Nerves of Steel: Taking a Closer Look at The Lower Extremity Nerve Differential
Pelvic Connections: Finding the Pathoanatomical problem, the Pathomechanical problem, and the Driver
Do you know our muscles would be nothing without the nerves? Also known as the gas pedal to the body, nerves play an important role in our daily life but, for so many of us, might be a complicated web of confusing language. At Pelvic Connections, we stress a pelvic health and biomechanical approach to every patient, and understanding the role specific nerves serve in our patient’s bodies allow us to find the driver of your pain more effectively.
The lower extremity nerve differential is the practice of differentiating pain that originates from nerves in the lower back, pelvis, and legs from other sources of pain. The nerves that innervate the pelvic floor and lower extremities can be a source of referred pain, meaning that issues in one area of the body can cause discomfort in another. This is especially true for pelvic pain syndromes. Have you ever heard of “sciatica”? Probably, but this is honestly a very over-diagnosed syndrome, as there are MANY more nerves of the pelvis and lower extremities.
Nerves are like trains on a track, at the beginning of the ride in between the thoracic and lumbar vertebrae, and abdominal muscles. You think of sitting which will cause more compression between two nerves. Using a train along the tracks, where is the nerve going for potential points of compression? It’s our job to figure out the specific place of compression that’s irritating the nerve to give it relief, or get the train back on the track!
The nerves that commonly affect the pelvic region include:
The Pudendal Nerve: One of the most important nerves for both sensation and motor function in the pelvic area. It provides sensory input to the genitalia, perineum, and anus, and controls the pelvic floor muscles. It is particularly susceptible to compression and entrapment due to pelvic muscle tension, trauma, or poor posture. Each one of our staff members are trained to identify the four various points of compression that exist for the pudendal nerve. This is imperative to provide a true in depth assessment and treatment to our clients coming in with pudendal neuralgia. Symptoms of pudendal neuralgia include burning, stabbing, aching, or electric shock-like sensations located in the perineum, genitals, rectum or buttocks. These symptoms often worsen with sitting and improve when standing, lying down, or when sitting on a toilet. Usually these clients report feeling of a foreign objective (like a golf ball or lump) in the rectum or vagina. They may experience urgency or frequency of urination, difficulty emptying their bladder, pain with bowel movements or constipation, pain during or after intercourse, sensation changes in the genitals or erectile dysfunction of the penis or clitoris, and pain radiating to the glutes or thighs.
(@Sydneypelvichealth: picture credit)
The Sciatic Nerve: Although it originates from the lower back, the sciatic nerve runs through the pelvis and down the legs, splitting at the knee. Once it splits at the knee, this nerve supplies the outer and inner aspects of the lower legs. This is why knowing your anatomy is so helpful, determining if foot/ankle/toe symptoms may actually be coming from up the train tracks at the sciatic nerve supply. It can become irritated or impinged, leading to pain that radiates from the lower back and buttocks down to the legs (and feet!). Pelvic floor dysfunction can contribute to sciatic nerve irritation. We can actually use the principles of childbirth, by opening points of potential compression through movement and manual therapy to relieve pain and nerve compression. (@Chiro du Portage à Gatineau pictural reference)
The Obturator Nerve: This nerve supplies sensation to the inner thighs and the muscles of the pelvic floor. When it becomes irritated, it can lead to pelvic pain, hip discomfort, or referred pain to the thighs and groin. Our favorite interesting fact about the obturator nerve is that it can mimic UTI-like symptoms due to its fascial attachments to the ischiocavernosus and compressor urethra, that can “tug” at the urethra, causing burning, pain, or urinary urgency/frequency symptoms. Although a UTI culture will be negative or inconclusive. (Hampton PT photo credit)
The Posterior Cutaneous Nerve of the Thigh (PCNT), though primarily a sensory nerve, plays a significant role in pelvic health due to its location and the areas it innervates. It originates from the sacral nerves (S2 to S3) and travels through the pelvis, providing sensation to the skin on the posterior thigh, the buttocks, and part of the perineum. This nerve is often overshadowed by the infamous sciatic nerve but can actually still be that back of the leg pain! This is again another important highlight to make sure your therapist knows nerve differential diagnosis. There are different points of entrapment for each of these nerves. In some cases, more than one can be involved.
The Genitofemoral Nerve: After emerging from the lumbar plexus, the GFN travels through the psoas major muscle and divides into two branches: 1) Genital Branch which supplies sensation to the scrotum (in males) or labia majora (in females), innervates the cremaster muscle in males (responsible for the cremasteric reflex, which raises the testicle in response to touch or temperature changes), and travels through the inguinal canal. the second branch is the femoral Branch which provides cutaneous (sensory) innervation to the upper anterior thigh.
The Ilioinguinal and Iliohypogastric Nerves: These nerves provide sensation to the lower abdomen, groin, and genitals. Irritation or entrapment of these nerves can cause groin or lower abdominal pain, often felt as sharp or burning discomfort. This is another favorite nerve set of ours! This nerve is one of the top candidates for our clients coming to us with testicular pain and/or abdominal pain. Interestingly, these nerves originate up at the T-L junction, where the thoracic and lumbar spine connect. This is an important area in our body, juggling our large thoracic cage on its back (literally). When we aren’t strong, or when we are in one position hinging for a long time, this area can weaken. When the area weakens, facet joint irritation can easily occur, which then can radiate to a magnitude of areas in the body including rib pain, back pain, leg pain, stomach pain, and genital pain.
Iliohypogastric nerve: Did you know if you’re experiencing lower abdominal pain, you may think it’s a bladder issue because it’s in the super pubic region but it’s very possibly the Iliohypogastric nerve is being compressed? This begs the question: Is it really your bladder giving you symptoms? (maybe not!)
Ilioinguinal nerve: Did you know the compression of the ilioinguinal nerve can lead to heightened sensation and pain in the inside of the thigh, front surface of scrotum, root of penis, and root of clitoris? (Fun (or not so fun) fact: clients who report pain only at the back of the scrotum give us a huge clue to look elsewhere, another important reason to KNOW YOUR NERVES)!
(spine-health.com image resource)
It’s important to consider, there are many different types of pain. For example, biomechanically induced pain which causes compression to the nerve actually means your nerve is not inherently the problem but there is a driver causing the problem. On the other hand, diabetic neuropathy is an example of the nerve being the source of the problem. Whereas, in a pelvic health context, often nerve pain is bio mechanically induced intermittent compression, irritation, or tension of the nerve.
In conclusion, at Pelvic Connections our goal is to educate our clients and the general public about the connection between pelvic floor health and the nervous system. The nerves innervate muscles and play a crucial role in their function, coordination, and response to signals from the brain and body. When there’s disruption or dysfunction in this communication, it can lead to issues such as pelvic pain, abdominal pain, constipation or bowel problems, incontinence, or sexual dysfunction. Understanding this relationship highlights the importance of looking outside the box (literally) and knowing your anatomy from the head down to the toes. Sometimes your pelvic floor pain or dysfunction is not your pelvic floor at all! It is up to us to find the driver, or root cause, of your symptoms, and we sure love to do it!
This is not a comprehensive list of the lumbosacral nerves. They are the most common that we see, although others will be on our road map, too! Which track is your train stuck on? 🧐
