Pain around the hip and pelvis may also be related to soft tissues (Figure2.1). Soft tissues are non-bony structures that connect, support, or surround other structures and include:

• the muscles, which allow you to move
• the tendons, which connect your muscles to the bone
• the bursae – small flat pockets of fluid that help all these things slide and glide against one another, reducing friction. There are bursae all around the body in places where different structures may rub against one another, for example where a tendon runs around a bone.
• the fascia – stretchy, thin, white fibrous tissue. All our muscles are enveloped in fascia, like stretchy stockings that help transfer energy from muscle and movement. Fascia also forms sheaths or tunnels for safe passage of blood vessels and nerves and wraps and supports all our bodily organs.

Soft Tissues of the Saddle Region:

The saddle region is the area between the hips that would contact a saddle when riding a horse or bicycle. There are a number of muscles and large ligaments that run through this region. The pelvic floor is the name given to a group of muscles that form a wide sling between the pubic bones at the front of the pelvis and the lower sacrum and coccyx (tailbone) at the back (Figure 2.2and 2.3). These muscles (levator ani and coccygeus), have a number of important functions:

• to support the organs of the abdomen and pelvis (e.g. bladder, bowel, uterus)
• to resist increases in pressure in the abdomen (intra-abdominal pressure), for example, coughing, laughing and lifting.
• urinary and faecal control (continence)

The pelvic floor muscles have strong connections with one of the deep hip rotator muscles (obturator internus). This muscle starts from the inner surface of the pelvis in the saddle region, then runs out through the back of the pelvis and across the back of the hip, through the lower buttock region (Figure2.3). You can read more about the deep rotators in the section on ‘Soft Tissues of the Lower Buttock’.

There are some large ligaments (Figure 2.4), the sacrotuberous and sacrospinous ligaments, that sit within the pelvis and connect between the sacrum and the pelvis. The sacrotuberous ligament runs from the sacrum to the inner edge of the ischial tuberosity (sitting bone) where it has connections into the hamstring tendons.

The sacrospinous ligament runs from the sacrum, underneath the sacrotuberous ligament and across to an area above the sitting bone, called the ischial spine. The sacrospinous ligament has strong attachments to the coccygeus muscle of the pelvic floor.

These ligaments play an important role in providing stability for the sacroiliac joints and assisting the pelvic floor in supporting the internal organs.

Soft Tissue-Related Pain in the Saddle Region

Pain in the saddle region may be due to problems with the pelvic floor muscles, often referred to as pelvic floor dysfunction. The muscles may be too weak or too active. If they are too active, known as a “hypertonic pelvic floor” then strengthening exercises may not be the best approach.

Pelvic floor dysfunction may result in:

• leakage or incontinence, urinary or faecal
• difficulty with passing urine, or moving the bowels
• pain: this can be in the saddle area but may also be felt in the groin, buttock or lower back.

Vaginismus is a diagnosis where the hypertonic pelvic floor (pelvic floor muscles that are too active) or muscle spasm affects the muscles around the vagina, making any penetration painful or impossible, for example, inserting tampons or sexual intercourse.

This is a complex condition and can have many causes. Some medical causes need to be ruled out. Psychological issues can also be relevant and must be addressed. However, in cases linked in particular to trauma (often from childbirth) or micro damage occurring around menopause, musculoskeletal therapy can be beneficial. Coccydyniais a diagnosis meaning a painful tailbone. This may develop in association with either weakness or overactivity/spasm in the pelvic floor muscles.

Pain may also be associated with abnormal strain placed on the large ligaments (Figure 2.4) of the pelvis (sacrotuberous or sacrospinous ligaments). This is usually secondary to problems with the sacroiliac joint, hamstrings, or pelvic floor muscles.

Your Hip Pain Professional can:

• assess the hip and pelvic region to identify problems that may be influencing the health of the soft tissues of the saddle region
• determine if some form of assessment of the pelvic floor muscles is required. This may involve:
  • non-invasive ultrasound assessment of pelvic floor function
  • an internal assessment from a Women’s or Men’s Health physiotherapist, a gynecologist or pain specialist with a special interest in this area or your general practitioner. This can give much more information on the type of muscle difficulties (weakness or excessive activity (hypertonicity)), the severity of the difficulty and an indication of which course of treatment is likely to be most effective.
• provide a variety of options for management of your particular type of problem. This may involve:
  • strategies to either strengthen or relax your pelvic floor muscles
  • self-massage or massage provided by a health professional trained in these techniques
  • home exercises or muscle relaxation strategies
  • other brain-based techniques (mindfulness, meditation, visualisation etc) or counselling to address any issues underlying pelvic floor muscle spasm or pain.
  • If your pain is related to pressure more in the saddle region a Keyhole Comfort cushion may be of benefit when sitting. You can read more by clicking here.

Although relatively more rare than soft tissue or joint problems, bony problems such as a fracture, stress fracture or very rarely, infection or tumour within the bone may cause hip and pelvic pain.

