Hard Flaccid Syndrome

"No two patients with hard flaccid are the same. We must treat every patient as an individual".

Adrian Wagstaff, Male Pelvic Physio 

For Online bookings please click here

 

Hard Flaccid Syndrome is a condition affecting the penis and is of unknown aetiology among men.  However, our observations suggest hard flaccid syndrome to be more prevalent between the ages of 18 and 35.  It is characterised by a change in penis size, shape and feel.  Penile stiffness or swelling when the penis is in a flaccid state and flaccid size is a common characteristic.  The penis is sometimes firmer to the touch, it is engorged and rubber in texture, and is often accompanied by a change in size or shape of erection.  There may be a loss in nocturnal erections, and it may require a greater degree of stimulation to achieve an erection.  There is often a loss in libido and a shattering of confidence.  However, the most common reason for someone seeking help when suffering from hard flaccid is because of alarming changes in penile shape and size.  Patients often self-diagnose hard flaccid from reading online forums.  It is different from peyronnie’s disease because there are no visible signs of tissue scarring and plaque formation. Nevertheless, hard flaccid is a distressing and poorly understood condition.  At Core Body clinic, our pelvic physiotherapists are experts in the treatment of Hard Flaccid syndrome. 

Until recently any male pelvic pain syndrome would fall under the umbrella term of Chronic non-bacterial prostatitis often leaving men in the no-man’s land of diagnostic labelling and therefore at a loss as to how their pain and symptoms could be rectified.

Hard Flaccid syndrome has largely been the subject of discussion and debate on male pelvic pain forums with little or no clinical information about the condition.  Therefore, diagnosis is difficult to the untrained eye and often clinicians are at a loss about treatment.  Seeing a male pelvic physiotherapist who has expertise in male pelvic pain and pelvic dysfunction is the best thing to get you on the road to recovery. 

 

What causes it?

With little by way of clinical research concerning hard flaccid, much of the theories relating to the pathophysiology are based on our observations of the patients who present in clinic.  However, in combination with the knowledge of anatomy and pain mechanisms an understanding has been developed which has enabled us to provide treatment solutions.

Injury to the penis and stress are likely drivers for this condition.  Our own practice at Core Body Clinic has observed many patients who present having engaged in excessive masturbation, exhaustive sex or who have attempted penis enhancement stretching, like jelking.  Such situations see the penile muscles in sustained contractile states leading to venous compression in the penis.  The blood vessels therefore failing to empty when in a flaccid state with blood remaining in the erectile tissue.  Erectile tissue fatigue occurs, as one would see in many other muscle tissues in the body.  An almost spasm like behaviour where the regulatory control of erectile function is lost, and the erectile tissue fails to disengage fully.  Likewise, in a continued semi stimulated state, the tissue struggles to fully erect because it has lost the normal feedback mechanism.  Autonomic and central nervous systems control erectile function and in states of fatigue the central and parasympathetic nervous system can no longer regulate this function.  Pain is sometimes a feature due to tissue injury and chemical irritation of nerve endings, caused by fatigue chemicals.  This further results in anxiety and distress. We know that psychological drivers transfer into biological processes and also the phyical injury gives rise to anxiety.  Stress causes the release of cortisol, adrenaline and no-adrenaline resulting in increased blood flow to the pelvic area.  This exposes already traumatised blood vessels to increased blood flow only helping to drive the process and maintain a hard-flaccid state.

It has been suggested that tension in the pelvis is strongly linked to stress and this in turn will help to maintain the poor regulation of blood flow in the pelvic floor.  The origin of the penile muscles from within the pelvis allows for easy influence of the tight pelvic muscles on the penile erectile tissue.  There is often associated tension over the perineal and anus regions.

However, tightness can often be confused with strong muscles and to further confound diagnosis patient often present with voiding complications.  They may dribble after micturition, finish toileting only to feel like their bladder has not fully emptied or experience pain after voiding. While there may be tension in the pelvis, we have found the strength of the pelvic floor to be poor and on testing using our diagnostic ultrasound scanning we find movement of the pelvic floor is often limited.

