David Wise, Ph.D.

I well understand the confusion about how to tell what useful physical therapy is and isn’t and how you know if you are getting the right physical therapy when you have pelvic pain. This perspective comes from working with many patients who have seen us at Stanford with whom we have used the Wise-Anderson Protocol over the years. We have described this briefly in A Headache in the Pelvis.

I have interviewed many patients who have seen a variety of physical therapists. I have listened carefully to the comparison of their experiences to their experiences with physical therapists competent in our protocol. I have looked at the results. I want to discuss these comparisons below. I am not a physical therapist although I have been very interested in Trigger Point Release for a number of years. I want to acknowledge with gratitude that I have learned both basics and fine points of trigger point therapy from Tim Sawyer, our senior physical therapist, and others. Whatever errors in understanding I make writing about pelvic floor physical therapy are my own and not attributable to them.

I have put together a brief description of the phenomenon of myofascial restriction and trigger point activity related to the pelvic floor in an informal essay. In doing so, let me be clear that I am not suggesting that anyone use this information as a substitute for proper in-person PT training nor am I suggesting that one treats oneself without proper instruction and training. Competently doing our PT protocol is not mastered quickly but by a thorough understanding of the trigger point phenomenon and by experience in successfully working with Trigger Point Release in and outside of the pelvic floor.

Before discussing Trigger Point Release related to pelvic pain, I want to reiterate what we have said in A Headache in the Pelvis that physical therapy is one part of the equation of treating a certain kind of pelvic pain. It is tempting to see an external fix like Trigger Point Release as the answer to pelvic pain. When you have pelvic pain of the kind we treat and decide to do whatever it takes to resolve it, you find out there is no quick fix but results come from committing yourself to the inside job of changing very stubborn inner habits.

The most exhaustive physical therapy done brilliantly, while essential in our protocol, cannot guarantee that the treated trigger points will behave. Consider that there are 168 hours in a week. Let us say that a person goes to see the physical therapist 2 times a week. That is quite a bit of physical therapy. In the physical therapy session, after a person takes off their clothes, gives the PT a report on their week and begins the physical therapy itself, at the most there is probably 30-45 minutes of hands-on treatment. After the treatment, the tissue is lengthened (although sometimes temporarily irritated in the process). That is at the most 1.5 hours of therapeutic treatment per week. In a good pelvic floor physical therapy session, the pelvic floor tissue has been lengthened and life has been made more livable for it.

However, after physical therapy, there are approximately 166 hours per week to live. The old habit of going 100 miles an hour in one’s life and tightening up the pelvis regularly and squeezing and shortening the irritated tissue can easily and quickly undo the therapeutic impact of the physical therapy session. A PT treatment that lasts less that .023% of your life cannot work if the old, symptom-provoking habits go on unabated. This is the why the ongoing relaxation of the pelvic floor and quieting of the nervous system with relaxation protocol like the one we use is necessary. In my view, the resolution of the kind of pelvic pain we treat is an inside job of cooperating with the healing mechanism of the body in the short run and the long run. Trigger Point Release is an essential and necessary component but not a sufficient one by itself.

In recent years we have come to understand that the PT components of our treatment must be done every day or every other day. For this reason the large focus of our 6-day clinics is to teach patients how to do the Trigger Point Release on themselves.

That all being said, let me address the issue of what physical therapy works for pelvic pain and what criteria there are to evaluate the physical therapy you are getting or want to get. Seeing someone who is a physical therapist and even seeing someone who holds him or herself out as a pelvic floor physical therapist offers no guarantee that our protocol, will be followed. One can do physical therapy for pelvic pain with a physical therapist with little understanding and experience in Trigger Point Release and receive little benefit. Going to a different physical therapist who is trained, talented, and experienced can make a huge difference.

In other words the experience, understanding and intuitive talent of a physical therapist doing Trigger Point Release can make the difference between success and failure of our protocol and the reduction or resolution of one’s symptoms. I am speaking from my personal experience and from my clinical experience in treating many people with pelvic pain. In our approach, we subscribe to a specific protocol. What I say below describes it.

