When Joint Pain Blocks Pelvic Rehab: What to Screen, Teach, and Train

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Transcript

Welcome back to the OTs in Pelvic Health podcast. Today we're going to talk about something that belongs in pelvic health OT, even though it's usually filed under orthopedics or sports medicine.

We're talking about bones, joints, and connective tissue, and specifically what it looks like to support joint health across the lifespan in a pelvic health practice. Because here's the thing, pelvic health is never just the pelvis. If you work with pelvic pain, postpartum clients, people with prolapse, endo, bladder symptoms, bowel issues, you're already treating people whose outcomes depend on how well they can load tissues, build strength, recover from training, and stay active.

And when someone can't tolerate walking, can't tolerate strength training, or tolerate impact because every joint is angry, pelvic rehab becomes so much harder. So today I'm going to connect with the science of joint health and bone health to pelvic OT, what's changing after 30, what accelerates after 50 for most women, why estrogen keeps coming up in the musculoskeletal conversation, what supplements actually have some evidence, and what I do with this information in clinic, especially when a client's pelvic goals are being limited by joint pain or fear of loading. Let's get into today's episode.

So a lot of people don't think about bones and joints until something hurts, and I'm definitely in that category. I am recording this episode with a raging tennis elbow, and man, I'm guilty of this.

But here's the thing, pain is an attention magnet, but clinically, the issue is when pain finally shows up, we're often dealing with a system that's been changing quietly for years. Bone density, it peaks early in life, and then it begins a gradual decline. Joint tissues respond to loading patterns over time, and muscle is either supporting joints as a shock absorber, or it isn't, depending on when someone has maintained strength.

And when someone enters a season of life where hormones shift, sleep becomes fragile, stress is high, and activity changes, those quiet tissue changes can become loud. What do I mean by loud? Loud is when your clients say, my hips feel unstable now, or my knees hurt when I try to walk, my back is constantly sore, my shoulders ache when I carry the baby, or I used to tolerate workouts and now everything flares. And sometimes they're calling it pelvic pain, but what they're really describing is whole body loading intolerance that is amplifying pelvic symptoms.

Okay, I want to talk about a pattern that's clinically obvious, but I think it's really under-discussed. Many women describe a shift around perimenopause to menopause, so, you know, mid to late 40s, early 50s, where joint pain increases, stiffness increases, recovery starts taking longer, and the body feels more inflamed. And it's not simply aging.

Here's what's happening. Estrogen acts like an anti-inflammatory hormone in a lot of our tissues, and there are estrogen receptors in places we care about as rehab clinicians, bones, muscles, synovium in joints, tendons, and ligaments. So when that estrogen declines, a few things happen that matter in day-to-day function.

Inflammation, it's higher, right? And higher inflammation is definitely associated with joint pain and sometimes faster cartilage changes. Have you heard that frozen shoulder becomes more common between 40 and 60? Tendon irritation, more common. People just talk about being stiffer, and it's not because they're not stretching enough.

Bone loss accelerates after menopause. Before menopause, bone density loss might be around, I don't know, like 1%, 1.1% per year. After menopause, it's closer to 2%.

That is double, right? And muscle is part of this too, right? Many people struggle to build and maintain muscle mass as hormone shifts. Yet muscle is one of our best joint protectors and one of our best bone density allies. So from a pelvic health OT perspective, I'm listening for that moment when a client's symptoms shift from localized pelvic concerns into my entire musculoskeletal system is less resilient than it used to be.

That's the moment where the plan often needs to broaden. One thing I've learned, and we talk about this often in my Level 1 Functional Pelvic Health Practitioner program, is that many clients don't actually know what arthritis is. They know it as like a scary word or a destiny or something their parents had.

So I explain it in pain language. Arthritis, specifically osteoarthritis, is often a gradual thinning and breakdown of the smooth, gliding cartilage at a joint. Over time, you get changes like bone spurs, thickening of the joint lining, stiffness, swelling, and pain.

It's not purely wear and tear. Even osteoarthritis has biochemical inflammatory components. 

There are inflammatory cytokines involved. There's a whole cascade that can contribute to cartilage breakdown and pain sensitivity. And then there are inflammatory arthritis like rheumatoid or psoriatic arthritis, where autoimmune inflammation is driving the joint damage much more aggressively.

You might be asking, why am I talking about this on a pelvic health podcast? Because pelvic health clients often have overlapping inflammatory conditions. Endo, IBS, autoimmune, migraine, thyroid disorders, perimenopausal inflammatory shifts. And when someone's system is inflamed, their pelvic symptoms and their joint systems don't live in separate boxes.

Also, fear around arthritis can become fear around movement. And that fear will definitely shape pelvic rehab outcomes. 

All right, let's address a belief that keeps people stuck.

Running will ruin my knees. The evidence we have does not support the idea that running by itself causes arthritis in healthy joints. In fact, when runners are compared with non-runners in some studies, runners are not more likely.

They're actually less likely to have arthritis. Now, I'm not saying everyone should run, right? It means we should be careful about fear-based blanket statements. For pelvic health, this matters because we're often talking about walking programs with our clients, graded return to impact, postpartum, return to sport, and progressive loading for pelvic floor function.

If someone believes impact is inherently harmful, they're probably going to avoid the exact dosing progression their tissues need. The nuance I use clinically is this. Movement is generally good for joints, and cartilage responds to load like a sponge.

It compresses and then rebounds. Motion helps cartilage get nutrients through the joint fluid. Motion is lotion is not just a cute phrase.

