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Levator Avulsion: Simply Explained

02 March, 2013

Seven or eight years ago, I had an ‘Oh My God’  moment in a lecture at one of our National Conferences. Professor Peter Dietz, a Sydney Urogynaecologist, was revealing to the attentive audience of doctors, physiotherapists and nurses that, what had been always attributed to nerve damage in the pelvic floor muscles, was in fact sometimes due to a concept called Levator Avulsion– where part or all of the pelvic floor muscles were pulled off the pubic bone on one or both sides. Peter used 3D/4 D ultrasound to confirm his findings and similarly Professor John DeLancey, a world-renowned anatomist and urogynaecologist from the USA, discovered the same concept through MRI technology. levator avulsion

The levator ani muscles (particularly pubo-rectalis) forms the levator hiatus and is of central importance in pelvic organ support and the maintenance of urinary and faecal continence. Avulsion injuries– are a disconnection of the muscle from its insertion on the inferior pubic ramus and the pelvic side wall associated with vaginal delivery.(1) Avulsion of the levator ani muscle from the symphysis pubis is known to occur in up to 36% of parous women. The levator hiatus represents the largest hernial portal in the human body- what this means is if the muscles have pulled off the pubic bones, the gap is wider and there is a clear opportunity for the internal organs to relax or prolapse down with increases in intra-abdominal pressure such as with coughing, lifting, bending, squatting etc. An analogy to make it easier to understand is if half of your deltoid muscle (shoulder) was cut through then it would be pretty hard to lift your arm if that muscle is not attached across the joint.
Now women are pretty shocked when they hear that they have avulsed their muscles off the pubic bone because it sounds pretty final- but often there is a moment of clarity as well-because the good devoted exercisers have been furiously working away at their pelvic floor exercises and are frustrated when there is no improvement in strength. So understanding about the process is very useful. What to do about this – I find if there is a partial avulsion it helps for patients to visualize the deficient right/left side on my model of the pelvis and I get them to take a photo of this model with their phone and view the muscles they are trying to recruit as they do the exercises. That allows them to use the BRAIN to help recruit every fibre.
photo of model of pelvis

Then once they know there has been significant, and for now, permanent damage of their pelvic floor muscles what is paramount is early prevention of prolapse. This involves the things we have talked about continually on this blog:

  • pelvic floor muscle training (of those muscles still attached),
  • bracing with increased intra-abdominal pressure (especially bending),
  • correct positioning and coordination for defaecation and particularly pelvic floor-safe exercising– avoiding those manoeuvres which will push pelvic organs down that hernia portal!

So in summary from Peter’s website: All we can say right now is that pelvic floor muscle trauma (‘avulsion’)

  • weakens the muscle by about 1/3 on average
  • makes the muscle more stretchy by about 50%
  • enlarges the opening of the pelvic floor (the ‘hiatus’) by about 1/4
  • more than doubles the risk of bladder prolapse
  • triples the risk of prolapse of the uterus (the womb).
  • triples the risk of a prolapse returning after pelvic floor surgery

The next Oh Yes moment will be when stem cell research has perfected the implantation of stem cells which will help re-grow the muscles. Did I ever tell you that I scoffed loudly when the movie Face Off was released…….

(1)¨Pelvic floor trauma following vaginal delivery. Best Pract Res Clin Obstet Gynaecol. 2005 Dec;19(6):913-24. Epub 2005 Sep 22  Dietz HP. ¨Pelvic floor trauma in childbirth – myth or reality? Aust N Z J Obstet Gynaecol. 2005 Feb;45(1):3-11 Dietz HP, Schierlitz L.¨Aust and NZ Journal of Obstets and Gynae2007 Aug;47(4):341-4¨International Urogynaecology Journal 2007 Nov 13
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8 Comments
  1. Dee permalink

    Sue, thanks for the post. Very informative! It’s very frustrating that muscle damage to the LA is a new concept or at least being looked at again and not by everyone the pelvic floor. Seems pretty obvious. I would think that many patients would assume their PF muscles are being checked for integrity, but it seems like this isn’t always the case. How can one palpate their own LA to check for problems? If one isn’t looking out for themselves, then damage might go undetected. That’s a big problem for anyone contemplating surgical repair. I’m reading that surgical is more likely to fail with a LAA and that current surgical practices aren’t effectively addressing LAA. Big deal if you aren’t wanting repeat PF repair failures.

  2. Dee permalink

    Sue, thanks for the post. Very informative! It’s very frustrating that muscle damage to the LA is a new concept or at least being looked at again and not by everyone treating the pelvic floor. Seems pretty obvious. I would think that many patients would assume their PF muscles are being checked for integrity, but it seems like this isn’t always the case. How can one palpate their own LA to check for problems? If one isn’t looking out for themselves, then damage might go undetected. That’s a big problem for anyone contemplating surgical repair. I’m reading that surgical is more likely to fail with a LAA and that current surgical practices aren’t effectively addressing LAA. Big deal if you aren’t wanting repeat PF repair failures.

  3. I like the valuable information you provide in your articles.
    I will bookmark your blog and check again here regularly.
    I’m quite sure I’ll learn lots of new stuff right here!

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  4. Hmm it seems like your blog ate my first comment (it was extremely long)
    so I guess I’ll just sum it up what I submitted and say,
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  5. Reblogged this on sue croft physiotherapist blog and commented:

    We’ve been having a discussion on Facebook in our Women’s Health group about the use of the Epi-No as a preventative strategy for Levator Avulsion and so I decided to re-blog my Levator Avulsion blog.

Trackbacks & Pingbacks

  1. Injury to the Pelvic Floor Muscles during Childbirth, and how Pelvic Floor Physiotherapy Can Help | Squamish Physiotherapy
  2. What They Don’t Tell You!: A Patient’s Story | sue croft physiotherapist blog
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