What do episiotomy scars and groin strains both share in common (…and no this is not a christmas cracker joke!) The answer is the superficial perineal layer of the pelvic floor and in particular a narrow band of muscle called the superficial transverse perineal muscle.
The Anatomy
Hopefully you can make out from the doodle above (sorry for my appalling drawing skills) that the superficial transverse perineal muscle (coloured in red) attaches from ischium to ischium on the bottom of your pelvis (just inside and slightly forward from your sit bones.) Its role amongst other things is to help support the perineum and the sphincters that sit within it. During episiotomy surgeries this muscle is cut to allow baby and mother a somewhat easier journey through labour, stitches then follow to tidy things back up and motherhood begins. The adductor muscles that are injured during a groin strain also have a direct fascial link to this superficial pelvic floor layer. In either case if you have chronically ‘tight’ adductors and no amount of soft tissue work or of foam rolling can make your inner thighs any looser then it may be time to start looking a little higher up at its fascial neighbour the superficial transverse perineal muscle.
Body phase II
When our bodies experience trauma do they ever really heal or do we just become really good at adapting and off we trot with the same body but just phase II of it? Imagine for one moment that you are a pelvic floor with an incision down the right side and a right hip facially connected to it. Would you chose to stretch and expose the surgery or protect it and keep it closed? In clinic I often observe the latter, resulting in a movement strategy that avoids placing any tension through the tissues both during the acute stages of healing (useful) as well as long after the heeling has taken place (maybe not so useful). In the second scenario the strategy becomes a habit or a form of ‘movement amnesia’. When an area is not moved the nerve receptors in the area are not stimulated and the brain quickly forgets that there was ever a muscle or joint there in the first place (try taping two fingers together and see how long it takes for your brain to begin recognising them as just one digit).
To continue being successful post trauma (after all our driving instinct is one of survival) other joints and muscles now have to pick up the extra work and the muscles around the hip joint become unbalanced (some are facilitated and some become inhibited) resulting in an un-centred joint that becomes painful and can eventually result in future joint compression and unbalanced wear. The same is true for a right sided groin/adductor strain. The last thing that you want to do is hit box splits and stretch it as it hurts and will very likely tear some more. In both examples the bodies strategies are similar…avoid moving the injured part and re-callobrate around it as body phase II.
In the short term acute phase, reduced movement and exposure to load are important as the tissue is repairing itself, HOWEVER if scar tissue is robbed of low level force due to immobilisation or fear of movement, it no longer has the stimulus to realign its collagen fibres resulting in haphazard, shortened, week tissue which further restricts movement – and so the cycle continues. When we suddenly need to ask this now weakened tissue to help out as we accelerate to avoid a bicycle jumping the lights or during a weekend kick around with the kids, we are now faced with 2 possible scenarios:
- Stress exceeds capacity and the groin “goes” again.
- The other areas of the body no longer have the capacity to help out and we run out of movement options. In clinic people will present with hip pain, lower back pain, knee pain, neck pain, issues with continence and pelvic discomfort. It is like a water pipe in a closed central heating system that can no longer hold the pressure asked of it and the weakest link (that cheep plastic compression fitting from B and Q) goes pop.
Gait – a whole body experience
While every one is slightly different there are definitely patterns that start to appear when you begin to watch people move. I have filmed a quick video below which might be easier to visualise rather than to read.
Hopefully you can see how an issue in your pelvic floor or groin could cause anything from plantar fasciitis and varicose veins on the right, all the way up to shoulder pain and sacroiliac joint discomfort.
How do I approach things
Well I guess the answer is “it depends”. Everyone is unique in their history as well as where they are in terms of time scale (a recent acute trauma would be handled very differently to a chronic long term issue) so please please get assessed by a good health care practitioner before just diving straight in (google and youtube do not count). That being said…
Post pregnancy I like to treat the episiotomy scar tissue (or any pelvic floor tearing for that manner) directly. This can be done very non invasively using P-DTR techniques which are incredibly fast and effective and we often see immediate changes in movement as soon as we reassess. Hips start to move and pelvises start to swing symmetrically from side to side.
In the case of an adductor strain we may need to figure out why the adductor was susceptible in the first place. Was it just a simple case of too much load to a tissue that was not prepared for it or was the adductor compensating for something else (I often see this with chronic ankle sprains on the same side) and it just did not have the capacity to help out any longer?
In both of the above cases I start tinkering with movement as soon as possible to create resilience, confidence and more movement options. If you tried the experiment mention above where you tape up 2 fingers and notice that they quickly behave as one, this movement exploration is equivalent to noticing the tape, removing it, then wiggling the two fingers till they once again feel separate. In the videos below I run through a couple of quick exercise examples I like to use (shout out to Gary Ward, Diane Lee and Andrea Spina who inspired them).
Half – Janu Sirasana
This stretch works on lengthening the adductor muscles and all the fascial connections up into the pelvic floor. This is great if there is a history of chronic scaring post surgery. Go gentle.
Happy baby pose
This is a modification of the happy pose in yoga. It might get some funny looks but when performed gently separates the attachment points of the superficial transverse perineal muscle and gives it a lovely gentle stretch. It also a great place to observe how when you inhale you can feel the pelvic floor lengthen like a balloon being blown up which then relaxes as you exhale.
4 point kneeling adductor PAILs
This is similar to a happy baby pose but in kneeling. When approached methodically it allows us to introduce load to the injured area while staying within the capacity of the damaged tissue. It is a little like training in the gym. Over do it and the body suffers; under do it and nothing happens at all; hit the sweet spot and your body adapts by getting stronger and fitter.
Shift/lateral lunge
The final video is ‘shift phase’ from anatomy in motion. This is not only a whole body exercise but is the first one which lengthens the adductors in the frontal plane (from side to side) but also in the sagittal plane (by tucking the pelvis under into a light posterior tilt). With a little playful exploration this posterior tilt can give the most lovely deep stretch. Its a little like hearing a note played on a violin compared to the same note on a cello. It just feels deep and heavenly. Add a little rotation to open up the inguinal area at the front of the hip and this somewhat complicated exercise can be right on the money.
Conclusion
“If you do not move it you loose it.”
Don’t let your pelvic floor hold you back and stop you from moving. A little gentle, pain free movement exploration can often create a ‘safe space’ where your pelvis can once again be reunited back with the rest of the body.