Layer 1 –Perineum, External genitalia muscles Ischiocavernosus, Bulbocavernous, Superficial Transverse Perineal, External anal sphincter Layer 2- Urogenital diaphragm EUS, Compressor Urethra, Urethral Vaginal Sphincter Layer 3- Pelvic Diaphragm Levator Ani , Coccygeus Pelvic Wall Muscles- Piriformis, Obturator internus Overwhelm In Layer one the muscles lie under the genitalia. They are termed the superficial genital muscles or the The superficial perineal pouch is a fully enclosed compartment: its inferior border is the perineal fascia (Fascia of Colles) its superior border is the perineal membrane muscles Ischiocavernosus muscle Bulbospongiosus muscle Superficial transverse perineal muscle other Crura of penis (males) / Crura of clitoris (females) Bulb of penis (males) / Vestibular bulbs (females) Greater vestibular glands (female)

Accessory Muscles of the PF Synergistic contraction of the pelvic floor muscles with Hip adduction Abdominal muscles Gluteals Bo and Stien (1994) used abdominal curl and backward tilting of the pelvis in a supine position Also consider these muscles in Substitution patterns Myofascial restrictions creating pain or difficulty contracting the PF ?

Adductor PF Fascial Connections ORTHOPEDIC PF CONNECTIONS Adductor PF Fascial Connections Scarpa’s abdominal fascia (over the ext obliques) continues to the labia minora and into the fascia lata (hip region) The superficial perineal fascia, Colles fascia surrounds the ischiopubic ramus at the adductor origins near Layer 1 PF muscles Ciba Medical Slide 455 KW personal collection © 2007 Herman & Wallace Pelvic Rehabilitation Institute

Abdominal PF Fascial Connections Layer 2 Abdominal wall Colles fascia, (Scarpa fascia continues into the perineum) emerges from the perineal membrane Attaches to the deep fascia of the posterior urogenital diaphragm near Layer 2 PF muscles Figure 5.68 Borders and ceiling of the perineum. A. Boundaries of the perineum. B. Perineal membrane. This membrane is important for attachment of the genitalia, muscles and fascia. Figure 5.35 Perineal membrane and deep perineal pouch. A. Inferior view. B. Superolateral view. Perineal membrane and deep perineal pouch. C. Medial view. Pelvic Floor 1 © 2011 Herman & Wallace | Pelvic Rehabilitation Institute Aug 26-28 2011

Layer 3 - Pelvic Diaphragm – Side Walls and Hip Connections Levator Ani - ATLA Internal view of Obturator internus ATLA - Fascial attachment for LA muscles ATLA - Fascial attachment for Levator Ani muscles

11 Why is the Pelvic Floor Overactive or Underactive? Is it the criminal or the victim? Causes of PFD Hartmann and Sarton (2014) Injury to the Pelvic Floor Muscles Inflammatory Pain Disorders Involving Pelvic Viscera Faulty Cumulative Behaviors of the Pelvic Floor Muscles Postural and structural dysfunction Faulty joint or movement biomechanics Injury- Childbirth or PUBIC FX endometrosis

What can happen to the Pelvic Floor Deformation = Strain The force may be: Compression force, applied by pushing; e.g. IAP Tensile force, occurring because of pulling; e.g. Scars Torsion, which is applied by twisting or joint position changes e.g. SI joint dysfunction Shaffer, R., Moalli, P., Physiology of the Pelvic Muscles, Vagina, and Anorectum    in Urogynecolgoy and Reconstructive Surgery, (2015) Chapter 5, 68-80. Recent work has sought to elucidate the biomechanical properties of the pelvic floor. The pelvic floor by default is load-bearing, supporting the pelvic organs against the effects of gravity and applied intra-abdominal pressure. Hence, the standard components of biomechanics, including force application, stress deformation, and structural movement, will have an obvious effect on its function. Applicable biomechanical parameters to this discussion include materials science terms including deformation , which is the general term given to the change in size or configuration of a material due to the actions of an external force or change in temperature. Deformation is also called strain . The force may be a tensile force, occurring because of pulling; a compression force, applied by pushing; or torsion, which is applied by twisting. The connective tissue within ligaments typically contributes to their viscoelastic property—the ability to initially resist strain, then to stretch as they begin to deform, and then to snap back and regain their previous configuration once the force is removed. If enough strain is experienced by the tissue, it may lose its recoil ability and undergo structural failure, in which rupture occurs. As an example from the orthopedic literature, we know that after ligaments are damaged, their collagen remodels as they heal. After healing from injury, the composition of the ligament changes; it is frequently stiffer and may be permanently stretched and elongated, losing its ability to recoil normally ( ).