 

What can we do about it?

At Core Body Clinic we have a lot of success in treating this condition with all our patients achieving a greater than 75% improvement**

Understanding the patient’s drivers and educating our patients about their condition helps with anxiety about the condition.  Information concerning the onset of symptoms is essential in removing any harmful behaviours or practices and emotional drivers.  Often this is a distressing and difficult time for the patient, and in some cases the cause is elusive and requires careful history taking to unpick the possible triggers.

Relaxation plays a significant role in re-establishing normal breathing patterns thereby facilitating appropriate abdominal movement.  Interruption of the normal diaphragmatic excursions during breathing is closely associated with pelvic tension.   Hard flaccid is distressing and leaves the patient in a state of anxiety causing shallow breathing, abdominal bracing and abdominal muscle fatigue.   

Physical therapies such as trigger point release and massage to the perienal area and internally within the pelvic floor may help some patients by providing feedback to patient and clinician about tension in the pelvis.  With careful and skilled practice it is possible to remove this tension to alleviate pain and tissue tension. However, there may be no tension at all. We also use diagnostic ultrasound to examine the pelvic floor and determine whether movements are limited and whether this is a result of tension or trigger points.  We must stress that trigger points merely relate to painful areas in the pelvic floor. The key to successful trigger point diagnosis is the reproduction of the patients pain. True trigger points in the pelvis are rare, we have found, in the case of hard flaccid  

Exercises to restore normal pelvic floor control is essential. Quite often online forums encourage the ‘Kegal’ exercises to strengthen the pelvic floor for enhancing sexual performance and many men attend the practice having done these only to end up in a worse state.  The confusion is that they have over exercised using kegals. It is often found that they have injured themselves and blamed the kegals.  One would then tend to focus on the ‘reverse kegal’.  This differs from the kegal by pushing the pelvic floor down rather than lifting it up. It aims and is believed to de-tension the pelvic muscles.  However, we must restore balance in the pelvis to ensure reciprocal operation of the pelvic muscles and therefore using diagnostic ultrasound feedback we teach the patients how to balance the normal rhythm of the pelvic floor muscles. We want them to do kegals and reverse kegals. These movements are normal for the pelvic floor and are often dysfunctional in hard flaccid states  Using diagnostic Ultrasound s a highly effective technique for such conditions and at Core Body Clinic it is Gold Standard for treating the pelvis. 

Hard flaccid is also thought to occur with weight lifting and patients believe that they have lifted excessively as the cause for the initial onset of symptoms.  Therefore, there is a reluctance to get back to training and part of our therapy is to coach the patient about normal lifting practices and ensure their breathing pattern and pelvic muscle control is appropriate. It is often they have injured themselves and then find weight training exacerbates their symptoms rather than a cause. Assessment of the pelvic muscles during exercise is key.

We also direct the patient through a set routine of stretches and loading activities to rehabilitate the pelvis. We look at hip, knee, ankle and spinal ranges of movement. Our aim it to get the body back to physical prime. That way patients are mentally and physically confident in their bodies. We also want to reduce as far as possible the facial interplay of connective tissue tension across the pelvis. While there is little evidence to support the concept that fascia in the body causes hard flaccid, getting our patients back to sound physical conditioning is well known to help mental wellness and pain. Our experience is that is hugely helps reduce symptoms in pelvic pain patients and also the symptoms of hard flaccid. 

 

Hard flaccid is a difficult condition to treat.  Specific men’s health physiotherapy is highly successful in resolving this condition. More importantly having a physiotherapist that understands the condition and knows how to treat an individual is key. 

Core Body Clinics are specialist centres for the treatment of Hard Flaccid.

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Achilles Tendon Clinic

Achilles Tendon Pain

 

At our tendon clinic we see lots of Achilles Tendinopathies and Achilles Heel pain.  We use our expertise in diagnosis using over 20 years of experience and ultrasound scanning to understand your problem and how best to fix it.  Our unique clinic combines all of our knowledge to understand how your pain started and what we can do to stop your pain coming back. 

There are two types of Achilles tendon pain: Mid portion Tendinopathy and Insertional Tendinopathy.

The mid portion one is the most commonly injured part of the tendon.  People often present with pain after they have been running and start to develop pain in the region or they may feel a sudden onset of pain in the tendon.  They typically find the tendon becomes stiff when first walking in the morning and they may have pain when running or after running.  On occasions, there is severe pain and you are not able to run.  Typical patients at Core Body Clinic are runners who have been training very hard or are attempting to compete.  Our desire gets the better and we run through pain.  Tendons become injured when they are overloaded.  We keep running beyond the capacity of the tendon and therefore we get tendon reaction and eventually the signs of degeneration.  Simply, the tendon can no longer cope and starts to thicken up with inflammatory tissue, scar and excess debris.

TENDON OVERLOAD

Tendons are composed of tenocytes and are therefore structurally different from other tissues in the body.  Initially, there is some inflammation but it appears this is not the main driving force behind the condition.  Because of pain, the calf muscle (in the case of the Achilles) is not able to deliver as much force or contraction. The tendon is loaded to a lesser extent and over time becomes ‘deconditioned’.  The tenocyte matrix is less organised and is again less tolerant to loading. There may be the presence of different cells like proteoglycans which are big sponges and can give the tendon its inflamed appearance.  There is also a suggestion of scar tissue build as the tendon tries to heal itself.

"I wasnt even training hard!"

In any case these tendons are not functioning and your capacity to run and eventually walk pain free becomes limited.  You are able to run a little and then not at all.  It gets better for a few days and then it worse again. Very frustrating.  The key to success is in the understanding of how the pathology and biology of your tendon has changed.  Only then will you become aware of the parameters of training to enable you to appropriately rehabilitate the tendon without over loading it. 

Sometimes, you may not even be aware of over loading the tendon.  You may have enjoyed a problem free year without pain, normal training and excellent times.  You may have been running on the sunny promenade on a day like any other, and then develop a sharp pain.  The key here is that your training may have become attritional and plateaued.  Your tendon starts to go backwards and is no longer functionally capable of loading without injury. This is the danger zone and makes you vulnerable to injury. or stiffness in the tendon.

"Im not very fit" or "Im new to running"

If you are severly out of condition, perhaps you have suffered a long illness or you have taken steroids for a long period of time.  Such persons are more susceptible to Achilles Tendon Pain. 

Snapped tendons or ruptured tendons tend to occur without warning.  It is not common to have a history of tendon pain and then rupture your tendon.  

 

Symptoms:

  1. Pain in the middle of the tendon 
  2. Pain on running
  3. Pain may get better or worse with activity
  4. Pain in the morning for the first 5 or 100 steps
  5. Pain on descending the stairs.
  6. Pain on hopping

 

What you will not have:

With Achilles diagnosis you will not experience burning pain and Pins and needles

You also will not suffer pain shooting up the leg and into the back

 

Assessment:

At Core Body Clinic we have a dedicated Tendon clinic for assessing the Achilles tendon.  We use a combination of history (what happened), examination and also Ultrasound Scanning.  The scan helps us to understand to what extent the tendon is damaged and this provides you with a prognosis.  We will use a battery of tests to diagnose your problem with checks of your balance, knee alignment during function, foot posture and strength.  

 

 

Tendon Scanning 

 

 

 

 

We will also check your hamstring strength and length, hip flexor length and also the ranges of movement in your spine.

We will look at calf strength and ankle flexibility and probably give the tendon a poke and prod.  While this helps to show us where the issue is it does not tell us

 

Treatment:

We know that activity is good for tendons. They love it! But in the early stages gentle massage, rest, ultrasound (big placebo but can be therapeutic), taping, R.I.C.E and Anti-inflammatories (NSAIDS) can all help.  But none of these will sort your tendon out.

Once we have confirmed diagnosis we will set about prescribing a bespoke plan of action to get you back to your normal functional level.

Isometric exercises are thought to be helpful by contracting the calf muscle, like a heel raise and holding the position for 30-60 seconds.  