First, a little background. Travell and Simon published the first edition of Myofascial Pain and Dysfunction: The Trigger Point Manual in 1983, which was followed by a second edition in 1992. These books were the culmination of research that went back to 1942 when Dr. Travell published her first article on myofascial pain. Janet Travell is not well know for the remarkable fact, as I understand it, that she was appointed the White House physician during the Kennedy and Johnson administrations as an expression of Kennedy’s gratitude for her successful treatment of his myofascial pain that threatened to end his political career.

The concept of trigger points is relatively new to medicine. It is very new to urology. Trigger points are defined as taut bands within a muscle, either at the surface of the muscle or inside the muscle, in the belly or at the attachment of the muscle. The trigger point characteristically elicits a twitch response, detectable on ultrasound or via electromyograph (a machine that measures the electrical activity in a muscle in millionths of a volt) that can be felt by a trained and sensitive practitioner while palpating the trigger point. When the trigger point is pressed there is often a ‘jump’ response in the patient, due to the reflexive reaction of the patient to the often exquisite tenderness of the trigger point upon palpation. Furthermore, the trigger point characteristically refers pain/sensation to the site being pressed or to a site remote from it.

A trigger point can be active or latent. An active trigger point is considered able to refer pain and recreate that pain upon palpation when the patient comes in with a complaint of pain. A latent trigger point has the capacity to be the source of pain (ie. has the capacity to become an active one) and under certain circumstances, becomes active but generally the patient does not complain of symptoms from latent trigger points. Trigger points are latent in many people. Often active trigger points never entirely go away with the best therapy and so the goal of both our physical therapy and Paradoxical Relaxation protocol is to teach patients to manage their own trigger points so that they stop being symptomatic.

The problem that occurs when urologists are asked to consider trigger points as essential ingredients in chronic pelvic pain syndromes is the problem of a ‘paradigm conflict’. Our book aims specifically at offering a different paradigm of chronic pelvic pain syndromes than the paradigm of conventional medicine. A paradigm is a model of reality. Urologists have little or no training or understanding of the role of trigger points in pelvic pain. The connective tissue and muscles inside and outside the pelvis are the sites in which many offending trigger points are found. This tissue and the trigger points that are found there in many pelvic pain patients have rarely been taken seriously as a source of pain by most urologists. This concept of trigger points in urology is poorly understood and not readily accepted for reasons that we discuss in our book.

Where one feels the trigger point pain is often not the source of the pain. For this reason pelvic pain diagnosed by someone unfamiliar with the workings of trigger points are often mistaken because they are unclear that the source of much pelvic pain is not where it seems to be. In other words, pain coming from trigger points often is not coming from where you feel the pain. While doctors understand the concept of referred pain, the idea that pelvic pain felt in the groin, penis, testicles or perineum may indeed originate inside the pelvic floor is a not part of a urologists training and understanding or belief. Part of the difficulty that doctors have with trigger points is that they have usually received no training in the subject. Furthermore, because there is no objective, litmus paper, gold standard test for evaluating them and the only way clinically to find and treat them is through palpation and this requires training and a sensitive touch, trigger points do not exist in the reality of many doctors. This is part of the paradigm conflict.

Recently a woman called me who had very severe rectal pain. She told me that during the course of one of her doctor’s pelvic exams, he hit a spot that the woman said, “sent me through the roof.” After the exam, the doctor told her that he really did not know what was going on with her, that he couldn’t help her and that she might simply have to live with the pain. The woman went home despondent, her pelvic floor very irritated and flared up. The next day she woke up and her pain was almost gone. It remained so for several days. She called up the doctor’s office happily bewildered to share with the doctor what happened. She told the nurse that she thought it was related to the painful spot the doctor pressed. The nurse relayed the news about the woman to the doctor. The doctor then told the nurse to tell the patient she could massage that point herself if it helped her. The patient felt more bewildered.

What probably happened is that the doctor inadvertently pressed and temporarily released a major trigger point for the woman and the woman responded like any of our patients typically respond… with some flare up and then a reduction of symptoms. The doctor, in not understanding anything about trigger point pain and treatment, essentially dismissed this event and the possibility of helping this woman. She remained confused after I spoke to her.

Trigger points refer pain directly on the trigger point site or to a remote site, which means that where you feel the pain is sometimes not where it actually is coming from. For instance, we find that tip-of-the-penis pain is often referred from trigger points in the anterior portion of the levator ani muscle as it attaches to the prostate. This is not obvious and is anti-intuitive. This trigger point is a good number of inches from the tip of the penis. Who would think that the source of tip-of-the-penis pain would come from a site so far away? By the way, if you do not have long enough fingers or if you do not understand how the trigger points work in the body, you miss this connection entirely.

The internal muscles that contain trigger points are close to each other and it takes someone who understands the internal pelvic anatomy and is experienced in feeling the muscles inside the pelvic floor, to tell them apart. You can look up in an anatomy book to see the location of these muscles to which I am referring. Below is a list of the internal muscles in which most internal trigger points are found. The relationship between symptoms and the location of associated trigger points is mostly found the Travell and Simons textbooks. Some of the connections reported below have not been published and come from Tim Sawyer’s extensive experience.

All of the muscles, both internal and external, must be thoroughly evaluated and treated. When muscles are known to contain trigger points referring pain to an area that the patient is complaining about, they should be extra carefully examined. The therapist must be trained in identifying trigger points and able to feel for superficial and deep trigger points located in the belly and the attachments of the muscles. When trigger points are located, they must be held with pressure release which involves pressing on a trigger point with constant pressure, usually for a period of 60-90 seconds. When appropriate the following techniques are used:

  • Voluntary contraction and release/hold-relax/contract-relax/reciprocal inhibition
  • Spray and stretch occasionally with stubborn external trigger points
  • Deep tissue mobilization including striping, strumming skin rolling, effleurage
  • Skin rolling
  • Myofascial release
  • Strain-counter-strain/ muscle energy release

Anyone who has pelvic pain of the kind we treat should know that specific trigger points in specific pelvic muscles tend to refer specific kinds of symptoms. We are currently preparing a paper for publication identifying specific trigger points with specific symptoms. This knowledge is critical for the physical therapist who is treating pelvic pain. For example pain in the tip of the penis or the sense of urgency and frequency is typically created by active trigger points in the anterior (front) portion of the levator ani muscle as it attaches to the prostate. When the physician or physical therapist does an examination, a knowledge of the relationship between symptoms and pelvic trigger points is essential to make the diagnosis of tension/neuromuscular related pelvic pain and dysfunction. When we find relationships between trigger points and the kinds of symptoms they typically refer, enumerated below, we are much more confident in our diagnosis and ability to help the patient.

Below is a listing of the internal pelvic and external pelvic floor related trigger points and the location of the pain and symptoms they typically refer. Certainly not all patients fit all the patterns we describe here. Sometimes one or two trigger points fit the referral pattern we describe below. And to reiterate, we sometimes can help people with tight and tender pelvic muscles where there is no discernable trigger point.


Pelvic muscle: levator ani

Pain and symptoms typically referred by trigger points in the levator ani muscle:

  • TIP OF THE PENIS PAIN (usually found in the anterior portion of the levator ani near to the prostate)
  • A feeling of GOLF-BALL-IN-THE-RECTUM DISCOMFORT which usually comes from trigger points in the middle and posterior (back) portion of levator ani muscle

Pelvic Muscle: sphincter ani (area in around the internal and external anal sphincter)

Pain and symptoms typically referred by trigger points in the levator ani:

  • ANAL PAIN pain
  • PAIN IN THE FRONT PART OF THE PELVIS (toward the pubic bone) if the trigger points are found toward the front (anterior) portion of anal sphincter
  • PAIN IN THE BACK PART OF THE ANAL SPHINCTER (toward tailbone) and can spread out if the trigger point is located in the back (posterior) part of the anal sphincter,

