This evening’s Physiotherapy Case Study focuses on a female endurance runner, suffering with pelvic pain and bladder issues.

The lady received typically thorough treatment, and, by a process of methodical analysis and hands on therapy, her pain and bladder problems were resolved by one of our five-strong team of physiotherapy experts.

She has now happily resumed her training for this year’s London marathon - find out how the issue was diagnosed and treated in our Case Study below.

Q.What was the problem the 43-year-old marathon runner presented with when she first attended the clinic?

A.This lady had started training for the London marathon last November, and had developed a pelvic pain on her left side, as well as an increased need and urge to urinate more frequently than usual. 

The pain started on the next run after a training run when she slipped off a curb. She thought nothing of the slip, but then on subsequent runs, noticed a gradual onset of pain to the left of her pubic bone. It got so bad that she went to the minor injuries unit to have an x-ray of the pelvis, which was normal.

She then rested for a couple of weeks and resumed running but it didn’t get any better. The lady also described a tightening in her mid-back area on the same side, but assumed that this was because she was running in pain and compensating. 

Q.What did the first examination involve in Blizard’s treatment room?

A.We examined her pelvic area, including the tenderness along the bone, muscle length, power, and the tenderness to touch in the piriformis muscle, hamstrings, hip flexors and quadriceps.

We then examined the symmetry of the pelvic area, as well as the movement of the sacroiliac joint. This was then followed by looking at the overall mobility and individual mobility of the thoracic and lumbar joints.

Interestingly, the pain and stiffness was evident in the thoracic and lumbar joints at the same level which supplies the bladder muscle. The decision was made to mobilise these joints, given the symptoms that she presented with, which were an increased and urgent urination - these joints can also refer to the pubic bone.

Given that there was no functional markers - in other words, she had not run for some time, so running on the treadmill caused no problems - the only marker we had was to send her away to try a run. 

What happened after she had tried running again?

A.She came back after two runs and said that, although the pain was better, it was "building up" again. The bladder frequency and urgency had not changed either.

What did our physiotherapist learn as a result of this?

A.The lady’s continuing issues indicated that either the area we treated in the back was not the source of her pubic pain, or that we had not done enough treatment to produce the desired change.

What was the next course of action to treat the endurance runner?

A.On re-examination, the joints in the back were no longer symptomatic. She was asked to run on the treadmill and her pubic pain appeared instantly. She received treatment in her back again in the same area, and was asked her to run on the treadmill once more. Her symptoms were the same. 

What was learnt from this step?

A.Through appropriate examination and treatment as in the above, we could rule out the back being a source of the pain, and thus we needed to re-examine. 

She was questioned about whether the pain could be related to a pelvic floor problem, given the lack of obvious signs on the external of the body but good signs to suggest a pelvic floor problem. She explained that recently she had noticed the same "pubic" pain with intercourse as well as the bladder symptoms. 

As a result, a pelvic floor examination revealed a "trigger point" in the pubovisceral muscle.

In addition, she had what is very common in female endurance runners - she was unable to contract and relax her pelvic floor rhythmically. The slip off the curb had sent this part of the pelvic floor muscle group into spasm.

This muscle prevents “leakage" of urine under load, as it acts as a sling around the bladder neck - as the muscle was now in spasm, it was irritating the bladder, causing her to feel the urgent and frequent need to urinate.

How was the endurance running lady successfully treated?

A.Simply, she was given a programme of pelvic floor relaxation and breathing exercises, which allowed the muscle to relax again and start working properly when required.

What were the results?

Two weeks into the program and although the symptoms are still apparent, pain is less and running mileage has increased. 

Q.What was learnt from this lady’s issue from a physiotherapy point of view?

A.This woman had not had children, and thus we can never assume a pelvic floor problem is only caused by childbirth.

The source of the pain will usually be revealed in the detailed questioning, for example, the bladder symptoms and the pain with intercourse.

Normal, healthy individuals usually respond well to treatment, so when we do not got the right results we expect, there is no point in repeating the same treatment and hoping for a better outcome.  

Please remember that we offer a FREE and CONFIDENTIAL Women's Health Physiotherapy Advice line, as well as Women's Health services at the clinic.

For help with any Women’s Health problems, contact our clinic on 01302 511755, or email info@blizardphysiotherapy.co.uk to make an appointment in confidence with Jenny Blizard or Kate Stowers, our specialist Women’s Health Physiotherapists.