Graduated exercises are the main stay once pain begins to settle. These are carefully constructed and prescribed in consistency with your pain. Over doing the exercises too quickly will land you back to square one. They need to be gradual and increase in load so that getting you back to climbing the stairs or Everest is a smooth pathway of recovery

Massage and Ultrasound can be helpful to manage pain to allow you to exercixse and load the tendon.

For more difficult tendon pains we can use Shockwave therapy and in very small numbers PRP injections are helpful. 

 

We may also use taping if you are struggling with pain and orthotics if we feel your footwear is a factor in your Achilles Tendon pain. 

Return to Running

At Core Body Clinic the focus of our Sports Physiotherapists is to work with you to get you back running.  We will NEVER say don’t run unless we truly belive it will do you harm.  If you are a keen runner then we will aim to get you running again at the earliest possible convenience.

We can manage your pain and symptoms with effective strategies like appropriate footwear, taping, load management (how much running and how much exercise you should do) and direct therapies (Massage, ultrasound).

Graduated running is KEY.  Start small.  Walk for 5 minutes, run for 5 minutes, walk, run, walk, run – get the picture? The tendon essentially stores kinetic energy and if in a state of reaction it will become more tender and painful over the time of the run.  Key is to stop before it becomes too sensitised.

Avoid hills to begin with (Hard to do in Reading and Tilehurst!) and have no expectations.  You may need a week or two off.  Aqua jogging is a great alternative early on and changing activity to cycling can be a great way to keep your cardio fitness up.

 
 
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New Mumbles Physiotherapy Clinic: Core Body Clinic, Swansea!

New Mumbles & Swansea Physiotherapy, Pelvic Pain and Sports Injury Clinic - OPEN!  

Hours: 

Monday: 8am to 8pm

Friday: 8am to 8pm

 

 

About our new Swansea Physiotherapy and Mumbles Physiotherapy Clinics

It is with great pleasure to announce that Core Body Clinic has opened their first and now second Physiotherapy clinic in Swansea and a second in Mumbles.  One clinic is based at the Swansea Wellbeing Centreand the other is at the Mumbles Dental Spa.  They are great places to base the clinics and so well located to allow access for the whole of the Swansea Bay area.

Mae'n bleser mawr gennyf gyhoeddi bod Clinig Corff Craidd wedi agor eu clinig Ffisiotherapi cyntaf yn Abertawe ac ail mewn Mwmbwls. Mae ein clinigau wedi'u lleoli yng Nghanoflan Lles Abertawe a yn yr sba deintyddol y mwmblws.  Maent yn lleoed gwych i gael clinig ac maent mewn sefylla dda i ganiatáu mynediad ar gyfer holl ardal Bae Abertawe.

 

Will physio help?

Yes!  But if you are wondering what the difference is between Physiotherapy, Osteopathy and Chiropractic then read our article HERE

 

 

 

 

 

 

 

 

 

 

 

 

What do we treat?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The list is endless and we treat all sort of problems from BACK PAIN to SPORTS INJURIES and we are also the ONLY clinic to treat MALE PELVIC PAIN in Wales.  We also treat PELVIC PAIN in women and we are experts at rehabilitation, spinal manipulation, sports and soft tissue massage.  Simple click HERE and be redirected to our WHAT WE TREAT page.  If your problem is not listed then please email the clinic as there are conditions that share common signs and symptoms.

  • Back Pain
  • Neck Pain
  • Sciatica
  • Sports injuries
  • Ankle Sprains
  • Tendon Injuries
  • Rehab after an Operation (Like ACL or FAI)
  • Plantarfasciitis
  • Breaks and Fractures
  • Pelvic pain
  • TMJ (Jaw) Pain
  • Headaaches

 

 

What Therapists Treat at Core Body Clinic physiotherapy Mumbles and Swansea?