Pelvic Muscle: coccygeus

Pain and symptoms typically referred by trigger points in the coccygeus

  • Pain in and around theTAILBONE
  • Pain into the GLUTEUS MAXIMUS
  • Pain after a BOWEL MOVEMENT
  • ANAL PAIN AND PRESSURE and a feeling of coccygeal trigger points can refer the pain and pressure associated with a feeling of a GOLF-BALL-IN-THE-RECTUM

Pelvic Muscle: obturator internus

Pain and symptoms typically referred by trigger points in the obturator internus:

  • THE WHOLE PELVIC FLOOR (toward the front and the back)
  • URETRAL PAIN (in women)
  • PUDENDAL NERVE PAIN and a DULL ACHE AND BURNING in the pelvic floor on the side it is being palpated

Pelvic Muscle: piriformis

Pain and symptoms typically referred by trigger points in the piriformis:


Pelvic Muscle: bulbospongiosis and ischiocavernosis

Pain and symptoms typically referred by trigger points in the bulbospongiosis and ischiocavernosis:

  • PAIN IN THE PERENEUM (area between anus and genitals)

In working internally, we generally work with patients in the prone position with a cushion under their stomach, an innovation of Tim Sawyer. The right hand is used to examine and work the left side of the pelvic floor and the left hand to work the right side of the pelvic floor. Patients tend to feel less vulnerable and more comfortable in this position and it affords the practitioner good access inside and outside the pelvic floor.


External trigger points can be as important in perpetuating a pain cycle as internal trigger points. We treated a man for whom significant groin pain came from his quadratus lumborum muscle, located on the side of the body. Again, this trigger point was a good foot away from where the pain was felt. When this trigger point was treated, the man experienced tremendous relief. Every doctor that this man saw in the years he suffered with this trigger point missed this. We have treated people who have had abdominal trigger points that refer excruciating pain into the pelvis.

To the experienced myofascial/trigger point therapist, the patient’s symptoms, as well as the physical examination give the essential clues as to the location of the trigger points. We are grateful to Dr. David Simon, coauthor of Myofascial Pain and Dysfunction: The Trigger Point Manual, and his publisher Lippincott, Williams and Wilkins for allowing us to use the original drawings in his book. We have taken the liberty of indicating the location of the trigger points with a pointing finger.

The identification under each drawing of external trigger points related to pelvic pain herein provides easy reference to the volume number and figure where the drawing originated in Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd edition by Janet G. Travell and David G. Simons, published copyright held by Lippincott, Williams and Wilkins (October 1, 1998) . Original drawings by Barbara Abeloff. Proofreading and editing by Lois S. Simons. Copyright 1989, Lippincott, Williams and Wilkins. The tip of the pointing finger marks the location of the trigger point likely to be causing the pain patterns illustrated in the shaded areas.

The external muscles that can contribute to pelvic pain are as follows:

Pelvic Muscle: quadratus lumborum

Pain and symptoms typically referred by trigger points in the quadratus lumborum

  • HIP

Pelvic Muscle: iliopsoas

Pain and symptoms typically referred by trigger points in iliopsoas

  • ANTERIOR (front part) THIGH

Pelvic Muscle: rectus abdominus

Pain and symptoms typically referred by trigger points in rectus abdominus


Pelvic Muscle: lateral abdominals

Pain and symptoms typically referred by trigger points in lateral abdominals

  • TESTICLES (lateral abdominals can be an important source of testicular pain and often missed by practitioners)

Pelvic Muscle: pyrimidalis

Pain and symptoms typically referred by trigger points in pyrimidalis:(trigger points are not present in the pyrimidalis of some patients)


Pelvic Muscle: adductor magnus

Pain and symptoms typically referred by trigger points in adductor magnus


Pelvic Muscle: pectineus

Pain and symptoms typically referred by trigger points in pectineus

  • GROIN (a major source of groin pain)

Pelvic Muscle: paraspinals (illiocostalis, multifidi)

Pain and symptoms typically referred by trigger points in paraspinals

  • LOW BACK (usually tightly contained)

Pelvic Muscle: gluteus (minimus, medius, maximus)

Pain and symptoms typically referred by trigger points in gluteus


I have often likened medicine to Christianity and schools of thought in medicine to the different denominations like the Baptists, Unitarians, and Episcopalians. In the world of physical therapy, there are different churches or schools of thought about how for instance you do myofascial Trigger Point Release. You might say that our protocol is the most orthodox method, which most closely follows the methods of Travell and Simons. I have seen many patients who have seen other physical therapists who come from different perspectives and use slightly different methods. These patients have then done our PT protocol and have shared the comparison of their experiences with our protocol and the others they have had. I am convinced that up to the present time, the methodology we use is by far the most effective one.

