Symptoms
Patients with trigger points in the anal sphincter usually complain of aching, diffuse pain in the anus, and pain during bowel movements. Trigger points in the bulbospongiosus muscle provoke aching pain in the perineum and dyspareunia in women - difficulties in sexual activity. In men, such trigger points cause discomfort when sitting with a straight back, induce pain in the rectum and scrotum, and sometimes lead to varying degrees of impotence.
Lesions in the ischiocosseous muscle also cause perineal pain.
Trigger points of the obturator internus muscle can cause a feeling of fullness in the rectum and pain, sometimes radiating down the back of the thigh, and can also refer pain to the vagina.
The most well-known source of myofascial pain in the perineal area is the levator ani muscle. Referred pain when this muscle is damaged can radiate to the lower back, sacrum, coccyx, pelvic floor, rectum, or vagina. The pain leads to discomfort in a sitting position, intensifies in a supine position and during bowel movements.
Trigger points in the coccygeus muscle cause pain in the tailbone, hip, or lower back, similar to pain in the levator ani muscle. Such pain also makes it difficult to sit. Trigger points in this muscle can trigger back pain during pregnancy and the postpartum period, and spasm and tenderness of the coccygeus muscle has been a major contributor to low back pain in many women undergoing fertility evaluation.
LEGS MUSCLES
Depending on their location, the leg muscles are divided into: muscles of the anterior surface of the thigh, muscles of the posterior surface of the thigh, muscles of the inner surface of the thigh.
Muscles of the anterior thigh
The muscles of the anterior thigh include the flexor muscles in the hip joint and the extensor muscles in the knee joint:
- Rectus femoris muscle
- Vastus medialis muscle
- Vastus lateralis muscle
- Vastus intermedius muscle
The quadriceps femoris muscle consists of the rectus femoris muscle , which has the shape of a convex roller on the front surface of the thigh, the vastus lateralis muscle , which is a significant part of the quadriceps muscle, which is adjacent to the rectus femoris muscle on the outside. When contracted, this muscle bends in the form of a relief roller, running towards the outer surface. The vastus medialis muscle is located on the inside. This muscle comes almost to the knee itself, i.e. lower than the outer head. The vastus intermedius muscle runs along the front of the thigh and is located under the rectus femoris muscle.
The function of the quadriceps muscle is to extend the lower leg and, in addition, to flex the hips. Other muscles are involved, for example, in squatting movements.
Muscles of the lateral thigh
The muscles of the lateral thigh include the adductors and hip flexors:
- Adductor brevis muscle
- Adductor longus muscle
- Adductor magnus muscle
- Pectineus muscle
- Thin (tender) muscle
- Sartorius
The sartorius muscle separates the adductors from the extensors. The outline of the inner thigh depends on the thin (tender) muscle. Contraction of this muscle does not have a significant effect on hip movement. A continuation of the inner head of the quadriceps muscle is the adductor longus muscle.
The pectineus muscle fills the space between the sartorius muscle and the adductor longus muscle. The adductor muscles are not particularly prominent. Their outlines are best seen if you bring your leg to the central axis of the body while overcoming resistance. In addition, the muscles of this group take part in flexion and rotation in the hip joint.
Hamstring muscles
The muscles of the back of the thigh include massive muscles, which, as they approach the popliteal fossa, separate, attaching in different places:
- Biceps femoris
- Semimembranosus muscle
- Semitendinosus muscle
The biceps femoris muscle, as its name suggests, has two heads. The long head goes down and then to the outside where it meets the short head. Attached to the head of the fibula, it limits the popliteal fossa on the outside. The function of the biceps muscle is to extend the thigh and flex the tibia, as well as to rotate the tibia outward.
The semitendinosus muscle is a relatively thin muscle. Together with the semimembranosus muscle, it forms the internal roller of the posterior surface of the thigh; the tendons of these two muscles limit the popliteal fossa on the inside. Both muscles function as flexors in the knee joint and rotators of the lower leg. The muscles in the hip joint are extensors.
Calf muscles
The muscles of the lower leg can be divided into three groups: the muscles of the anterior surface (extensors), the muscles of the posterior surface (flexors) and the muscles of the outer surface:
- Calf muscle
- Soleus muscle
- Tibialis anterior muscle
- Peroneus longus muscle
- Peroneus brevis muscle
- Extensor digitorum longus
The gastrocnemius and soleus tendons unite to form the Achilles tendon, which wraps around the ankle joint and attaches to the heel bone. The calf muscles are responsible for extending the leg at the ankle joint (for example, when we walk on tiptoe). The contribution of these calf muscles to this movement depends on the angle at which the leg is bent at the knee joint. When the leg is straightened at the knee, the main load falls on the gastrocnemius muscle, and the soleus muscle comes into action when the leg is bent at the knee. Note that the gastrocnemius muscle covers both the knee and ankle joints, so it has a dual purpose - bending the leg at the knee and extending it at the ankle joint.
