Do you experience burning, stinging or rawness in your vulvar area? Maybe you feel itching, throbbing, or aching in the perineum and pelvis. You are not alone. These symptoms are typical of vulvodynia.
Vulvodynia is a pain condition of the female genitals: clitoris, vestibule (vaginal opening), labia, and perineum.
There are two main subtypes of vulvodynia:
- Generalized Vulvodynia is pain in different areas of the vulva. Pain occurs spontaneously and can be relatively constant. Activities that apply pressure to the vulva, such as prolonged sitting, wearing pants, riding a bicycle typically make the symptoms worse.
- Vulvar Vestibulitis Syndrome (Provoked Vestibulodynia) is pain in the entrance to the vagina, (vestibule). Often a burning sensation, this type of vulvar pain comes on only after touch or pressure, such as during intercourse or placing a tampon. This type is further classified as Primary: pain experienced with first attempt of vaginal penetration, or Secondary: woman has experienced pain free penetration prior to the development of pain.
Vulvar Vestibulitis Syndrome
Self Care Strategies
Self-care and treatments for vulvodynia can help bring relief and recovery. Unfortunately, there is not a "one size fits all" treatment. Working with a trained healthcare provider who understands vulvodynia is crucial to getting out of pain. Here are a few suggestions to alleviate symptoms:
Avoid Irritants to the vulvar tissue
- Use dermatologically approved detergent and don’t use fabric softener.
- Use unscented toilet paper that’s soft and white.
- Wear 100% white cotton underwear, menstrual pads, and tampons.
- Avoid getting shampoo on the vulvar area.
- Avoid perfumed creams or soaps (no Massengill or Summer's Eve cleaning products), pads or tampons, and contraceptive creams or spermicides.
- Avoid hot tubs or pools with lots of chlorine.
- Rinse the vulva with cool water after urination and intercourse.
- Avoid foods that make urine more irritating. This may include foods such as greens, beans, berries, chocolate, or nuts.
- Wear loose-fitting pants and skirts; don’t wear pantyhose.
- Keep the vulva clean and dry.
Relieve pain and ease pressure
- Use a water-soluble lubricant during sex. Olive and coconut oil can also be used as a lubricant.
- Avoid activities that put direct pressure on the vulva. This includes bicycling and horseback riding. Intense exercise that creates friction at the perineum.
- Learn how to sit with a neutral pelvis, this decreases pressure on the coccyx and tailbone. LImit sitting time to 20 minutes, then get up and move around.
- Soak in lukewarm or cool sitz baths.
- Apply heat, ice or a frozen gel pack wrapped inside a hand towel.
- Relaxation techniques and walking can improve blood flow, increase circulation and calm the nervous system.
Make an appointment with your local Pelvic Health Physical Therapist
Weak gluteal muscles can be blamed for many low back, hip and knee pain/injuries. Without the muscular support, the back, hip and knee are subject to increased loads and excessive motion leading to friction and wear and tear. The 3 gluteal muscles: maximus, medius and minimus assist in controlling the trunk and the leg as it is loaded during foot contact to the ground as in walking, running, jumping, going up/down stairs, as well as moving from a sit to a stand or bending.
When the gluteal muscles are weak, you will notice increased movement of the trunk toward the side of weakness, and the knee will cave in toward the midline. Are your glutes weak or strong?
Start to observe what you do when you go up/down stairs: do you turn your foot out to give yourself more support, does your knee drift to the midline, do you shift your torso over to the planted leg to make it easier to step up? If yes, then your glutes are weak
What happens when you bend down to pick something off of the floor or transition to get in and out of a chair: do your knees come together? If yes, then your glutes are weak.
Gluteal assessment: Step down from a stool.
Stand on a stool. Slowly begin to lower one leg down, tap the floor with your heel and then return back up. Repeat 5 times. Notice if your standing knee collapses toward midline, or if your torso leans to the side. If either or both happens, you need to strengthen your glutes!
Strengthen your glutes: standing progression
1. Start by standing on your left leg. Keep your thighs parallel and bend your other knee so your foot can tap down on the floor like a kick stand if you need it to balance. Check yourself in the mirror. Make sure that your pelvis does not rotate. Keep your ASIS facing forward (that is what I am pointing to). Ideally you want to have your pelvis level. Check your waistband: if the right side is elevated then you are using your back muscles to compensate, if it has dropped, then you are not activating your left glute! Work toward standing for 1 minute. Switch sides.
From a side view, try to maintain vertical alignment: midpoint of shoulders and hips over ankle bone (I am not quite there, helps if you have a mirror to look into). Keep the standing leg straight, and your quads in front of the thigh relaxed!
