Every Day I’m Hustlin'

It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di

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This is a free preview of a paid episode. To hear more, visit mskmag.substack.com

With cases from James Noake In musculoskeletal medicine, we are trained to recognise patterns. Most of the time, the answer sits comfortably within the familiar: overload, strain, tendinopathy. But every so often, something doesn’t quite fit. The story is slightly off, the response to treatment unexpected, or the clinical picture just a little too inconsistent. This is where the ‘Zebra Farm’ comes in. Each time, we explore a trio of real-world cases as written up by Dr James Noake (Consultant in Musculoskeletal, Sport and Exercise Medicine) in his upcoming book ‘Real World Sports Medicine and Musculoskeletal Case Studies : Knee and Lower Leg’. The cases challenge diagnostic instinct; presentations that look routine on the surface but reveal something far less obvious underneath. These are not just rare conditions for rarity’s sake; they are reminders of the cognitive traps we all fall into: anchoring, pattern recognition bias, and premature closure. Because sometimes, when you hear hoofbeats, it isn’t a horse. This is the Zebra Farm. In musculoskeletal medicine, few diagnoses are more common than patellofemoral pain syndrome (PFPS). Anterior knee pain, stairs, squatting, sitting, running, jumping pain all form a pattern to clinicians. Most of the time, the diagnosis is correct. But, every so often, patients present with what appears to be classic PFPS, only for the real diagnosis to sit somewhere entirely different. Perhaps in connective tissue, instability, or an embryological remnant hidden within the joint itself. This is where the Zebra Farm comes in. Each time, we explore a trio of real-world cases as written up by Dr James Noake (Consultant in Musculoskeletal, Sport and Exercise Medicine) in his upcoming book Real World Sports Medicine and Musculoskeletal Case Studies: Knee and Lower Leg. These cases remind us that not all anterior knee pain is created equal, and that pattern recognition can sometimes become pattern misrecognition. Because sometimes when you hear hoofbeats, it isn’t a horse. This is the Zebra Farm. Case 1: The Patellofemoral Pain That Was Actually hEDS and POTS An ex-ice skater, now into weight training, presented with: * Bilateral anterior knee pain * Generalised fatigue * Postural dizziness * Occasional palpitations At first glance, the knee symptoms looked like entirely plausible patellofemoral pain syndrome in a young athletic individual. However, the clue wasn’t in the knees - it was in everything else. The patient described: * Light-headedness on standing * Fatigue disproportionate to activity * Palpitations * Generalised hypermobility Increasing the chance that this is a systems issue, rather than an isolated knee injury. Diagnosis: Hypermobile Ehlers-Danlos Syndrome (hEDS) with Postural Orthostatic Tachycardia Syndrome (POTS) The anterior knee pain was merely one manifestation of a broader connective tissue disorder. The patient required multidisciplinary assessment including cardiac evaluation and investigation for POTS, which is strongly associated with hypermobility and Ehlers-Danlos Syndrome. Why It Fooled Clinicians * The presenting complaint was knee pain * Many patients with hypermobility are highly active athletes or dancers * The autonomic symptoms may be volunteered only when specifically asked Key Sign ➡️ Anterior knee pain accompanied by fatigue, dizziness, palpitations or widespread musculoskeletal complaints should prompt consideration of a systemic cause. Clinical Pearl As performing arts Physiotherapist Liz Bayley notes in her accompanying reflection: “Dancers, gymnasts, circus artists, divers, and skaters occupy a space where artistry and athleticism are inseparable, and where hypermobility is not only common, but actively celebrated. In these populations, hypermobility spectrum disorders (HSDs) and Ehlers-Danlos Syndrome (EDS) appear with notable frequency. It is not difficult to understand why. Children who are naturally “bendy” find themselves in environments where those quali