The extensor longus is involved in straightening the toes and lifting the foot upward. The outer part consists of two muscles: the peroneus longus and the peroneus brevis. The long belly of the first muscle is located near the extensor digitorum longus; its long tendon goes around the outer ankle, passing to the plantar surface. Interacting, both of these muscles flex, reward and abduct the foot, the arches of which also depend on the work of the mentioned muscles.
Survey
Patients with trigger points in the pelvic floor muscles move rather slowly and sit down with caution, often resting one half of the pelvis on the edge of a chair, often changing position while sitting. After sitting for a long time, when getting up from a chair they complain of acute pain.
Active trigger points in the obturator internus muscle limit its stretch range. In the supine position, the patient has limited internal rotation of the leg straightened at the knee joint. If you bend your leg at the hip joint to 90° and then bring it down, you can achieve a much greater stretch of the muscle, but this will lead to increased tension in the twin muscles, piriformis and obturator internus muscles.
Movement in the sacrococcygeal joint is normally not limited. Women have a greater range of motion in the sacrococcygeal joint than men. With bilateral tension of the coccygeal muscles, flexion occurs at the sacrococcygeal joint. With unilateral tension of the coccygeus muscle, the coccyx shifts towards the affected side, it is especially noted that if there are complaints of pain in the lower back, painful sensations are detected in the area of the apex of the coccyx. Such cases lead to the development of kyphosis of the coccyx, tilting it towards the pelvis. But when pressing on its dorsal surface and movements in the sacrococcygeal joint, pain is not felt. It is very difficult to examine the apex of the coccyx due to this curvature, as well as due to the increased tone of the adjacent gluteus maximus muscles, so this patient complaint is often not taken into account. However, in the presence of such pain, this source must be detected, which can be achieved with intrapelvic examination.
It is also necessary to exclude the presence of pelvic curvature and asymmetry, as well as damage to the pelvic joints.
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Pelvic muscles
The pelvic muscles primarily refer to those muscles that originate on the pelvic bones and then attach to the femur. They affect the hip joints. As for their location, they are divided according to this criterion into two divisions. These will be external and internal divisions. The external ones include the gluteus maximus, both gluteal muscles, the quadratus muscle, the muscle responsible for stretching the wide connective tissue membrane of the thigh, including both gemini muscles and the external locking muscle. The internal pelvic muscles include the obturator internus, piriformis, and iliopsoas muscles.
All pelvic muscles belonging to the group of external ones are located in the buttocks area and on the lateral area of the pelvis. Most of their surface is located on the bones of the pelvic girdle, where, in fact, they begin. Many of these muscles reach the attachment point, which is located on the femur. This muscle group has three layers. Namely superficial, deep and medium. The surface layer is represented in the form of a large muscle of the buttocks, another muscle capable of straining the connective tissue membrane of the thigh. The deep layer refers to the gluteus minimus and obturator externus muscles. But the middle layer includes the largest number of muscles. To be more precise, the gluteus medius, quadratus femoris, those parts of the piriformis and obturator muscles that are located outside the pelvis, and both gemini muscles.
The gluteus maximus is considered a medium-strength muscle. Its structure was called large-beam. It stands out in relief due to the large mass in the buttock area. The large buttock muscle is developed much better in humans than in anyone else, and all thanks to our upright posture. Its origin is located in several places, namely on the ilium, the first zone of the muscle responsible for straightening the spine, on the dorsal region of the sacrum and coccyx, and the sacrotuberous ligament.
The gluteus medius muscle developed on the gluteal portion of the ilium, but some of it developed on the connective tissue sheath. Then it passes down, gradually turning into a thick tendon, which in turn joins the upper region of the outer zone of the greater trochanter.
The gluteus minimus is present below the gluteus medius. Its origin is located on the edge of the greater sciatic notch, still on the outer part of the wing of the ilium, approximately in the area of the two lines of the buttocks. This muscle is attached to the anterolateral part of the greater femoral trochanter. Some bundles of the minor muscle are connected to the capsule of the hip joint. The trochanteric bursa, which belongs to the minor muscle of the buttocks, lies in the area of the greater trochanter and directly the tendon of this pelvic muscle.
