Sometimes as rehab providers, we find patients have deep posterior pain, or they have a “hitting something” sensation with intimacy. Maybe they have a deep pelvic ache or nerve sensation with sitting or passing bowels.
We know the deep structures all have the word “coccygeus” in them: iliococcygeus, pubococcygeus, and coccygeus. We also know there are ligaments that attach to this coccyx (sacrospinous ligament and sacrotuberous ligament), creating a web of support in the posterior pelvis, which has very little bony structure. When we are treating someone with deep vaginal or deep posterior pelvic pain, do we really have to “go there” and treat the coccyx internally?
Did you know that actual spinal cord fibers enter the top of the sacral foramen, travel through this tunnel in the sacrum, and come out the bottom, where they fuse with the posterior coccygeal ligament on the dorsal surface of the coccyx? They can be a tremendous source of neural and pain dysfunction in the pelvis.
In addition, the gluteus maximus attaches at the coccyx, as well as attachments from a deep bowl of fascia, called the endopelvic fascia, that lines the pelvis. The endopelvic fascia is a tremendous source of support in the pelvis but is also often a pain generator. On top of this, the massive sacrotuberous and sacrospinous ligaments also attach at the sacrococcygeal junction.
In Sacral Nerve Manual Assessment and Treatment, scheduled for May 31 through June 1, we spend time addressing how to externally treat the deep structures that attach at the posterior pelvic floor and coccyx. We address ways to treat the incredibly dense sacrotuberous and sacrospinous ligaments that attach to the coccyx from the outside. All of the nerves that supply the posterior hip, glutes, and pelvic floor squeeze between the piriformis and the sacrospinous ligament. This site where these nerves, including the pudendal, sciatic, inferior gluteal, nerve to obturator internus, and posterior femoral cutaneous, can also be a common site of dysfunction and compression. We will learn how to decompress all of this in class, as well as the surrounding soft tissues.
So, coming back to our question. With all this soft tissue and ligament work that can be external, can we forego internal rectal work? Actually….no. Both are important. The best way to treat a side-bent coccyx or an excessively flexed coccyx is internally. However, the real magic is addressing the alignment interiorly and then addressing all the softer tissues (ligaments, fascia, skin, muscle) that keep pulling the bone back into its old bad habits and misalignment.
AUTHOR BIO:
Nari Clemons, PT, PRPC
Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment and Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jenna Ross, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jenna Ross. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.
Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel