Issue link: https://www.massageandbodyworkdigital.com/i/1476304
L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 25 pain is usually more severe with sitting and relieved or improved by standing. The pudendal nerve's winding passageway through the pelvis makes it vulnerable to entrapment in several areas, but the two most common sites are between the piriformis and coccygeus muscles and between the sacrotuberous and sacrospinous ligaments (Image 2). Since there is no reliable pain provocation test, pinpointing pudendal neuralgia is an assessment of exclusion. To avoid confirmation bias on my part and assure Mark I was respecting his self-diagnosis, I ran him through a battery of SI joint orthopedic tests, all of which were negative. EASING PUDENDAL COMPRESSION To help open the space between the sacrotuberous and sacrospinous ligaments on Mark's right symptomatic side, I used my right thumb to hook under the contralateral sacrotuberous ligament just adjacent to the coccyx, then braced with my other thumb. Mark was then asked to begin a slow pelvic tilting motion while I gently but firmly pulled the ligaments off the pudendal nerve (Image 3). During the initial session, this maneuver elicited mild testicular pain, which did not occur in subsequent sessions. In Image 4, I address Mark's piriformis tightness. Muscle spasm in this area often squashes the pudendal nerve against the underlying coccygeus muscle, and indeed, the area was very congested. While working the external hip rotators, I had a feeling this may be the "main event" that had been triggering his pudendal nerve symptoms. Following our fourth session, Mark began reporting less pain and was back to training for the big race. He was convinced the ligament and muscle work was responsible for the relief from his testicular pain. However, I credit some of the pain reduction to my physical therapist friend, who helped Mark retrofit his bike to better fit his body. Referrals are so important when it comes to improving performance and achieving overall wellness, and they certainly worked for Mark, who placed 11th in the cross-state race. SUMMARY When dealing with suspected pudendal nerve pain, it's important to remember that clients may be hesitant to discuss their condition due to the location of the referred pain. A careful intake and assessment can help them tell the whole story, drawing out the details needed to prepare an appropriate treatment plan. 4 Note 1. Ilan Leibovitch and Yoram Mor, "The Vicious Cycling: Bicycling Related Urogenital Disorders," European Urology 47, no. 3 (2005): 277–87, http://doi. org/10.1016/j.eururo.2004.10.024. Erik Dalton, PhD, is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, he has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit erikdalton.com. 2 3 Two possible entrapment sites are between the sacrotuberous and sacrospinous ligaments and the piriformis and coccygeus muscle (not shown). My thumbs hook under the contralateral sacrotuberous ligaments and lift while the client performs a slow pelvic tilting movement. My forearm hooks the piriformis tendon at the greater trochanter and drags inferiorly while the client slowly rocks his pelvis forward and back against my resistance.