When An Orthopedic History Leads To Pelvic Floor Dysfunction: A Pediatric Case Presentation

As a physical or occupational therapist, you may think of orthopedic conditions and bowel & bladder dysfunction as separate issues. However, children do not develop in systems. A child with back pain may develop constipation. A child with breathing dysfunction may struggle with postural control. An orthopedic injury can create compensations that influence far more than movement.

In the KBB Professional Village, a recent case discussion highlighted these connections. A therapist presented the case of a 12-year-old boy with severe chronic constipation. Let’s call the patient Seth*.

At the time of referral, Seth was having bowel movements only every five to seven days despite significant medical management. His medication regimen had evolved from Miralax to a combination of Linzess, bisacodyl, and daily Fleet enemas to facilitate bowel evacuation. Anorectal manometry had demonstrated dyssynergic defecation, yet no additional motility testing had been performed.

What immediately stood out was that the constipation appeared to be only one component of a much larger clinical presentation. Seth had a history of L4-L5 and L5-S1 disc herniations. Although he had been an active tennis player, his participation in sports had significantly declined as his symptoms progressed.

The therapist described him as visibly deconditioned with notable muscle wasting. His abdominal distension was so significant that it limited his food intake, and he frequently appeared uncomfortable throughout treatment sessions.

According to his mother, Seth had strained his diaphragm while attempting to have a bowel movement. He demonstrated significant discomfort with breathing, was unable to tolerate lying flat because of reflux symptoms, and remained highly sensitive to touch throughout the abdomen. Even basic assessment and treatment strategies were becoming increasingly difficult due to Seth’s discomfort and guarding.

While the discussion of this case presentation initially focused on constipation and pelvic floor dysfunction, the attention quickly shifted toward the diaphragm. Seth’s presentation suggested broader impairments in pressure management rather than an isolated bowel dysfunction. The combination of abdominal distension, dyssynergic defecation, reflux, deconditioning, movement avoidance, and a history of spinal pathology raised questions about how effectively his diaphragm was functioning within the larger postural and pressure regulation system.

The diaphragm is often discussed primarily as a respiratory muscle, yet its influence extends far beyond breathing. The diaphragm contributes to intra-abdominal pressure regulation, trunk stability, postural control, and coordination with the pelvic floor. During bowel evacuation, a coordinated relationship between the diaphragm, abdominal wall, and pelvic floor muscles is essential for efficient pressure generation. When one component of this system is not functioning optimally, compensatory patterns may emerge.

In children with dyssynergic defecation, clinical attention is frequently directed toward the pelvic floor. While this is certainly appropriate, it is also important to consider whether the pelvic floor is responding to dysfunction elsewhere within the pressure system. If the diaphragm is unable to descend properly, pressure generation may become inefficient. Children may compensate through excessive abdominal bracing, breath holding, rib cage elevation, or increased pelvic floor activity. Over time, these compensations contribute to difficulty coordinating bowel evacuation.

This perspective does not suggest that the diaphragm is solely responsible for constipation. But it highlights the importance of viewing bowel function through a systems-based lens. In complex pediatric presentations, dysfunction is rarely isolated to a single structure.

Another important aspect of this case was the child’s history of lumbar disc pathology. Research has demonstrated altered diaphragm function in individuals with low back pain, suggesting that breathing mechanics and spinal stability are closely linked. For you as a therapist, this relationship is particularly important because the diaphragm plays a foundational role in postural development.

The diaphragm functions as part of an integrated pressure management system. When diaphragm function becomes compromised, children may demonstrate altered postural strategies, reduced trunk control, decreased endurance, and movement avoidance. These changes can ultimately influence participation in physical activity and contribute to progressive deconditioning.

In Seth’s case, the therapist described a child who had become increasingly sedentary as symptoms worsened. His loss of strength and endurance was not the result of constipation itself, but rather the cumulative impact of chronic discomfort, reduced activity levels, altered breathing mechanics, and diminished movement variability.

An additional observation of Seth was his limited willingness to move, particularly with spinal rotation. Diaphragm function cannot be separated from rib cage mobility. The diaphragm attaches extensively to the lower rib cage, and normal respiratory mechanics depend upon coordinated movement of both structures.

When thoracic mobility becomes restricted, diaphragm excursion may also be affected. Similarly, when children adopt protective movement patterns due to pain or fear, they often lose the variability necessary for efficient breathing and pressure regulation. Restoring gentle rotational movement and rib cage mobility may therefore become an important component of treatment.

For Seth, treatment needed to introduce bits of thoracic rotation and trunk mobility, while relating these activities to his long-term goal of returning to tennis. Framing your interventions around meaningful functional goals improves kids’ participation, particularly when children have become frustrated by symptom-focused treatment approaches.

One of the most valuable aspects of this case discussion was the reminder that the same systems influencing posture and movement also influence bowel and bladder function. For you, as a therapist, this highlights the importance of looking beyond a child’s primary diagnosis and considering how breathing, pressure management, and mobility may contribute to symptoms across multiple body systems.

You do not need to be a pelvic floor specialist to recognize these patterns. A stronger understanding of diaphragm function allows you to better appreciate how respiration, movement, posture, and continence are interconnected. This broader perspective can help guide your assessment and treatment decisions, particularly when traditional approaches are producing limited results.

When evaluating children with constipation, it may be worthwhile to consider questions such as:

• How effectively is the diaphragm moving?
• How is the child managing pressure throughout the trunk?
• What movement strategies are being used during functional activities?
• Is thoracic mobility restricted?
• Is the child demonstrating signs of chronic sympathetic nervous system activation?

These questions often provide valuable clinical information that extends beyond the pelvic floor.

The Pelvic Floor, the Diaphragm, the Core and their Role in Postural Development in Children (PFDC) course is not just for pelvic health specialists. It is intended for physical and occupational therapists who want a deeper understanding of how the diaphragm influences development, movement, continence, and function across a variety of pediatric populations.

By understanding the diaphragm as more than a breathing muscle, you can develop a better comprehensive framework for evaluating complex pediatric presentations and identifying connections that might otherwise be overlooked.

*patient name changed for privacy