Editor’s Note: The first article in this series (published in the December 2025 issue) focused on exercise protocols for pregnancy-related pelvic girdle pain (PPGP). This article explores a specific combination-therapy protocol for pelvic pain that can benefit both women and men.
Pregnancy is an obvious cause of pelvic floor discomfort, but so are high-impact sports injuries and certain types of jobs – especially healthcare workers like chiros because we move around, bend over and lift bodies a lot.
Being in practice 43-plus years, I’ve seen what happens to an aging pelvic floor, especially during pregnancy when women experience general ligament relaxation, specifically in the pelvic area. However, I have also seen many of my female and male patients suffer ligament relaxation, and this may be partly related to hormonal changes associated with age.
Potential Contributing Factors
Increased ligament relaxation can result in loss of proprioceptive function of the sacrotuberous ligament and attachments.1 I’ve observed that the biceps femoris muscle, which connects to the sacrotuberous ligaments, can become affected with latencies that are risk factors for pelvic floor issues in all ages.
Perhaps the biceps femoris muscle and the sacrotuberous ligament connection prior to pregnancy was already altered (or functioning in a significantly different way) in some manner, placing these women at heightened risk of pelvic pain. Think of checking the biceps femoris in your pre-childbirth evaluations.
Regarding childbirth, you’ll hear the term parity, which refers to the number of times a woman has given birth after 24 weeks of pregnancy. Higher parity, especially from vaginal deliveries, can increase the risk of pelvic floor strain, leading to pain or dysfunction.
Number of pregnancies and body-mass index (BMI) are just two factors that interact with the biceps femoris muscle to predict PPGP. The literature mentions BMI and parity as having strong risk factors for developing PPGP during pregnancy.2-3
Both variables are highly likely to contribute to increased pelvic instability by promoting more load (increased BMI) and more pre-disposition to pelvic instability. Studies have shown that multiparous (multiple pregnancy) women present with increased symphyseal width and shift compared with nulliparous (women who never gave birth).4-5
We are also seeing younger patients, male and female, get assessed for pudendal nerve entrapment at the levator ani. We all need to look at these patients from an orthomusculoskeletal standpoint and do either a rectal exam and learn to assess the tone to see if pelvic symptoms can be reproduced with palpation to the pudendal nerve, or refer out to a pelvic floor specialist.
Don’t Forget the Male Pelvic Floor
Men, as we age we need prostate screenings, but few doctors offer more than pill therapy for prostate issues. If a male patient is having any urinary hesitancy, reduced flow or erectile dysfunction, ask him, “When was your last prostate exam?” Know what his PSA is and what his numbers have been over the past few years.
PSA increases naturally with age, but if it increases at an elevated rate, that can be an indication there is a problem. The prostate is famous for getting enlarged and causing a variety of pelvic symptoms.
Also ask patients (men and women) if they are having any constipation or have a history of constipation. I’m thinking about strain to the pelvic floor with valsalva in defecation. I make sure I know about patients’ bowel habits and offer ways to improve them. Defecation posture is important and full relaxation of the puborectalis muscle is needed. Men have a tendency to sit a long time on the toilet. Make sure they are not sitting for more than 2-3 minutes at a time.
Treating the Pelvic Floor
Many therapies and modalities are popular these days to treat the pelvic floor. TECaR therapy [Transfer of Energy Capacitive and Resistive] is on the top of my list to treat pelvic floor pain. Using TECaR allows us to think about treatment in a slightly different way.
I like to use TECaR along with something I’ve specialized in over the years, which is a type of reflexology I learned from Major DeJarnette, DC, DO. Traditional and complementary medicine practitioners have addressed various ailments, including pelvic floor pain, or centuries through these “old-school” approaches, often rooted in traditional Chinese medicine (TCM), ayurveda, or early chiropractic and osteopathy.
A historical nod goes to DeJarnette for SOT, Terance Bennett for neurovascular points, Frank Chapman for neurolymphatic reflexes, and George Goodheart for applied kinesiology. Others include William H. Fitzgerald and Eunice Ingham, who also developed systems that focus on applying pressure or touch to specific points on the body.