2. Next progression begin to bend your knee as far as you can and then return to start position. Perform 10 reps and then on the last one, keep it bent as you balance for the final minute. Again, make sure that the pelvis doesn't rotate or drop.
3. Stand on your left leg. This time your pelvis will elevate because you won't be bending your right knee. Keep your leg straight as you move it out to the side and in. Work toward 1 minute and then switch sides.
4. Side step with a light resistance band (if you have had a hip replacement do this without the band). Make sure to keep feet straight ahead and plant your foot with the outside edge straight.
Make sure not to bend your knees. Most people cheat by bending the knee because the glutes are weak. Don't do it!
Make sure to land your foot with the outside edge straight, this position engages your glut med and min. Return to normal hip width distance. Make sure to relax your quads between steps!
5. Now for the glute max finale! Standing on your left leg, extend your rlght leg behind you. Begin to lower your torso as you hinge at your hips bringing your hips behind your ankle, and then return.
Make sure the movement is coming from your hips, not your spine! Pelvis should stay level. This is challenging, mostly from a balance perspective. If this is hard for you, then get into position and hold.
Photo courtesy Wikipedia
In my practice I work with a lot of people who have low back pain, and sacroiliac (SI) pain. How we stand, how we sit, and how we move in our bodies over time, contributes to our dysfunctions and potential pain syndromes.
Being mindful of HOW we stand and sit are simple steps to begin to unravel the increased loading and compression on the spine and SI joints, as well as the tension and pull on corresponding ligaments and muscles.
Before going over standing and sitting, let’s look at the anatomy: The pelvic girdle is comprised of the 2 pelvic (inominate) bones and the sacrum. The inominate bones join in the front by a thick fibrocartilage disc similar to that of the vertebral discs. This area is called the pubis or pubic symphysis. In the back, the inominate bones attach to the sacrum, creating the sacroiliac joints.
The function of the pelvic girdle is to transfer the loads between the trunk and the lower extremities via the spine and hips (lumbopelvic-hip complex). There are 35 muscles that attach directly to the pelvic girdle. Therefore, the mobility and stability of the SI joints depends on the interaction of these muscles, ligaments, fascia and nerves that surround the pelvic girdle.
Photo courtesy: www.pt.ntu.edu.tw
In healthy movement, the sacrum moves relative to the inominate bones. When the sacral promontory moves forward into the pelvic bowl, the motion is called nutation; counternutation is the opposite motion. The optimal position for the sacrum in standing and sitting is slightly nutated between the inominates. This is the goldilocks position: not too tight and not too loose.
During sitting and standing, you can diminish stress on the SI joints by maintaining a neutral pelvis.
Learning how to stand
Look around you, most people stand with their pelvis out in front and their shoulder’s and ribcage back (as in the pic below).
This posture causes the sacrum to fully nutate, meaning that this is the maximally closed position of the SI joints. This position can create low back and SI joint aching during prolonged standing.
Incorrect Alignment: Anterior Pelvic Sway
Correct your alignment by shifting your hips back, allowing your trunk to move forward so the line of gravity travels through your joints: shoulder, hip, knee and ankle. Now the pelvis is in neutral: the pubic bone and ASIS line up vertically, and the SI joints are in optimal position.
Neutral Pelvis: ASIS and pubic bone line up vertically.
Learning how to sit
Many people slump their spine and pelvis while sitting watching TV, or sitting slumped at the computer. In this posture, the weight of the body is positioned behind the SI joints. This places the SI ligaments under load, the sacrum is tucked (counternutated), and pressure is at the tailbone (coccyx).
Photo from www.physioadvisor.com.au
The stress of this position will stretch the ligaments of the SI joint, and can also create tailbone pain. Maybe you can relate to having pain while trying to walk after sitting like this for awhile. The initial steps are excruciating until you are able to walk it out as the ligaments regain their normal position.
Correct your alignment by sitting on your ischial tuberosities (SITS bones). The pelvis and spine should be in neutral.
Photo from www.posturereview.com
Trigger points in a muscle can be the culprit in many pain disorders. In this post, I provide a self care technique to assist with these potentially troublesome trigger points. The muscles that can refer pain into the hip area are the tensor fascia lata, iliacus, psoas and sartorious. If you are interested in learning more about what causes trigger points and how to treat them, I have listed some websites dedicated to trigger points and myofascial pain syndromes at the end of the blog. Click on the pictures below to enlarge the picture and to link you to triggerpoints.net, an amazing resource for trigger points and referred pain.
Tensor Fascia Lata (TFL) attaches to the iliac crest/ASIS and into the fascia lata that terminates at the lateral knee. The primary functional movement of this muscle is to stabilize the pelvis and the knee. Its action is hip abduction, flexion and medial rotation. Trigger points related to the TFL refer to the outside of the thigh.
Iliacus & Psoas = Iliopsoas
attaches to the iliac fossa and the Psoas
attaches to the transverse processes of L1-L5 and the lateral aspect of T12-L5. They share a common attachment point on the lesser trochanter of the femur. The iliopsoas flexes the hip and trunk.
Trigger points in the iliopsoas refer to the anterior thigh and low back.
Sartorious attaches to the ASIS on the pelvic crest and to the medial condyle of the femur. Its action is hip flexion, external rotation, abduction and knee flexion. Trigger points in the sartorious refer to the anterior and medial thigh.
If you are experiencing any of these pain patterns , try this:
Release tension in the psoas, and the surrounding hip musculature by performing a constructive rest position with a bolster. Allow yourself to breathe and relax for 5 minutes. For instructions on how to do this click here
Perform a release technique utilizing myofascial release balls such as Yoga Tune Up
Therapy Balls for Self Massage (that's what I have and I love them), Melt Method Products
, or good old tennis balls. There are a lot of different ways to get into the muscles. For this technique you will take two balls held together in a sock or bag. My finger is pointing to my ASIS on the iliac crest
. Place the balls horizontally just below the ASIS.
You will be working near a tender area due to the superficial exposure of the femoral vein, artery and nerve at the femoral triangle. If you start to feel tingling and nerve sensations, move to a different area. Just underneath the vessels and nerve lies the iliopsoas. The next muscle laterally (to the right in this pic) is the sartorious, and the muscle in red is the tensor fascia lata. Sandwiched in between the two is one of the quadricep muscles, the rectus femoris. This will get released as well.
The balls are placed as above on the left side here. With the right leg you can adjust how much body weight you put down into the balls. If it is more comfortable, you can prop up onto your elbows. If you are not able to get down onto the floor, you can place the balls at your hip, and lean into the wall or a door jam. Try to allow your muscles to relax and mold over the balls. If you find that the balls are too intense to start with, place a folded hand towel over them to disperse the pressure. If you are holding your breath and tensing your muscles to deal with the pain, this defeats the purpose. You should be able to feel the sensation and breathe into the area as the muscles release. Once you feel that the muscle has let go, move the balls into a new area. Spend 5 minutes on each side. Enjoy how you feel when you get up to walk. Feel the freedom in your hips!
In my practice, I see many people with back and neck pain. When I assess the spine, I often find that the thoracic spine and ribs are frozen stiff. When the thoracic spine is not mobile, the low back and neck may compensate for this lack of motion, which can lead to overuse, tension and dysfunction.
Last weekend I purchased a lecture on the Thoracic Spine by Sue Falsone, PT, ATC
from the website Movement Lectures. I was impressed with the material, and was inspired to include some of the exercises that she recommended to regain thoracic mobility into my Restorative Exercise™ class last week.
I have also been loving my new Yoga Tune Up®
self massage therapy balls, so I added some myofascial release into the class as well.
Below I share with you 3 movements to free your thoracic spine.
Thoracic rotation assessment
Breathing Exercise: Enhance Rib mobility, improve rotation
Get into child's pose with arms down by sides. This position will limit your ability to breathe into your belly and will encourage you to expand your breath into the back ribs. Take 5 good long breaths. Try to expand the ribs on the inhale, and on the exhale, close the ribs.
Reassess thoracic rotation: More motion
thoracic extension and myofascial release with ball
Place two tennis balls in a sock. A sock will keep the balls from rolling all over the place. Lie down on your back with the balls underneath you just below your shoulder blades. Your spinous processes should be between the two balls.
Notice how much the ribs lift up when you lay down over the balls. You will need to prop up your upper back and neck to make sure you stay in alignment.
The balls are placed at the bottom of the shoulder blades and the upper back is propped up so the ribs relax down against the body wall.
Lift the arms overhead. Make sure to only lift as far as you can before the ribs start lifting up. Complete 3-5 times and then move the ball up your spine.
As you move higher up your spine, you will not need a prop under your shoulders.
Flexion and extension of both of the shoulders creates a flexion/extension moment at the thoracic spine. The ball helps to decrease the tension on the paraspinals.
I would love to know how great you feel after practicing this for one week!
pic taken from wikipedia
Not quite a month ago I wrote a post
about raking leaves and waking up the next day with pain at my shoulder blade. I was able to relieve it after a few minutes of exercise. Well.... it came back after a weekend of hovering over my computer.
This time I had a different strategy: address the tension in my neck and pectoralis minor.