Here are some important points about the physical therapy of the pelvic floor. If the trigger point is not palpated vigorously and specifically enough, the trigger point can simply resist deactivation. Yet there is danger of injuring the tissue if the pressure is inappropriately vigorous. This is where a PT’s experience and talent in feeling the tissue and sensing how much to palpate comes in. Physical therapists who are inexperienced in dealing especially with male pelvic pain in my experience of comparing the reports of hundreds of patients err in several directions. Most importantly, they do not find the trigger point, or they are not vigorous enough when the trigger point is found, or they do not use pressure release on the trigger points for the 30-90 second period.

Our general rule of thumb is that the trigger point should be pressed between 30-90 seconds. This is no small feat especially when a PT with delicate hands is working on a muscle inside the pelvic floor of a large and strong man. A large stress is put on the PT’s finger in every myofascial session and the physical therapist’s finger is prone to injury unless the finger is used properly and the PT is endowed with a certain level of strength and a certain kind of finger. Doing Trigger Point Release therapy can put your fingers at risk of injury.

Flare-up of symptoms is common especially after the first number of Trigger Point Release sessions. These flare ups usually abate as treatment continues although they can recur in times of a flare-up. Without some PTs knowing this, I have seen inexperienced therapists back off from treatment after a patient’s flare-up out of fear that they did something wrong. This concern is immediately gotten across to patients who become concerned that they are going down the wrong road. Doubt about physical therapy and the whole course of treatment arises and it is not uncommon for patients to stop treatment. This is all because the therapist did not have enough training and experience to see the big picture of treatment and the common occurrence of flare-ups after treatment.

When people do Trigger Point Release, it is best, when possible to not immediately go back into a situation of demand and tension. If you think about the physical therapy that we do as stretching and lengthening of contracted tissue that can allow it to rest and heal, taking time after a PT session to remain quiet and rest the pelvic floor is important. A tightened pelvic floor is sometimes the physical expression of a psychologically defended state and releasing the pelvic tissues can trigger emotional release and psychological insight during and/or after the PT session. In my view both the PT and patient need to be aware of this possibility and regard such reactions as positive signs of healing. Abreactions should be allowed and not suppressed or denied.

The management of expectations in Trigger Point Release is essential and both patient and therapist must clearly understand that flare-ups are common and to be expected and progress often occurs over the period of many months. Often treatment can feel like three steps ahead and two steps back for quite a while. The idea that there should be a quick fix, and that the therapist is responsible for making it all happen often results in the failure of treatment.

The method of treating intrapelvic trigger points is a kind of Braille method. The therapist cannot see what he or she is doing and cannot be observed by another. The finger is out of sight. In a training situation, the only way to tell whether the PT is on the right place or not is by the patient reporting to the PT if he or she is hitting the same point and with the same pressure as the teacher.

There can be multiple trigger points either inside or outside the pelvic floor that refer to the same area of pain and if not all of them are treated, then the pain can persist. There is a sometimes a very perplexing network of trigger points that are involved in pelvic pain to the inexperienced myofascial/trigger point therapist. I myself would not go to someone who was ‘going to school’ on me. I would only go to someone who has lots of experience with trigger points in general and pelvic floor trigger points in particular. If the PT is motivated to learn and the patient is willing to be patient with the PT, therapists new to this work can learn it. Seeing someone with little experience whose work is not being supervised by a someone trained and experienced can result in disappointment and abandonment of the protocol.

We have defined what we include in our protocol and what we do not. Here is a summary below.

