Pelvic Floor Tension Myalgia: A Musculoskeletal Key to Chronic Pelvic Pain (for Providers)

Recognizing Pelvic Floor Tension Myalgia as a Common Source of Chronic Pelvic Pain

Chronic pelvic pain (CPP) continues to present a formidable diagnostic and therapeutic challenge for OB/GYNs and other pelvic health providers. While the traditional focus has been on visceral etiologies such as endometriosis or adhesions, many patients undergo surgery only to experience persistent or recurrent pain. Emerging evidence points to an often-overlooked cause with significant clinical relevance: pelvic floor tension myalgia (PFTM)—a treatable musculoskeletal condition that responds well to physical therapy.

Why the Musculoskeletal System Matters

Myofascial pain is now recognized as the most common somatic source of CPP in patients with negative laparoscopy findings (1). PFTM, a subset of this spectrum, involves a shortened, hypertonic pelvic floor with active myofascial trigger points. These dysfunctions often refer pain to regions far beyond the pelvic floor—confusing the diagnostic picture and delaying appropriate intervention(2).

PFTM has been strongly linked to:

• Dyspareunia

• Urinary urgency and frequency

• Interstitial cystitis

• Vulvodynia

• Anismus

• Coccydynia

• Generalized pelvic and perineal pain (3)

Clinical Picture: Recognizing the Pattern

Patients with PFTM often present with:

• Achy or pressure-like pelvic discomfort

• Sharp or burning vaginal pain

• Suprapubic or lower back pain

• Pain exacerbated by intercourse, sitting, or pelvic exams

• Voiding difficulties or urgency

Red flags that should prompt musculoskeletal evaluation include:

• Persistent symptoms despite normal laparoscopy or cystoscopy

• Lack of response to antibiotics for culture-negative urinary symptoms

• History of pelvic surgery, trauma, or childbirth-related dysfunction

Pathophysiology: More Than “Tight Muscles”

PFTM involves more than just increased tone. Segmental innervation overlap between pelvic floor muscles and pelvic viscera (L1–S4) means that pain is often misattributed to visceral organs, while central processing in the medial thalamus blunts patients’ ability to localize the source of pain. (4) Furthermore, levator ani hypertonicity can impede voiding, irritate the detrusor reflexively, and drive dysfunctional guarding behaviors—exacerbating symptoms over time. (5)

The Role of Pelvic Floor Physical Therapy

Physical therapy is now a first-line, evidence-based treatment for PFTM and chronic pelvic pain syndromes.(6,7) A comprehensive pelvic floor PT program addresses:

• Muscle imbalances & kinetic chain dysfunctions

• Myofascial trigger points and tissue restrictions

• Neural tension, especially pudendal & sciatic nerves

• Abnormal voiding mechanics and pelvic floor tone

• Postural misalignments and scar adhesions

Interventions may include:

• Manual myofascial techniques (including trigger point release, counterstrain, PNF)

• Biofeedback or proprioceptive re-education

• Scar mobilization

• Neuromuscular retraining

• Prescriptive exercise to correct faulty recruitment patterns and restore movement efficiency

The Role of Fascial Counterstrain in Addressing Pelvic Floor Tension Myalgia

In addition to traditional physical therapy interventions, Fascial Counterstrain (FCS) offers a powerful and complementary approach to treating pelvic floor tension myalgia (PFTM). This technique addresses not only the muscles of the pelvic floor, but also the surrounding fascial and connective tissue systems that influence pelvic tone, circulation, and pain signaling.

FCS targets dysfunction in multiple tissue types, including:

• Arterial and venous vessels, improving perfusion and drainage

• Visceral and abdominal fascia, which can create mechanical drag on pelvic structures

• Myochains and ligamentous strain patterns that alter posture and pelvic alignment

• Periosteal tension affecting sacral, coccygeal, and pubic bone mobility

• Peripheral and autonomic nerves, helping downregulate nociceptive input and central sensitization

By resolving these silent contributors to tension and inflammation, Fascial Counterstrain can significantly reduce symptoms and enhance the effectiveness of traditional pelvic floor physical therapy—especially in refractory or severe cases of chronic pelvic pain.

Evaluation: A Collaborative Approach

A thorough assessment requires collaboration with a skilled urogynecologic physical therapist trained in both internal and external evaluation of the pelvic floor. Key components include:

• Internal palpation of the levator ani group, obturator internus, piriformis, and coccygeus

• Trigger point mapping and referral pattern reproduction

• Assessment of proprioception and relaxation capacity

• Screening for neural tension along the pudendal pathway (Alcock’s canal)

A cotton-swab test may help differentiate PFTM from conditions like vestibulodynia when vulvar symptoms are prominent.

Referring Your Patient: What to Look For

When choosing a pelvic floor PT, consider:

• Do they perform both internal and external work?

• Are they trained in treating pelvic pain vs incontinence?

• What manual therapy techniques do they use (e.g., counterstrain, myofascial release)?

• Are they familiar with neural entrapments and visceral-somatic interplay?

Resources:

• International Pelvic Pain Society

• American Physical Therapy Association

Conclusion

Pelvic Floor Tension Myalgia is a common, underrecognized contributor to pelvic pain. Incorporating musculoskeletal screening into pelvic pain evaluation not only improves diagnostic accuracy but offers a pathway to lasting symptom resolution through conservative means.

By broadening our lens beyond gynecologic pathology and embracing interdisciplinary collaboration with pelvic floor physical therapists, we can drastically shift outcomes for a large subset of patients experiencing chronic pelvic pain.



References

1. Howard FM. The role of laparoscopy in chronic pelvic pain: Promise and pitfalls. Obstet Gynecol Surv.

2. Butrick CW. Pathophysiology of pelvic floor hypertonic disorders. Obstet Gynecol Clin North Am.

3. Weiss JM. Pelvic floor myofascial trigger points: Manual therapy for IC and urgency-frequency syndrome. Int J Urol.

4. Fitzgerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor. Int Urogynecol J.

5. Tu FF, Hellman KM, Backonja M-M. Mechanisms of visceral pain: Lessons from functional disorders.

6. Jarvis SK, Abbott JA, Lenart MB, et al. Myofascial dysfunction in patients with chronic pelvic pain. J Minim Invasive Gynecol.

7. Montenegro ML, Mateus-Vasconcelos EC, Rosa-e-Silva AC, et al. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract.