Travell & Simons published the “Trigger Point Manual” in 1983, which was the first compendium on the diagnosis and treatment of myofascial pain. A trigger point is a sore spot in soft tissue. It is also called knot, a patch of involuntarily contracted muscle fibers that affect blood supply which in turn makes the area sensitive to pressure, it causes aching and stiffness. Trigger point therapy is mostly rubbing and pressing on trigger points. In this treatment for pelvic pain, the therapists try to Identify the site of clusters of trigger points inside and outside the pelvic floor. Now, regarding pelvic pain, we’ve chosen to talk about T.P. and basic stretching referring to Dr Wise’s book : A headache in the pelvis (Stanford Protocol).
Although controversial, this book is and remains a “must read” for anyone who suffers of pelvic pain and wants to get information about CPPS. It talks about the mind/body connection and how the body respond (fight flight mode) by develloping chronic muscle tension (guarding) causing less blood supply to organs and tissues. It covers the following topics : Patients stories, paradoxical relaxation, internal and external trigger point therapy, basic streching. Let be honest, this is also a self promoting book for the 6-day immersion clinics described in the book. To know more about Wise-Anderson Clinic here is a Reddit post : “One Guys Personal Review“
Internal Pelvic Floor Trigger Points in Men
The anterior levator ani (superior portion or Puborectalis) : The levator ani muscles are mostly innervated by the pudendal nerve, perineal nerve. In Dr Wise’s book this area is described as responsible for the pain men feel at the tip and shaft of the penis and it can refer to the bladder, urethra and the pressure/fullness sensation in the prostate. So according to Dr Wise, this is one of the most important trigger point sites for pelvic pain.
The anterior levator ani, middle portion (Elevator of prostate) : This area refers to pain/pressure to the base of the penis, prostate, bladder and pelvis (frequency/urgency).
The anterior levator ani, inferior portion : Can refer to pain/pressure to the perineum, the base of the penis and the prostate.
The middle levator ani (Iliococcygeus) : Can refer to anal sphincter and perineal pain, prostate fullness.
The coccygeus/ischio-coccygeus : Can refer to the golf ball sensation (rectum), coccyx/gluteus maximus pain, pre/post bowel movement pain.
The sphincter ani : Can refer to anal sphinter pain and radiating pain to the front and back of the sphincter
Prostate : massage to stretch the associated connective tissues.
Piriformis : Can refer to sacroiliac joint, hip girdle, hamstrings and increased pain at palpation site.
Obturator Internus : Can refer to the golf ball sensation (rectum), coccyx pain, hamstrings, post thigh, urethra, vagina/vulva
The coccyx : An immobile coccyx can perperptuates tp that cause pelvic pain
External Pelvic Floor Trigger Points in Men
ADDUCTOR MAGNUS : The adductor magnus is a critical muscle to check for trigger points which can refer pain throughout the pelvic floor including perineum, bladder, and prostate, Trigger points in the adductor magnus can refer the sensation of having a golf-ball-in-the-rectum
Trigger points in the bulbospongiosis and ischiocavernosis can refer pain and sensation to the base of the penis and the perineum.
Trigger points in the gluteus maximus can refer pain and sensation into the hip, buttocks, tailbone, sacrum, and hamstrings.
Trigger points in the gluteus medius can refer pain and sensation around the buttocks, hip girdle, and down the leg, as well as into the testicles
Trigger points in the gluteus minimus can refer pain and sensation down the leg and sometimes into the testicles
Trigger points in the iliopsoas can refer pain to the groin, anterior (front part) thigh, and low backTrigger points in the iliopsoas can refer pain to the groin, anterior (front part) thigh, and low back
Trigger points in the lateral abdominals can refer pain to the whole stomach, up into the ribs, down the groin and into the testicles… this is an important source of testicular pain
Trigger points in the paraspinals tend to refer pain and sensation into the low back, however this is pain that doesn’t tend to fan out but is tightly contained in a specific area
Trigger points in the pectineus can refer pain and sensation to the groin… this is a major trigger point for groin pain
The pyramidalis is not present in some individuals but when it is present and has trigger points, they can refer pain and sensation to the bladder, pubic bone, and urethra
Stretching the adductors (pectineus)
This stretch is done while lying down on a firm surface and first bending one knee while the other unbent leg is resting on the floor. The hand on the same side as the bent knee is placed on the inside of the knee and then slowly pushes the bent knee outward toward the floor. The bent knee is held down toward the floor by the hand for between 15 to 30 seconds and then return the bent leg is returned to the upright position or slide leg down to rest on the floor. This is repeated with the other leg. This is done three times or as needed during the day.
In this stretch, the knee that is supporting you is bent slightly in order to increase or decrease the stretch on the inner thigh. The leg that is stretched out is placed on a stool. This should be held for 30 seconds or longer. Change leg after one adductor is stretched to stretch the other adductor. This stretch should not be done if there is any pain experienced in the knees.
Stretching the lateral rotators and the piriformis
This stretch is done lying down on a firm surface and like stretch #1, one knee is bent while the other leg is resting unbent on the floor. The hand that is opposite the bent knee is placed on the outside of the bent knee and pulled down toward the floor as illustrated in picture. The stretch is held for 15 to 30 seconds. This stretch is repeated three times and done as needed during the day.
This is a well known yoga stretch and is done lying stomach down while slowly pushing upper body upward by straightening the arms and bending back the lower back. This is held for 15-30 seconds. For those with low back pain, this can be partial cobra with the arms partially extended rather than fully extended. This stretch is repeated three times and done as needed during the day.
This stretch is done on a firm surface, face up with both knees bent. The abdomen and buttocks are tightened with the result of rocking the pelvis and putting the lower back flat against the floor. The lower back is held for 5-10 seconds against the floor and then rested. This is done three times and done as needed during the day.
This exercise is done on the back on a firm surface. Both knees are bent with feet resting comfortably on the floor. One leg is taken below the knee and pulled back toward the chest and held between 15-30 seconds. This is done three times and done as needed during the day.
Kneeling stretch of the iliopsoas
This exercise is done kneeling on one leg with the other leg pulled back. With the upper body vertical and erect, without bending the head forward, the body is shifted forward stretching the thigh and groin for 5-20 seconds. This is repeated 5-20 times twice a day.
Stretching the quadratus lumborum and hip abductors
This exercise is done standing with hands on the hips. One leg is crossed in front of the other rests on the floor. The hips are bent forming a “C” and stretching the other side of the body. This is done three times and repeated as needed during the day.
This stretch opens up the pelvic floor. Squatting on both feet with the back supported against the wall without your “sit-bones” touching the floor. When there is no discomfort, this pose can be done for one + minutes or longer depending on the advice of your physical therapist or physician. This stretch should not be done if there is any pain in the knees.