Bone Related Pain

Bone related pain in the saddle region may be due to a fracture (break) of the coccyx. This can occur in a fall onto the bottom or during child birth. The coccyx is a small triangular shaped bone that is joined below the sacrum, forming the tip of your tailbone (Figure3). As the coccyx is held in place by strong ligaments, a fracture is usually treated with relative rest and pain relief medications as required. A coccyx cushion with a hole cut out in the tailbone area can be useful to avoid pressure on the bone when sitting. Pain should ease once the fracture has healed. Pain that continues after bone healing is referred to as coccydynia. You can read more about coccydynia in the joint related tab of this section.

Your Hip Pain Professional can:

• perform a thorough assessment and let you know if a bone issue may be suspected. In these cases, you may be advised to undertake further imaging or referral to a medical specialist for further advice
• provide advice regarding management of bony pain
• provide rehabilitation for ongoing pain, at an appropriate time following bony injury

Pain experienced around the hip and pelvis sometimes has nothing to do with problems in this area.

Problems in the lower back can result in back pain and/or pain through the hips, pelvis and down into the legs.There are two main ways this might occur:

Referred pain

Referred pain is pain felt in a part of the body other than its actual source. For example, if there is a problem in the discs or joints of the spine, small nerve endings serving these structures generate ‘danger’ messages that are transmitted along small nerve fibres into the spinal cord.

However, this area of the spinal cord also receives information from structures in the hip and pelvis. The brain is unable to distinguish where the information came from, (the spine, the hip or the pelvis) so you might feel pain in any one or a combination of these areas.

Referred pain:

• is usually a dull, aching or gnawing pain
• can expand into a wide area that is difficult to localize
• is not related to a problem of the nerve roots in the spine
• is not associated with other nerve-related symptoms such as tingling or numbness

Radicular Pain

Radicular pain is pain associated with irritation of the nerve roots as they exit the spine. Most commonly this is associated with inflammation or compression from the nearby disc. The nerve roots that exit at each level of the spine give rise to sensation in different areas of the skin, called dermatomes (Figure 4.1).

When a nerve root is irritated at the spine, pain may be felt in the area of skin that the nerve root supplies. Radicular pain in the saddle region is most likely to be associated with the sacral nerve roots (S3-5)(Figure 4.1).

The sacrum and the sacral nerve roots sit at the very end of the spine, within the pelvis.

Radicular pain:

• is related to a problem of the nerve roots in the spine
• is usually accompanied by stabbing or shooting pains
• is usually easier to localise than referred pain
• may also be associated with an additional or background, deep, dull ache
• may be accompanied by other nerve related symptoms such as tingling, itching, burning or numbness

If the pain in your saddle region is due to a problem in the spine, you can spend valuable time and money getting unnecessary treatment on the wrong area and this might delay an important diagnosis and your recovery.

It is also important to be aware that pain in some regions is often assumed to be back-related pain when the pain may be all or partly due to a problem of the hip. Again, you may spend valuable time and money getting unnecessary or incomplete treatment.

Your Hip Pain Professional can:

• provide a skilled assessment
• help figure out the actual source of the problem and if you have more than one area contributing to the problem
• develop a comprehensive plan to help the problem – If your pain is spine-referred or radicular, you may need treatment on your spine and not your hip or if you have two problem areas, both will need to be addressed within a comprehensive management plan
• recommend further tests or refer you to another specialist if the problem does not appear to be in the musculoskeletal system.

The nervous system (Figure5.1) isa complex network of nerves and cells that carry messages between the brain and spinal cord and your body. It is through this system that we feel, move and control our bodily functions. Nerve roots leave the spinal cord via the intervertebral foramina (holes or spaces between the vertebrae) and join together from various levels of the spine to travel as cord-like structures, called nerves, to their destinations. It is these nerves that travel outside the spinal cord that are referred to as“peripheral nerves”. Some peripheral nerves travel only a short distance and others all the way from the lower back to the foot. Along their journey they run between and through muscles and fibrous tunnels. While radicular pain arises from a problem as the nerve root exits the spine, nerve-related pain may develop due to a problem along the pathway of a peripheral nerve, outside the spine. Pain related to a nerve is called “Neuralgia”.

Neuralgia felt around the hip and pelvis may develop in many ways including excessive compression or stretch of the nerve. This may be caused by a sudden, acute mechanism, for example a fall or blow to the area resulting in compression, or the leg being caught and wrenched, resulting in stretch. Alternatively, the onset may be subtle, with a gradual onset associated with sustained postures or repetitive movements that cause cumulative nerve irritation. Nerves will also be influenced by the health of the tissues they run through or alongside. For example, high muscle tension or tendinopathy may over time result in irritation of neighbouring nerves. Nerve related symptoms are usually experienced differently from pain associated with muscle and joint problems. Peripheral nerve irritability may result in:

• symptoms in the area served by that peripheral nerve (which is different from dermatomal patterns associated with nerve root irritation-radicular pain)
• burning pain
• odd zings or zaps of pain
• tingly sensations or numbness
• weakness–only for those nerves that supply muscles, like the femoral nerve

Nerves of the Saddle Region:

Nerves that supply the saddle region (Figure 5.2 and 5.3) include:

• the genitofemoral nerve
• the pudendal nerve and its branches
• the inferior cluneal nerve
• the coccygeal plexus–small nerves that supply the area around the coccyx (the bone at the very bottom of your tailbone). The anococcygeal nerve serves the skin in this area.