Due to the attachment on the coracoid process of the scapula
, tension in the pec can pull the scapula forward lifting the bottom edge away from the body
, potentially creating dysfunction for the entire shoulder girdle.
I was inspired by Jill Miller's YogaTune Up® Blog
on the pec minor. So I share with you pics from my 2 minutes of myofascial work with a tennis ball, and "bam" no more pain!
Find the deltopectoral groove at the front of your shoulder.
Place the ball at the groove, just under the clavicle.
Find a corner and lean into the wall.
You can add more pressure by shifting your weight forward into a lunge. Find a tender spot and allow your muscles to release. Come down farther onto the ribs and find another spot. Work 2-3 minutes.
I felt good all day! Until I woke up the next morning and there it was again: pain in my left shoulder blade! This time I released my pec minor AND added the ball release to the muscles at my neck just above my clavicle. Five minutes later, no pain! Check out how I did it by watching this video:
Recently I had the opportunity to work with a woman 7 weeks postpartum. She had been experiencing heaviness and pressure in her vaginal area with walking, lifting, and prolonged standing. At her 6 week check in with her midwife, the midwife said she had a mild prolapse. Concerned about the discomfort and the inability to perform daily activities: lifting her 5 yr old and newborn, walking, standing...etc., and the potential further descent of her organs, she made an appointment with me (smart woman).
My evaluation confirmed her midwife's diagnosis of prolapse: a mild rectocele
and urethrocele (see pic above).
In our session we worked on making her aware of habits that increase downward pressures which can contribute to prolapse, with the ultimate goal of reducing or eliminating such patterns.Automatic habits addressed in the first session
My client stood as most of us do, with her pelvis out in front of her. She also lifted her ribcage to bring her shoulders back. Ideally we should stand with our pelvis stacked over our ankles and our ribcage stacked over our pelvis; think about our functional core connection here: diaphragm, transversus abdominis, pelvic floor and deep back muscles. (For an educational read, get the book, The Pelvic Girdle by Diane Lee.) When the pelvis is out in front, we no longer have a neutral pelvis, which is important for the position of the pelvic organs (bladder, uterus) to have support of the pelvic ring below (notice in the pic above on the left, the bladder and uterus rest on the pubic bone). This means more grativational load on the fascia and ligaments leading to tissue failure (and descent of the organs). So my client learned how to stand.
Poor alignment: anterior pelvic sway. Notice the hips in front of the ankles. The ribcage is lifted up and in front of the pelvis.
Improved alignment: pelvis is stacked over the ankles and the ribcage is stacked over the pelvis.
Sucking in the stomach
Pulling in the gut to “look” slimmer freezes and shuts down the diaphragm, not to mention increases pressure in the cavities above and below. Read more about sucking in here
: So my client learned how to breathe.Tension in the pelvic floor
All muscles need to be able to contract and relax optimally. When the pelvis is out in front, the muscles in the pelvic floor are held in a shortened position. When there is increased pressure in the abdomen and pelvic cavities from sucking in, the pelvic floor muscles try to create balance by increasing contraction to maintain continence. Chronic tension means decreased blood flow, decreased oxygen, decreased waste removal = potential for pain signals. So, my client learned how to relax her pelvic floor
Very shortly my client returned to the clinic with noticeable improvements
Within a week she felt less heaviness and pressure in her vaginal area. She felt pressure only with heavy lifting. She possessed the education to continue her home program from the initial visit and we added gluteal strengthening to her program.
Two weeks later she returned to clinic reporting continued improvement. She was able to walk and perform yard work without any discomfort! She had a follow up visit with her midwife who reported upon exam significant reduction of prolapse! She was given additional functional movement reeducation for her home program. I will follow up with her in a month and more than likely discharge treatment.
Moral of the story is this: if you feel pressure or heaviness in your vaginal area pospartum (or at any time), get it taken care of, go see a pelvic health physical therapist. Or contact me for more information!
If you are in the Salt Lake City area, I am offering a Postpartum Workshop
December 8, 2012 where we will address these issues and more. The workshop will be held at Vitalize Studio in Sugarhouse, 2154 S. Highland Drive from 9:30 to noon.
We had a good storm this week to blow off all of the leaves of the frontyard tree.
I spent two hours raking and bagging. The next morning I woke up with pain and pulling at my left shoulder blade.
I am sure that many of you can relate.
So, instead of waiting it out and griping about it all day, I took 15 minutes to work with the muscles and set freedom to my scapular sling muscles. Post session, no pain!
Below I have pics and video of the simple movements and stretches I went through to decrease the pain in my shoulder girdle.
