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Finding the Missing Pieces of the Low Back Pain Puzzle

January 5, 2022 • Pelvic Health

A pelvic health therapist can be hard to find, especially in the small town of Sierra Vista, Arizona. Before Nick Rainey, PT, DPT, OCS, FAAOMPT, started his training, the nearest pelvic health therapist was 100 miles away in Tucson.

Dr. Rainey was finishing up the Orthopaedic Manual Physical Therapy Fellowship with EIM and noticed a pattern – patients coming into his clinic with low back pain who weren’t getting better. As a motivated and skilled orthopaedic therapist, these patients pushed Dr. Rainey to dig further into what could be hindering their recovery. The pattern of symptoms he saw emerging included urinary leaking, dyspareunia and constipation, alongside low back pain. He realized, “I’m missing something.”

Then, Dr. Rainey had a new patient come into his clinic. A few years before, she had been driving an hour and a half twice a week to see a pelvic health physical therapist for treatment, but the commute back and forth burned her out. She asked Dr. Rainey if she could be on an exercise program. As he continued talking with her, he learned she had been diagnosed with an obturator internus dysfunction. “About the only thing I know about the obturator internus was that it was a muscle in the body that I had learned about in entry-level PT school,” said Dr. Rainey.

The patterns emerging and this new patient drove Dr. Rainey to search out further education.

Dr. Rainey knew that what he was missing with his struggling low back pain patients and new patient was linked to the pelvic floor and how it affected the rest of the body.

He decided to take EIM’s Pelvic Health I weekend intensive course to try out this type of training. During the weekend course, he learned more about the muscles that make up the pelvic floor and identifying issues with those muscles. Dr. Rainey knew immediately that he wanted to dive into the Pelvic Health Specialist Certification. The weekend had solidified for him that pelvic health was the gap in his training.

There are clinicians that want to completely avoid the pelvic floor when treating patients, but Dr. Rainey believes that there is just a misconception about why it’s necessary for general orthopaedic PTs to have a general knowledge about treating the pelvic floor even if they aren’t specialists in that area.

He compares this approach to treating the shoulder, saying, “I can treat a lot of people with shoulder pain, because I’m an orthopaedic manual physical therapist. But I wouldn’t feel comfortable stepping into major league baseball and treating pitchers with shoulder pain.”

He continued, “You can pretty easily become proficient with treating some pelvic health conditions. You don’t have to be able to see everything. But you need to be able to identify when it is a pelvic health issue and have some baseline treatments that can help most people in the same way that I can help most people with shoulder pain.”

The two best parts of pelvic health training are the opportunities for recruitment and mentorship.

Completing the Pelvic Health Specialist Certification has given Dr. Rainey the ability to recruit clinicians interested in pelvic health and mentor new clinicians so they won’t have a knowledge gap as they begin treating patients.


Dr. Rainey’s clinic hired a new graduate from South College that wanted to do an Orthopaedic Physical Therapy Residency and also get training in pelvic health. Dr. Rainey said, “Because of my training, I was the only one that really offered the combo that she was looking for. She did an EIM ortho residency with us, and then I trained her on the pelvic health side. Now she sees most of our pelvic people that get referred to our clinic.”


Dr. Rainey is also recognizing that when he is mentoring other new general clinicians, he can give them tools on how to better question people. “We had a woman come in with a pain pattern, and I’m talking to my resident that’s with me, saying, ‘Okay, what’s on our differential? Pelvic floor has to be on our differential here. The resident goes in and asks the patient questions and comes back and says, ‘It’s a no to these pelvic floor issues.’ But I went back to the resident and said, ‘Let’s question some more.’ So, I questioned the patient and sure enough, it’s a pelvic floor issue.”

Over and over again Dr. Rainey has found, “It’s about making sure you can get detailed enough questions pulled out.” He adds, “I rarely do any internal work. I think there’s a place for that. I just don’t usually need it with the population that I see. When I’m mentoring, I focus on external techniques that can be done and that they – and every clinician- that treats ortho patients can recognize.”

Referrals are flooding in.

Dr. Rainey has been able to build up the pelvic health aspect of his clinic through the pelvic health mentoring and recruiting and now has a host of referrals coming in from other health care providers.

They have been able to fill a huge gap in their community. He said, “It was crazy how quickly patients would come without any advertising. All of a sudden people were calling us from Tucson to get information when normally nobody from the city travels out here to get physical therapy. This is probably the only type of referrals where they’ve reached out to us.”

He says, “The midwives in our town are the providers that value what we do. Our ortho resident grad who I trained in pelvic health has been able to build a great relationship with the midwives. She’s in contact with them more often than I am. She has really helped us build up that side of our practice.”

Pelvic health education for general clinicians

As Dr. Rainey looks to the future, he is creating a standardized training program for the general clinicians in his own clinic. EIM is offering a brand new certification designed specifically for general clinicians that need musculoskeletal pelvic floor skills and techniques called, Certificate for Advanced Musculoskeletal Management of the Pelvic Girdle. Dr. Rainey’s focus on asking the right questions on patient differentials and external pelvic floor techniques is the perfect example of what general orthopaedic clinicians can learn from this new certification. Dr. Rainey says, “I think this type of training is crucial for everyone who treats low back pain, hip pain and SSI joint pain because they are seeing people with these complaints that they’re not able to help, even if they aren’t recognizing these complaints as an issue with the pelvic floor.”

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