 

Adrian Wagstaff (originally from North Wales, and also Welsh speaking!) is the director and founder of Core Body Clinic in Reading.  He has built up an international reputation since he qualified in 2001 with a BSc (Hons) in Physiotherapy and then again in 2012 with an MSc in Manual Therapy.  He is a member of the MACP and is one of just 1200 physiotherapists world wide to hold the qualification of this advanced status in MSK care.  Having worked in 2 premiership football clubs (Manchester City & Wolves), the NHS, private practie in the UK and in New Zealand Adrian has a broad experience from chronic back pain to ligament rehabilitation in the elite sports person.  Adrian specialises in the diagnosis and treatment of musculoskeletal pain and has an interest in chronic pain and pelvic pain.  He is one of the few practitioners to treat Male Pelvic pain in the whole of the UK and is trained to use diagnostic ultrasound to help with diagnosis and to retrain the pelvic floor.  Adrian is a teacher of spinal manual therapy and manipulation having taught on the Masters degree at Coventry university, he also travels to teach this very skilled hands on technique.  Read more about Adrian here

 

 

 

How to Book:

You can call 01189310053 (our Reading Central Office) or 07748152377.  We also have a booking system that is integrated into the diary meaning you can see appointment times in real-time.  All you need to do is click BOOK ONLINE and register using either your tablet, iPad, phone or computer.  

Once you are set up you can book an appointment. It is very easy and should you suddenly find your appointment is no longer convenient you can simply change the appointment at any time.  Of course, you can still email or call the clinic and one of the staff members will be more than happy to guide you through the booking process.  Hours for online booking are 24 hours. 

If you have a particularly difficult problem and you are not sure if we can help then please call the clinic and ask to speak to someone.  This could be a difficult back pain or sciatica that you have had for a long time.  It could be a chronic tendon problem that has not resolved.  You might be suffering form chronic headaches or pelvic pain for which no one else has been able to help.  Its worth picking up the phone or emailing and asking for our advice.  Its simple to email  - This email address is being protected from spambots. You need JavaScript enabled to view it., or send a text to 07748152377 and ask for a call back.

 

 

 

 

 

 

 

 

What happens at the appointment?

 

The process of examination and diagnosis:

 

Assessment:

 We will first work out what the problem is by assessing the causes.  This will involve a comprehensive discussion about the history of your complaint, how it started, what makes it better and worse, when does it hurt most in the day, does it disturb your sleep and do you have any other symptoms beside pain.  We will also take a history of your past medical conditions.  We will ask about medication and also about what sports and activites you like to do.  We will ask about your home life ad what you do for a living, whether you drive to work and how often you take time off. 

All of this is called the 'subjective history' and it is really important because it gives us the information to work out what is wrong.  We may ask you a lot of questions and this is called differential questioning and helps us to diagnose one condition from another. It may follow the format of a medical examination similar to what you may experience when seeing a doctor or surgeon.

Examination:

In this part of the assessment we will look at the range of bodily movement or joint.  We will test muscle strength, neurological fuction and normal everyday movements.  We will also perform some special tests to isolate certain structures.    Physiotherapists are trained in delicate handling of the body. However, testing may cause some discomfort.   

Sometimes it is necessary to ask your GP to arrange bloods tests or xrays.  Physiotherapists are trained to look for common conditions and are particularly good at looking for problems not ameanable to physioatherapy.  We can tell if you need to see a surgeon and will refer you to the GP should we deem this necessary.

 

Treatments: 

See our list on treatments to see the types of techniques we offer. 

 

What about Covid and Lockdown?

No probelms, we run a COVID SAFE clinic so you are in safe hands.  This means that during the Swansea Lockdown, you can still attend for physiotherapy appointments.  We cant have people in pain and throughout the pandmic we kept our Reading clinics open for emergency Face to Face and online sessions.  Pain and injury causes misery to millions each year.  With little access to GP or hospital, we have been a life line to patients and this will continue with the opening of our Swansea clinic.  We wear full PPE, as you to wear a mask, ensure you have signed our consent form and check your temperature on your way in.  We like to call it a belt and braces approach.  We have tons of hand sanitiser so we have now officially swapped our hand shake with a blob of hand sanitiser.  Of course, if you dont feel safe then you can select an ONLINE appointment instead of a F2F.  We have been conducting online video appointments for the last 5 years, covering the whole of the UK and the entire world! So, we know they work - just ask the last patient we treated in Dubai! 