These are also great exercises to perform daily to combat shoulder blade, arm, and neck tension from computing, driving, hair styling, pushing strollers, carrying babies, etc.
The first movement is called the Rhomboid Pushup. Complete 5-10 repetitions. Make sure that your fingers and elbow creases face forward, and keep your elbows straight.
After the rhomboid pushup, perform a shoulder stretch as shown here.
Repeat the rhomboid pushup 10 more times and then go into this next stretch, Quadruped Rib Twist.
Complete another cycle through of each, the rhomboid pushup, the shoulder stretch and the rib twist. Finish up with some wrist stretches shown below.
Place forearm vertically, flex wrist and pull fingers down and toward your forearm. Hold for 30 secs.
Now pull each finger individually, hold 10-20 secs.
Bend elbow to 90 degrees. Extend wrist and pull all fingers down and back, keeping fingers straight. Hold 30 secs.
Now pull each finger back individually and hold 10-20 secs.
Hip mobility is key to the health of the spine. When we lack the motion at our hip joints, the spine will take up the slack by moving into flexion or extension. Here I am trying to lift my leg backward. Compare the two pictures. You can see the increase of the lumbar curve on the left, this is called extension. This creates compression and degeneration of the tissues and tension in the back muscles. This picture on the right shows my true hip motion without compensating by getting more motion through my spine.
Now, here I am lying on my back with my knees bent. On the pic on the top, the dots demonstrate having a level pelvis. As I bring my knee toward my chest, I moved past my actual motion at my hip joint and my pelvis tilts posterior or toward the floor. This action creates flexion at my spine and places more stress on the lumbar discs making me more susceptible to a disc herniation or degeneration.
Restore mobility to your hips, and save your spine from wear and tear from all that extra motion! Below are 10 of my favorite Restorative Exercises™ to free up the hips and the spine! Unless stated otherwise, hold the stretch for one minute each side.
Psoas release: Place a block under your sacrum with your knees bent so your shins are perpendicular to the floor. Relax here for 5 minutes.
After the release, bring one knee toward the chest and hold it at arms length. Kick the other leg out straight and begin to lower slowly keeping the knee straight. This uses the psoas in an eccentric contraction and allows the hip to move into extension. Repeat other side.
Bend your knees and bring the soles of your feet together.
Cross left leg on top of the right. Repeat other side.
Cross left leg over right. Make sure to sit with a neutral pelvis (not to tuck sacrum or round your spine). Repeat other side.
Get into the lunge position. Make sure your spine is neutral (no flat back or increased curve) and your hips are square. Begin to shift weight forward, moving your R hip into hip extension. Keep your front shin perpendicular the the floor. Switch sides.
Lift your left leg in the air so your hip, knee and ankle are at 90 degrees. Keeping your left shoulder down, take your left leg across the body toward the floor. Take it as far as you can and maintain your left shoulder on the floor. Switch sides.
Begin by starting in the same position as previous stretch. This time, take the knee all the way to the floor. You will notice that your shoulder comes up. Relax your torso to allow your shoulder to come down to the floor. Repeat other side.
Start with knees bent. Place a block in between the knees and lift legs to 90 degrees. Begin to rotate your hips by bringing your feet away from each other and then return to start position. Repeat 10 times for 3 sets.
Maintain neutral pelvis. Cross your right leg over left.
Bring your knees toward your left side until your foot hits the floor. Try to make sure the your right shoulder stays on the floor. Repeat sides.
This Saturday, September 22 marks the beginning of Fall. The change of seasons here in Salt Lake City is invigorating: brisk mornings and evenings require putting on layers, and the leaves are turning orange, yellow and red. This change feels so synchronized, steady and effortless.
If only changing habits and behaviours could be so elegant...
A transition of seasons may appear effortless, because of the consistency in change month after month. We can
apply this concept of change to our own habits and behaviours: big changes most often happen from a sequence of small solutions strung together.
Using research from business, psychology, sociology and neuroscience, brothers Chip and Dan Heath have written a book called Switch: How to change things when change is hard.
This is a “how to” book that begins with a premise:
All change efforts have certain patterns that are similar
- You must start acting differently
- You must change your situation
- You must change how you feel and what you think
- You must get the emotional brain and the thinking brain to integrate
This Fall, ALIGN has teamed up with SoulSalt
coaching to create a program for change. We call our program Ultimate Freedom: Finding your way out of pain. We are seeking individuals who are in pain, and who are ready to move through it! Ultimate Freedom is a 5 week intensive, that is offered in either a group or an individual format.
Utilizing principles of coaching, neuroscience, movement and neuromuscular education, Ultimate Freedom will assist to restore you through a season of change, and a future of no pain!