Historically, foot reflexology is the most documented and described practice for influencing pelvic floor pain. (In part 3 I will make the fascial connections from the foot to the pelvic floor, which I think is the “why” it could work.)
I’m going to ask you to take off your shoes and socks and join me in this exploration. Come on, do it! In reflexology the heel of the foot, particularly the medial (inner) and lateral (outer) aspects, corresponds to the pelvic region, including the pelvic floor muscles, reproductive organs, uterus, ovaries, prostate, and lower back.
In the 1930s-1940s, doctors emphasized the heel for pelvic issues, as it’s believed to stimulate circulation and relax tension in the pelvic area. Is it just that a good foot massage relaxes the pelvic floor muscles, or is it, with our understanding of fascia, that if we release tight areas, we can influence the pelvic floor?
I think it’s through the fascial connections that we can influence the pelvic floor (to be discussed in part 3). (It has been documented that the tongue is connected through the fascia to the pelvic floor as well.)
When I do these techniques I apply firm, sustained pressure to the heel with the intention to relieve pelvic pain, whether menstrual cramps, postpartum discomfort or chronic pelvic pain. I press gently but firmly on the heel for 60 seconds, focusing on tender spots, which may indicate tension in the corresponding pelvic area. With TECaR I use small, round applicator heads (or bracelets around my forearms that transmit radiofrequency) with the return plate either over the sacrum or the lower abdomen. Usually, I spend 5-8 minutes doing this; I want the patient to feel a 6/10 warmth sensation.
If I want to influence the sciatic nerve reflex, I go along the outer edge of the foot, near the heel, from the heel up to the midfoot, and sometimes into the Achilles tendon area.
The sciatic nerve reflex is targeted for pelvic pain linked to nerve irritation, as the sciatic nerve runs through the pelvis and can contribute to pain in conditions like piriformis syndrome or pelvic floor dysfunction. We already associate this area with lower back and pelvic nerve pathways.
Using TECaR I apply pressure along the outer edge of the foot, moving slowly to find tender points, and massage for 60 seconds per spot.
The inner ankle and foot arch represent the reproductive organs reflex. Palpate along the medial ankle, near the malleolus and the central arch of the foot. The inner foot is linked to the uterus, ovaries and prostate in reflexology maps.
Gently press the inner ankle or arch, holding for 60 seconds, especially if tender. This can be done on both feet to address bilateral pelvic issues.
The inner foot, near the arch, relates to the bladder and urinary tract reflex. Locate the medial midfoot, just below the arch, near the instep. This point corresponds to the bladder and ureters, which are relevant for pelvic floor pain related to urinary dysfunction (e.g., incontinence or painful urination).
Target this point for pelvic pain associated with urinary tract infections or bladder pressure, common in pelvic floor dysfunction. Same treatment: Press firmly but gently on the inner arch for 60 seconds, repeating on both feet.
References
- Owens JM, Boyd JS, Groves J. Putative proprioceptive function of the pelvic ligaments. Surg Radiol Anatomy, 2002;24(6):353-356.
- Albert HB, Godskesen M, Westergaard JG. Risk factors in developing pregnancy-related pelvic girdle pain. Acta Obstetricia et Gynecologica Scandinavica, 2006;85(7):817-822.
- Bjelland EK, Eskild A, Johansen R, Eberhard-Gran M. Pelvic girdle pain in pregnancy: the impact of parity. Am J Obstet Gynecol, 2010;203(2):146.e1-146.e6.
- Abramson, D., & Robinson, R. (1934). Changes in the width of the symphysis pubis in pregnancy and labor. American Journal of Obstetrics and Gynecology, 27, 353–362.
- Garras DN, Santore RF, Ching RP. Single-leg-stance (flamingo) radiographs to assess pelvic instability. J Bone Joint Surg (Am), 2008;90(10):2119-2124.