Nerve Related Pain/Neuralgia in the Saddle Region

Pudendal neuralgia is the most common type of neuralgia reported in the saddle region.This small nerve may be compressed or irritated on its pathway through the buttock, where it travels from inside the pelvis to outside the pelvis and then turns around and travels in to the perineal (pelvic floor) area (Figure 5.4).

It runs between the strong pelvic ligaments (sacrospinous and sacrotuberous) and through a fibrous tunnel (Alcocks canal) and may be compressed or irritated on this journey (Figure 5.4 & 5.5).

Unfortunately, pudendal neuralgia is often misdiagnosed.

Symptoms of pudendal neuralgia include:

• pain over the external genitalia and the skin around the anus and perineum (Figures 5.2 and 5.3)
  • aggravated by sitting–sitting can put pressure on the nerve as it passes through the deep buttock area. In contrast, sitting on the toilet seat is not painful.
  • that builds during the day but is usually better at night or when lying down, when the gravitational pressure on the pelvic floor, and thus the nerve, is reduced
• symptoms related to the nerve’s motor supply (the ability to make the muscles work/contract) to some of the pelvic muscles. Examples of this include:
  • symptoms such as bladder frequency (needing to urinate frequently or urgently)
  • the sensation of an urgent need to open the bowels and sexual dysfunction
• altered sensation/feeling or numbness in the perineal region (area between the pubic bone at the front, and the coccyx or tailbone at the back) served by the nerve (Figure 5.2 and 5.3).

This condition may occur:

• following childbirth or pelvic trauma or surgery
• in association with sacroiliac joint problems
• due to hypertrophy (large size) of the piriformis muscle, where the muscle presses the nerve against the overlying sacrospinous ligament
• due to direct pressure in the area – e.g.long durations cycling or during hip arthroscopy surgery where a stabilising ‘post’ may press against the perineum.

For Pain Related to Nerves/Neuralgia throughout the Hip, Pelvis, Buttock and Groin:

Your Hip Pain Professional can:

• perform specific tests in the clinic to see if nerve involvement is likely
• provide treatments and give you exercises that may improve the health or movement of the nerve
• help improve health of the muscles and tendons beside the nerve (this may be the source of nerve irritation)
• review the positions you spend time in and activities you perform daily and provide strategies when performing these tasks that might help protect the nerve, thus reducing your symptoms. This may include changing your sitting or lying posture, or changing stretches or strength exercises that you have been performing that may be contributing to the irritation the nerve
• If your pain is related to pressure more in the saddle region a Keyhole Comfort cushion may be of benefit when sitting. You can read more by clicking here.
• provide nerve gliding or mobility exercises that can be useful in some situations
• refer you for further tests or to a neurologist, orthopaedic specialist or other pain specialist if required.
• In some cases, your hip pain professional may refer you to a pelvic floor physio for further assessment should they consider the pelvic floor muscles are involved.

*Please note: Nerve supply can overlap and be quite variable between individuals. The diagrams provided in this section only provide an approximate guide of nerve supply in each region.

There are other processes that may produce pain around the hip and pelvis.

These include:

• Systemic/Rheumatological conditions: eg Rheumatoid Arthritis, Polymyalgia, Polyarthralgia
• Infective processes: Septic arthritis, Osteomyelitis, Viral Arthritis
• Neoplastic processes (cancer)
• Vascular issues: Avascular Necrosis, External Iliac Artery Entrapment, varicotic gluteal vessels compressing the sciatic nerve

These conditions are relatively rare compared to musculoskeletal pain, but when present you will need to see a medical practitioner and usually a specialist for that system or problem, for example, a Rheumatologist, Orthopaedic Specialist, Oncologistor Vascular Specialist.

Lower abdominal and pelvic pain can also be associated with organ problems (ovaries, uterus, bowel, bladder, prostate). One of the most common causes of organ-related pain in females is endometriosis.

This occurs when tissue that is similar to the lining of the uterus (womb) grows outside the uterus attaching to other structures such as the pelvic ligaments or the bladder and bowel.

This can lead to debilitating pain that may be cyclic, relating to the menstrual cycle.

Diagnosis and management of organ related problems will usually require the assistance of a specialist, for example a gynaecologist (female reproductive organs), urologist (bladder and prostate) or gastroenterologist (gut/bowel).

A skilled assessment by a Hip Pain Professional will help clarify if the problem requires further medical attention and whether it is likely to be related to a musculoskeletal problem or not.

Your Hip Pain Professional can:

• provide a detailed assessment
• assist in determining if the problem is musculoskeletal or not
• develop a plan to help if the problem is musculoskeletal
• recommend further tests or send you to another specialist if the problem does not appear to be in the musculoskeletal system.