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24 m a s s a g e & b o d y wo r k s e p te m b e r/o c to b e r 2 0 2 2 KEY POINTS • Pudendal nerve pain can sometimes be misdiagnosed as sacroiliac joint strain. • Clients may be hesitant to discuss their condition due to the location of the referred pain. • A careful intake and assessment can help draw out the details needed to prepare an appropriate treatment plan. Sometimes clients don't tell us the whole story. Such was the case with Mark, a 39-year-old competitive cyclist referred by a local chiropractor. During the history intake, he complained of sacroiliac (SI) joint pain that began after an accident while training for a cross-state race. He and two other cyclists had collided on a tight turn, and Mark landed in a ditch on his right hip. After a quick Google search, he had self-diagnosed his condition as SI joint strain and insisted the chiropractor focus on that area. He was treated twice weekly for a month with little relief. When I asked Mark to place one finger on the most sensitive area, he simply said, "It hurts low down in the buttocks area." When asked if he'd experienced similar symptoms before, he said he'd had the same pain a year earlier, but it had improved after he was advised by a fellow cyclist to change the slant on his bicycle seat. Aha . . . the rest of the story! Mark was not wrong to think his pain may have resulted from trauma to the SI joint or its ligaments. However, once he disclosed he had previously suffered the same pain and that altering his saddle had helped, I immediately began to suspect pudendal nerve trauma. Pedaling while sitting on a slim, hard saddle and being constantly subjected to repetitive impacts can trigger extreme perineal pressure, which can directly or indirectly compress pudendal nerves (Image 1). An incorrectly positioned or improperly shaped bicycle seat may also result in tension or thickening of the sacrotuberous and sacrospinous ligaments, which can occlude branches of the pudendal nerve. Pain from this condition is reported in an astounding 50–91 percent of cyclists worldwide and simply results from spending too much time on a narrow bicycle seat. 1 Although pudendal neuralgia is a relatively common long-distance cycling injury, most with this condition complain of painful sensations in their groin and scrotum—not in the hip. When I continued to question Mark about the exact location of his pain, he finally confided that sometimes he felt a stabbing pain in his testicles, that his family doctor told him it was probably coming from an enlarged prostate gland. PUDENDAL NEURALGIA The term pudendal comes from the Latin word pudendum, meaning "parts to be ashamed of," and clients may be reluctant to report any issues in this area. Pain from pudendal nerve trauma will typically refer into the groin area and in front of the rectum, slightly laterally. In men, the pain often shoots into the posterior aspect of the testicles and penis; in women, pain is reported in the labia and lower vagina. The pain can feel deep and internal or more superficial like a burning, numbing, and prickly sensation. Pudendal nerve Bicycle Seat Neuropathy Addressing Pudendal Nerve Pain TECHNIQUE By Erik Dalton, PhD MYOSKELETAL ALIGNMENT TECHNIQUES 1 Pedaling while sitting on a slim, hard saddle can compress the pudendal nerve.