It's a useful mental model. But if someone has existing arthritis or if their physiological envelope is low right now, their joints may swell or flare if they jump from zero to a lot. That's not running causing arthritis.

That's dosing mismatch. Do you get that difference? Dosing mismatch is something OTs can treat all day long because it's habit, routine, pacing, and graded exposure. Okay, I'm going to share a few case studies that shows what this looks like.

Case number one, postpartum and hip and knee pain while she was derailing pelvic goals. So Sarah, we'll call her Sarah, came to me primarily for pelvic heaviness, and core weakness. She also had knee pain and hip pain that started when she returned to long stroller walks.

That was why she came to see me. Her pelvic symptoms weren't improving because she couldn't tolerate consistent movement without flaring her joints, and she was avoiding strength work because it made her feel worse. Our OT work wasn't to tell her to stop walking.

It was actually to widen her options. We treated walking like an occupation with performance parameters. So we talked duration, pace, terrain, footwear, rest breaks, and load.

We reduced dose, we changed terrain, and we added short strength sessions that were joint friendly so her muscles could start doing the shock absorbing work again. As her joint irritability settled, she tolerated more movement, and as she tolerated this, her pelvic symptoms improved because she could actually implement the pelvic plan consistency. 

Okay, case number two.

This is where a client with a long history of pelvic pain was starting perimenopause, and Jen suddenly developed diffuse joint pain. She was talking about her hands, her hips, her shoulders. She kept telling her providers, I feel inflamed.

And she just kept being told, well, Jen, you're getting older. From an OT lens, the most important intervention was validating the shift and creating a plan that wasn't all or nothing. We focused on strength training as long-term joint strategy, but we had to start with symptom guided dosing.

We discussed sleep because her sleep was fragmented, and that was amplifying pain sensitivity. I recently recorded an episode on the importance of sleep. Check it out if you want to know more about that.

I also encouraged her to speak with her medical team about menopausal symptoms more broadly because pelvic OTs are often the first clinicians to connect the dots and help our clients advocate for appropriate evaluation and options. The outcome wasn't pain-free forever. It was increased capacity and reduced fear.

She could load, recover, and keep momentum. My last case study with you today is about Lisa. Lisa had urinary urgency and she wanted to return to running.

Lisa was told, don't run. It's going to make prolapse worse. Impact is dangerous, is how Lisa internalized that message.

So we framed this. Impact is a dose, and a dose can be trained. We built a graded plan, a strength base, then short impact exposures.

Then, then we got to return to walk intervals. We paired it with bladder strategies, and of course, breath and pressure management. Her symptoms didn't improve because she avoided impact.

Her symptoms improved because she learned to dose impact safely and consistency without catastrophizing every sensation as damage. And that to me is pelvic health OT at its best, translating physiology into behavior people can actually do. 

Okay, let's talk supplements.

One area that's gotten more interesting is collagen for joint health, especially type 2 collagen, right? There are forms you're going to hear about, potentially through your own research, being inside my membership community, Pelvic OTPs United, where it's just $39 a month, and you're going to be supported by over 200 members that have your back. The first one you might hear about is undenatured type 2 collagen. The second one is hydrolyzed collagen peptides, which are broken down to be absorbed.

What I take from the data is this, collagen formulations may help symptoms in early joint stages, even if they don't clearly stop arthritis progression. Symptom improvement still matters because symptom relief can increase activity. And honestly, my friends, activity is one of the biggest levers we have.

Other supplements your clients may bring to you for joint symptoms are curcumin or turmeric, and there is definitely evidence out there it reduces pain, the need for anti-inflammatories. For bone health, we probably are hearing about vitamin D, calcium, magnesium, vitamin K. The main point I emphasize with clients is that bone health is not just supplements, it's loading. Supplements don't replace loading.

They support the system, which is awesome, especially when diet is limited or deficiencies exist. But with NOT, I usually say something like, look, if you're considering supplements, talk to your physician or a dietitian, and let's make sure your movement plan and your nutrition plan are aligned because activity without recovery can backfire. This leads me to the next point.

If you want a simple sentence for clients, it's this, your bones respond to load, your joints like motion, your muscles protect both. So strength training is a joint intervention. Strength training is a bone intervention, and it's also a pelvic intervention because pelvic floor function is integrated with the whole system of pressure management, hip strength, trunk control, and movement confidence.

Impact can add an extra bone stimulus, and it doesn't have to be dramatic. It can be a small number of jumps. It could be low amplitude.

It can be modified. Some people may not be impact candidates right now, and that's okay.

We can still load through strength and weight bearing. The key OT point is dosing and adherence. A perfect program that someone can't maintain because it flares them is worse than a modest program that you can do consistency.

All right, let me conclude this episode with the pelvic health takeaway. Joint health and bone health aren't extra. They're foundational to pelvic rehab because they determine whether someone can move, lift, carry, train, have sex without fear, and engage in occupations that make life feel like life.

If you're a pelvic health OT, you don't need to be an orthopedic surgeon to talk about this well. You just need to connect the dots. Hormone shifts, inflammation, strength, loading, pacing, and realistic routines.

And the next time a client says everything started falling apart after 45, or I can't train like I used to, I want you to feel confident saying let's talk about what's changing and let's make a plan you can actually live with. Thank you so much for joining me for another episode. If you enjoyed our episode today, please, please, please take five seconds.

Go over to where you listen to your podcast. Leave me a quick review. It helps other OTs find this incredible specialty of pelvic health, which is undeniably the most rewarding specialty there is.