Pudendal Nerve Patterns
While every musculoskeletal pain that walks into my office has an element of nerve irritation/aversion by the brain to place additional compression and tension on a nerve branch, most of the time it is in the absence of any neuralgia symptoms, and there are a few patterns I run across regularly where the nerve that can drive the symptoms and dysfunction the patient is experiencing are hard to identify as a relevant problem because they do not actually innervate any of the structures that the patient is noticing are irritated. The pudendal nerve is the perfect example of this situation, and fairly common.
The pudendal nerve supplies the rectal sphincter, perineum and some of the genitals, so normally we may expect symptoms to those areas when it is in distress, which it certainly can, though rarely do we see a pudendal nerve irritated enough to cause noticeable neuralgic symptoms. However the majority of the consequences of an irritated nerve are most frequently not directly neuralgic symptoms, but the 'overload' symptoms of the brain enacting compensatory motor patterns from a theoretical 'plan A' to something less ideal and less sustainable, but necessary for safety in context. In this case because the nerve at its mid to distal end is positioned between the sacrospinous and sacrotuberous ligaments, irritation in any of these three structures can cause notable dysfunction to all three.
Dysfunction Presentation
The sacrospinous ligament has a very strong relationship with the piriformis and deep six stabilizers. If the brain does not like tension on this ligament, the chances of a well stabilized SI and hip joint on that side are significantly less, which has big implications for both hips and the overall pelvic girdle. The sacrotuberous ligament is a fascial continuation of some of the lumbar extensor tendons through to the hamstring and adductor magnus tendons (most functionally affecting the hamstring), with significant impact on spinal function, hip extension, and most notably hamstring cramping that we can't find any other obvious cause for or otherwise can't seem to conclude.
So if your patient is running into symptoms that you are having a hard time tracking down in these tension and functional lines, check out these structures.
Assessment
To confirm the relevance I'm going to want to check function (with manual muscle testing, and if so desired, functional tasks and relevant passive/active joint ranges of motion) of the affected sides piriformis, lumbar extensors and hamstring (be careful with this one, if anything is going to cramp or spasm during testing when irritated, it's the hamstring), and anything else that appears symptomatically relevant in the area.
If we get poor function, or hypertonic function (not muscle tone, we're talking neuromuscular function. I won't cover what that means here), I want to manually stabilize the pudendal nerve superiorly and with that held, simultaneously check the deficit functions and see if they normalize. If they do (or if it makes function notably worse)…we have a relevant therapeutic target, and we will want to treat all three even if only one seems highly relevant. If there is enough irritation, suspected injury or other motivating reason, we can also manually stabilize each of these ligaments (holding the ends together into slack for the ligament body) and test with those as well.
Treatment
So let's get to treating this thing. Whatever skill set you have to approach these, feel free to go for it, but do be gentle with the area, especially the nerve. This is just what I do for the local level of treatment, as we still want to track down why this happened but that's a much broader question.
First I (in the Barral visceral terms) will address the local listening (LL) and carry out an induction on the sacrospinous ligament until it goes silent, and add a tension (with a vagal nerve parasympathetic 'stim,' which also won't be covered here), and then carry out similar with a superiorly directed perpendicular traction to ensure it moves independently of the sacrotuberous ligament. I will then carry out the same LL inductions and longitudinal tensions on the sacrotuberous ligament, and lastly we will do the same with the distal pudendal nerve itself, (very gently).
After these steps we will recheck our work and move on, though I do like to direct infrared treatment to this area to help with any local inflammation as well (5 joules to the pudendal nerve at the depth of the nerve itself, 10j to the ligaments if those are the more primary concern or you have the ability to do specific treatments on each structure).
So in summary:
This set of three structures (sacrospinous/sacrotuberous ligaments and pudendal nerve) often have a tied relationship in each other's dysfunctions, symptoms of which may include issues of piriformis/deep 6 function, lumbar extensor or hamstring function (including hypertonicity and cramping/spasm), SI and hip stability and mobility deficits, and in the worst cases may irritate nerves affected by these structures, most commonly the sciatic branches.
We assess for relevance by checking function of the ipsilateral piriformis, lumbar extensors and hamstring (careful for spasms/cramping with hamstring testing) and see if gently tractioning the pudendal nerve superiorly to give slack improves function, or worsens them with light inferior traction. We can check manually stabilizing the two ligaments as well if we suspect there was an injury to one of them, and can also check passive/active range of motion and relevant functional tasks and see if they improve with the same manual stabilizing.
Once confirmed, we treat local induction (in direction of the local listening and in tension with vagal stim) of the sacrospinous and sacrotuberous ligaments, including superiorly directed perpendicular tension on the sacrospinous to ensure the two ligaments are independent of each other. We then gently do the same with the pudendal nerve itself.
Recheck our measures to see if we're done. Treat with infrared if available.