You can read all about COVID and our safety procedures here and our online appointments here

 

Our “my pain is still there" Service

Even if you have visited 20 physios, 10 chiropractors, 5 osteopaths, an acupuncturist, the GP or 2 orthopaedic surgeons………..we would still love the opportunity to take a look.  Challenge us with the problem!.   

 

We look forward to seeing you soon! 

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COVID 19 Face to Face appointments

GOOD NEWS! We are back open for Face to Face sessions!  

Please Read Below or Call us TODAY!

If you need to see a physiotherapist, you can book Online or call the clinic.  If you think you need a face to face physiotherapy session, then please consider the current climate and understand there remains a risk of transmission if you are stepping outside the house. If you are in doubt then you must call 01189310053 or email This email address is being protected from spambots. You need JavaScript enabled to view it. and ask for a call back. 

We really want to see you and help you get out of pain so we have developed some policies and procedures to ensure we can do this.  Please read through the information below and get in touch. 

 

If you require a face to face session, we have to ensure, under regulator and governing body rules, that you understand the risks of transmission that remain.  We must explain to every patient that there remains a risk of community transmission of COVID19 and we must not play down this risk.  The risk is getting less all the time and we have taken huge steps to ensure you are safe when you come to the clinic.  If you just need some advice or exercises then we suggest having an online session.  This is the same as any face to face where we dont need to put our hands on you.  Its safe and effective for a lot of conditions.  If we feel your condition is unlikely to recover with remote physiotherapy, then we advise a face to face session.

Every patient must pass a risk assessment prior to booking.  Our criteria for face to face sessions are: 

  • A condition that will not respond to remote physiotherapy or you do not want an online session ( conditions: ie a nerve problem, pain that is not easing with exercise alone, where an accurate diagnosis will not be possible via video).
  • You are free from COVID19 and you have not been in contact with anyone who has had COVID19 within the last 21 days.
  • You have not travelled out of the UK in the last 14 days.
  • You do not suffer from: Heart disease, breathing problems (chronic airways disease), diabetes, cancer (in chemotherapy treatment) or any other reason for shielding.
  • If you are over 70 there remains an increased risk and this is case by case assessed so please ask! 
  • You must read and sign our consent form electronically and send back to the clinic and you must accept there is a risk of tranamission and ***declare you understand this risk***.
  • You MUST wear a mask and one can be provided.
  • Your temperature will be taken on entry and if it is raised above 37.9 then we will not conduct the assessment and you will be rebooked (at no extra charge as this is not your fault).     

 

Our priority is to get you better and to do this without risking your health.  Our guidance is derived from that issued from the UK government, Health and Care Professions Council, Chartered Society and Physio First. 

 

During lockdown the clinic has remained open for essential treatment only. However, for the vast majority of patients we have been conducting online sessions via video link and this has been the safest way to assess and deliver physiotherapy. Government guidelines have been in place meaning we have not been allowed to offer non-essential face to face sessions due to the risk of cross infection and transmission of COVID19. While some restrictions have been lifted, the guidance on 2m remains in place for social distancing in the community.  Some physiotherapy and other clinical services are difficult to conduct with the restriction of 2m and therefore, where we are unable to keep 2m apart, safety measures are in place to ensure safety to you and our staff.  The safety measures are a combination of risk assessment, infection control and personal protective equipment (PPE).   During your consultation, the physotherapist will be using PPE.  For techniques that are aerosol producing, a full visor is worn.  Safety if our priority so please understand that while ensuring you are safe, we need to be safe too. 

 

We really want to help so please get in touch!

 

Adrian Wagstaff

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The Truth about Frozen Shoulders

 

"Many patients are told they have a ‘Frozen Shoulder’ when they walk into the Doctors office with severe arm pain. Frozen shoulders are one of the most common causes of shoulder pain in middle-aged people. Typically patients are told to take regular painkillers and the injury will get better by itself! However this is not always the best advice.

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