The muscle responsible for tensioning the lata of the thigh begins at the highest point of the frontal iliac spine, located next to the iliac crest zone. Among other things, it is located in the area between the plates of the wide connective tissue membrane, that is, between the superficial and deep. Then, having reached the limit of the upper and middle zones of the thigh, it turns into the iliotibial tract of the lata. Then it descends even lower and is attached to the lateral condyle of the tibia bone.
The quadratus femoris muscle is considered to be a flat, quadrangle-like muscle. It lies in the zone formed by the gemminis muscle and the superior point of the adductor magnus muscle. Moreover, in one case it goes along the top, and in the other – along the bottom. At the peak of the outer part of the ischial tuberosity, the quadratus muscle is formed. Its attachment occurs in the area of the upper point of the intertrochanteric ridge. The synovial bursa is located in the area between the frontal part of the quadratus muscle and the greater trochanter.
Another triangular muscle is the obturator externus muscle. Its origin lies at the outer zone of the pubic bone, including on one of the branches of the ischium, and on the middle two of the three parts of the obturator membrane. Its associations go backwards, then go sideways, and only after that go up. The obturator externus tendons run behind the hip joint and ultimately attach to the trochanteric fossa and joint capsule.
The internal pelvic muscles include the obturator internus, iliopsoas and piriformis muscles. In turn, the iliopsoas is divided into two muscles - the psoas major and the iliacus. They originate from different places, that is, from the lumbar vertebrae and the ilium, respectively. But they still come together at a certain point. This creates a muscle that attaches to the lesser trochanter of the femur. Two parts of this muscle are actively involved in creating the posterior wall of the peritoneum.
At the obturator entrance area, another muscle begins, which received two words in its name - internal and obturator. Its origin lies on that part of the obturator membrane that is located inside, the pelvic surface of the ilium and on the obturator connective tissue membrane. From the pelvic area it passes through the lesser sciatic foramen, then at an acute angle passes through the area of the lesser sciatic notch.
The piriformis muscle placed its initial part in the area of the pelvic sacrum, or rather slightly to the side of the holes of the same name. It passes through the interior of the pelvis and then arises from the greater sciatic outlet. In the area of the posterior surface of the femoral neck it transforms into a round tendon, attached at the highest point of the greater trochanter. A small space under it is occupied by the synovial bursa of the piriformis muscle.
Treatment
For any problems with the pelvic floor muscles, manual therapy is necessary first of all. The main goals of treatment are to remove trigger points in the pelvic floor muscles, restore mobility and place the iliac bones, sacrum, and coccyx in their anatomically correct place, as well as normalize the position of other structures of the musculoskeletal system, the displacement of which can provoke relapse of pain in the pelvic floor muscles. Acupuncture is also often used to reduce pain, restore muscle tone and blood flow.
Corrective exercises
If local treatment is ineffective or in a situation where the improvement becomes only temporary, it is necessary to exclude the possibility of eating disorders and other systemic factors that determine the continued existence of trigger points in the pelvic floor muscles. In patients with trigger points in the levator ani muscle, as well as the coccygeus muscle, all changes in the joints should be identified and corrected, if possible: sacroiliac, sacrococcygeal and lumbosacral. The elimination of pain in such cases is facilitated by the treatment of chronic inflammatory diseases of the pelvic organs, genitourinary infections, and correction of posture in a sitting position is also necessary.
If you have internal hemorrhoids, trigger points in the anal sphincter cannot be treated. Patients are prescribed medications that help soften stool. Increased fluid intake and a high-fiber diet are indicated. Local use of painkillers and anti-inflammatory drugs is prescribed, as well as enemas with baby petroleum jelly before bedtime. If conservative therapy is not effective, then ligation or surgical removal of internal hemorrhoids is prescribed.
Causes of muscle weakness
- Pregnancy and childbirth
, complicated or repeated natural births. These are the main risk factors predisposing to pelvic floor dysfunction. During pregnancy due to the pressure of the increasing weight of the uterus, during childbirth due to the passage of a large baby through the vagina, due to an episiotomy. In the postpartum period due to early stress on the abdominal muscles. - Active strength sports
, including jumping and lifting weights, which increase intra-abdominal pressure can lead to loss of pelvic floor tone even in very young women. - Age-related changes
in hormonal levels can lead to a loss of tissue elasticity in the pelvic area and contribute to the weakening of the levator muscles. - Genetic predisposition
. Two out of ten women have congenital weakness of the pelvic floor muscles. - Everyday habits
: holding urine for a long time when there is an urge to urinate, strong straining during bowel movements. - Other reasons that cause severe abdominal pressure
are excess weight, constipation, chronic cough and stress.