  • The emphasis of our physical therapy work with pelvic pain is on Trigger Point Release. We consider a thorough examination of possible interior and exterior trigger points to be essential in our protocol. Our protocol is most promising when we can find internal or external trigger points that then to recreate symptoms. It should be said that while we have the most consistent success with people in whom we can find trigger points that recreate their symptoms, sometimes we have helped people with no clear trigger points but a very contracted pelvic floor.
  • At this point, as a rule we do not use pelvic floor biofeedback therapeutically in which an anal probe is inserted and patients are asked to do EMG monitored Kegel exercises. Also we consider unremarkable pelvic floor biofeedback readings a poor measure of what is going on in the pelvic floor or whether our protocol is indicated. I have written about these subjects elsewhere.
  • Generally, we do not use electrical stimulation either at the office or for home treatment.
  • Reiterating, the physical therapy emphasis that we do for pelvic pain is on Trigger Point Release. If postural/mechanical factors appear related to the pelvic pain, we refer the patient back to a physical therapist in their home area and reserve the often-precious time we have with them for Trigger Point Release. In looking at the results of physical therapy of my patients, I have not been impressed with physical therapy for pelvic pain emphasizing posture and alignment. I know that there are physical therapists who will disagree with me.
  • As part of our protocol we sometimes recommend skin rolling or connective tissue massage… some patients are shown how to do this and asked to do skin rolling at home regularly, especially on areas that are tender and areas above trigger points. It is not uncommon for patients to do this form of self-care 2-6 times per week. Skin rolling involves gently pinching a roll of skin in between the index finger. third finger and the thumb and pushing the thumb down while pulling the skin up with the index and third finger thereby ‘rolling the skin’. We often suggest that this be done from the breastbone to the knees all across the front and sides of the body. When there is a partner, the partner can do skin rolling on the back and parts of the body that one cannot reach oneself. Where there are areas of soreness, the skin is gently rolled back and forth and pulled up and sideways and down as a way of stimulating the area and helping release the soreness. Again this needs to be done under the supervision of an experienced therapist.
  • We encourage patients to do home Trigger Point Release using a Theracane, a tennis ball and/or knobber
  • We only do prostate massage when prescribed by a physician and when the prostate is tender. It is not done routinely. It is important to understand that in our understanding, the purpose of prostate massage is not done for prostatic fluid drainage but for stretching the associated connective tissue especially where it attaches to prostate.
  • While we appreciate the efficacy of Feldenkrais, cranio-sacral manipulation, the Alexander method, internal Thiele massage and other modalities for many kinds of problems, we generally do not use or recommend these methods for the pelvic pain we treat.
  • Before and after treatment, we use gentle, moderate or deep effeurage or Swedish type massage on the external areas (gluteals, back, leg and stomach)
  • Our physical therapy is informed by the knowledge that multiple trigger points can refer to one place and each trigger point must be evaluated and treated.
  • We use pressure release of trigger points in which case the trigger point is held for 30-90 seconds.
  • We encourage patient self treatment both internally and externally after proper supervision.
  • When possible and with the patient’s permission, we train the person’s partner to do our form of Trigger Point Release.
  • We believe that the success of a patient appropriate for our protocol depends on regularly doing the home practices that we prescribe.

The muscles of the pelvic floor are easily contracted but stretching them in the way that you can stretch your shoulders or arms is not so easily accomplished. They can, however, be stretched to some degree. We consider it essential to train patients in relevant stretches we have illustrated in A Headache in the Pelvis. They include:

  • adductor/pectineus posture
  • lateral rotators and piriformis posture
  • cobra posture
  • pelvic tilt posture
  • knee pull posture
  • iliopsoas posture
  • quatratus lumborum posture
  • squat posture
  • adductor posture

I hope that this discussion helps to shed some light on the physical therapy that we recommend. The physical therapy I have discussed is what we have seen be most helpful in alleviating the pelvic pain and symptoms we treat.


National Center for Pelvic Pain Research, Box 54, Occidental, California 95465
Telephone: 707 874 2225 Fax: 707 874 2335
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