Contribution of Pelvic Floor Muscles to Stability of the Pelvic Ring (Pel 2008) PF contributes to lowering of the vertical Sacroiliac joint (SIJ) shear forces, increasing SIJ compression and hence increasing SIJ stability JUST RIGHT NEEDED< conversely too much can cause a problem. Ann Biomed Eng. 2008 March; 36(3): 415–424. Published online 2008 January 18. doi:  10.1007/s10439-007-9385-8 PMCID: PMC2239251 Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces J. J. M. Pel, C. W. Spoor, A. L. Pool-Goudzwaard, G. A. Hoek van Dijke, and C. J. Snijder In both sexes the simulated tension counternutated (backward rotation of the sacrum Multifidi contribute to nutation

PF Muscles Alter Pelvic and Hip Alignment Bendova 2007 ORTHOPEDIC PF CONNECTIONS PF Muscles Alter Pelvic and Hip Alignment Bendova 2007 14 female subjects MRI- functional stimulation to unilateral pelvic floor The femoral head, innominate and coccyx showed the greatest displacement with PF muscle stimulation Bendova, P., Ruzicka, P., et al. (2007). "MRI- based registration of pelvic alignment affected by altered pelvic floor muscle characteristics." Clinical Biomechanics 22: 980-987. © 2007 Herman & Wallace Pelvic Rehabilitation Institute

Attachment Sites for the Pelvic Floor Muscles Bone Coccyx Pubes Ischial Tuberosities Ischial Spines Ischiopubic Rami Key Fascial Attachments Perineal Body Clitoris ATLA Lets look at this from an orthopedic perspective!

Muscle, Joint, Fascia Relationships Demo Pubococcygeus (Pubovisceral, Pubovaginalis) O: Dorsal surface of the pubic bone and fascia of the obturator internus. I: Anococcygeal body, between the tip of the coccyx and the anal canal. A: Supports the pelvic viscera ATLA  Iliococcygeus– Posterior and lateral fibers of levator ani O: Arcus tendinous levator ani (a fibrous band suspended between the pubic bone and ischial spine). I: Anococcygeal body and the coccyx. A: Support of viscera and lateral coccyx Coccygeus (Ischiococcygeus) O: Arises from the spine of the ischium I: On the caudal portion of the sacrum and coccyx A: Flexes the coccyx, supports pelvic viscera, and stabilizes the sacroiliac joint. Perineal BODY Superficial Transverse Perineal Muscle O: Ischial tuberosity I: Central perineal tendon = perineal body A: Stabilizes perineal body CLITORIS Bulbocavernosus (Bulbospongiosus) Muscles Female O Central perineal tendon, travel under the labia I Fascia of the corpus cavernosum of the clitoris A: Functions as a vaginal sphincter and assists in erection of the clitoris Ischiocavernosus Muscle Female O: Ischial tuberosity and ramus I: Inferolateral aponeurosis over crura of clitoris A: Clitoral erection Coccyx fall Coccyx childbirth Pubic symphysis separation Right anterior rotation of the ilium Theraband demo adapted from -Franklin, E. (2002). Pelvic Power: Mind / Body Exercises for Strength, Flexibility, Posture, and Balance for Men and Women. Hightstown, NY, Elysian Editions Princeton Book Company

Simulations with the bones and muscles