A 40-year-old woman, referred for osteopathic evaluation by her gynecologist, presented with complaints of perineal pain that began about a year earlier. Initially, she experienced left hip, hamstring, and buttock pain after a vigorous walk. She then developed pelvic floor pain that became a constant ache, and sexual intercourse became painful. Pain in her left hip and pelvic floor worsened when lying on her left side or with prolonged sitting. A cystoscopy and vaginal ultrasonography were normal. Management consisted of 6 months of physical therapy (PT), including ultrasound therapy, dry needling, an SI support belt, and a heel lift on the left. For the last 3 months, PT specifically focused on the pelvic floor was added as part of her treatment. Due to limited treatment response, she had 3 trigger point injections and 4 vulvar Botox injections to manage the vulvodynia, both of which helped only temporarily. Approximately 6 months prior to her osteopathic referral, she also started amitriptyline 10 mg daily, which was noted to be ineffective and discontinued. Two months before referral, she started gabapentin 300 mg taken 3 times daily, which helped, but made her feel dull and tired. She stated that she felt depressed for several weeks prior to presentation.
The patient was an accountant, married, and stated that her husband was kind and supportive. She was nulliparous and had no past medical, surgical, or relevant family history. Medications included birth control, multivitamin, and gabapentin. She denied tobacco, alcohol, or illicit drug use.
The patient's physical examination was normal, with the structural examination revealing SDs that included: sphenobasila symphysis compression; C2 ERrSr; T6-T12 N SrRl, T12FRlSl; paraspinal hypertonicity of left greater than right thoracolumbar junction; left SI joint restriction with decreased primary respiratory mechanism; left greater than right suprapubic fascial tension; left pelvic floor inhaled, with severely limited and delayed movement when compared with thoracic respiration; left innominate posterior, outflared; left lower limb functionally short; left gluteus medius tenderness; left hip externally rotated; left hamstring hypertonicity; left lower ribs inhaled; left hemidiaphragm inhaled.
OMT was applied to the affected areas using balanced ligamentous tension, myofascial release, and osteopathy in the cranial field. Most attention was given to the pelvic diaphragm to amplify and coordinate its movement to the thoracic outlet diaphragmatic breathing. With the patient supine with a bolster under the knees, the physician's (A.G.) caudad hand contacted the medial border of the ischial tuberosity, applying a very gentle, cephalad-lateral balanced tension. The cephalad hand was placed on the left 11th and 12th ribs and applied a balanced lateral traction to engage the thoracic diaphragm. To manage the suprapubic tension, one hand contacted the sacrum and the other was placed anteriorly on either side of the suprapubic midline to lift with balanced tension and soften the fascia and balance the uterine and bladder ligaments. The pelvic SDs were corrected using BLT at the SI joint, which resulted in the correction of the left functionally short lower limb. She was advised not to wear the heel lift.
On the first follow-up visit, she stated the vulvodynia had lessened, but her left hip and hamstring pain was more noticeable. Sitting was less painful. There was decreased restriction in the pelvic floor, but the left side was still more hypertonic than the right. The diaphragms were moving more synchronously, and her lower limbs were even. An MRI of the left hip was ordered and revealed a high signal in the region of the left hamstring tendons’ insertion, with a subtle high signal in the adjacent soft tissues, reflecting tendinosis or partial thickness tearing. There was no labral tear or hip effusion. On 3 subsequent weekly visits, the vulvodynia continued to lessen in severity. The patient's symptoms of depression and pain both improved. After 3 monthly visits, the patient was feeling significantly better and weaned off gabapentin.