Although your pelvic floor and your feet may seem as though they are different and non-related structures, this is not the case. The connections are fascial, neural and biomechanical. Your feet are your foundation; how they contact the ground dictates all movements at your ankle, knee and hip. Soft tissues and fascia in your feet have vast connections to the legs, hip and back. The feet and pelvic floor, despite the distance from each other, also share neural input!
Fascia is the thin covering of your muscles that looks like a spider web. The posterior fascial line runs from the bottom of your feet, up the back of your legs and torso and to your head. Along the path, the fascia connects to the ischial tuberosities, or the “sit bones”. Muscles from your pelvic floor also attach here! So tension along this fascial line will directly impact your pelvic floor. Essentially, any joint the fascial line crosses and soft tissue in the area can be effected. A great place to start is the feet! Use a lacrosse ball to mobilize the fascia and tissues in the bottom on your foot and around the ankles.
The nerves that are responsible for function around your pelvic floor—sphincters, PF muscles, deep hip rotators—are also responsible for the function of your intrinsic foot musculature. Signs of foot weakness may by indicative of pelvic floor weakness, and vice versa. So, strengthening the foot musculature and stimulating these nerves may help with pelvic floor function. Unfortunately, many athletes wear big, padded shoes which decreases the amount of work the foot musculature must do! Neglecting to walk around on bare feet is robbing your feet of their natural ability to stabilize and form to the surface but also decreases in amount of neural input.
We suggest barefoot walking and running to increase the input through your feet and begin to re-strengthen the small foot muscles. The best way is to find a grassy area, about 50-100m in length and run repeats barefooted. Your feet will be challenged much more than when running in squishy shoes, so ease in. You will also notice that your running form is probably different (better). Heel striking when barefoot in quite painful, so the body will automatically shift to more of a midfoot strike—which is good!
The ankles drive the movement of the whole kinetic chain- the knee, hip and pelvis and spine. Dysfunction or pain in any of these areas can be stemming from faulty foot mechanics. For example, walking with the toes pointing outwards will cause your ankle joint to perform on a slightly different axis than it was designed. This will be demanding on the ankles and all the way up the kinetic chain.
The knee tends to be stuck in the middle and pushed around. The ankle dictates the movement of the lower leg and then influences the upper leg. The knee is just where these two units connect. So you will notice, we do not focus on biomechanics of the knee.
The hip has a direction connection with the pelvic floor. One of the deep hip rotators, the obturator internus, connects to the pelvic floor. With this connection, the amount of hip rotation will change (increase or decrease) the tension of the pelvic floor.
Putting it all together: Our feet control the movements of the joints above it. If your arch collapses (flat feet), the lower leg will rotate inward and the knee will follow. Up the chain, the thigh will also rotate inwardly which changes the tone of the pelvic floor. The angle of the knee will change with all of this, but remember it is not the driver of the dysfunctional motion, rather the passenger. Living with faulty biomechanics (however slight) can perpetuate back, hip and/or pain and dysfunction. Rather than starting with an MRI for the back or kegals for the pelvic floor, why not see if changing how you move can decrease symptoms?
A simple way to put this into practice is a slight change during a body weight squat. Move your feet to a comfortable squat position. Before sending your hips back and down for a squat, screw your feet into the floor. That is, acting as though you are moving your big toes further apart but your feet are not moving. Keep the toes on the ground! This creates torque at the hip. By engaging the external rotators, you are creating tone at the pelvic floor--remember the connection? You may also notice that the arch in your foot becomes more pronounced. Hello intrinsic foot musculature! This motion is also helpful for those with hip pain, especially pinching at the front.
In the photos below, my feet are not in a squat stance, but I am showing the subtle external rotation. You can see the largest differences at my knee caps and the direction they are facing. Also, notice my arches after the external rotation (bottom photo). They are higher! You can see a greater difference on my left foot. My whole foot stays in contact with the ground.
Recap: The foot and the pelvic floor have more connections than you may realize. They share fascial connections as well as neural. Taking the time to mobilize tight tissues and allow for more input with bare feet can have positive effects on hip, back and pelvic floor issues. The ankles largely drive the entire kinetic chain from the bottom up. So, taking care of the foundation of movement will be the most beneficial!
Thanks for reading,
Dr. Jackie, DPT
Tennis players need a combination of speed, agility, flexibility and power to become successful at the sport. As with any overhead sport, it is not unusual to have shoulder and elbow pain, but tennis can be especially hard on the torso and lower body as well. Whether you are a serious competitor or a weekend warrior, there are a few key areas to keep supple and strong to avoid injury and improve skill.
Feet & Ankles: The ability to move laterally and sprint is essential for a tennis player. But how can you do this effectively with stiff, painful ankles and feet? My favorite way to mobilize feet and ankles is using a lacrosse ball. Mobilizing the fascia on the bottom on the feet can decrease foot pain and allow for more range of motion of your big toe- which is a big deal for push off! Pressure-based soft tissue work to the calves can decrease tightness and pain in these areas as well. Many people ask if a tennis ball would be sufficient, but it’s too soft! Our recommendation is using a lacrosse ball for 2 minutes in each area, per side, daily. Try it before and/or after a match and see which timing works best for you!
Hips: Pain in the hips can occur with faulty movement patterns or tightness elsewhere, but I want to focus on hip strength. I’m always surprised when athletes come in and have poor balance on one foot or less than ideal hip strength. Running and cutting is essentially moving from single leg stance on one side to single leg stance on the other. Without balance and control in this position, your knee will take a beating. Do you ever have sore knees? Don’t blame your knee, first look at your hip! A great exercise for single leg balance and hip strength/control is the single leg deadlift. There are many ways that you can adapt it to make it more or less challenging. When you try it, notice what happens at the knee. With poor control and strength at the hip, your knee may be moving in towards the other or shaking a bit. This is not ideal and likely the root of the knee issues. Work these into training days, 8-10 repetitions for 2 sets will be a good place to start. They can be sneaky and make you quite sore the next day!
Thoracic spine: Having the ability to rotate the torso is important for power production in concert with the hips. A stiff spine will disrupt the power couple and the hips will have to compensate. As mentioned before, dysfunction at the hips can then cause knee pain. Disrupting this kinetic chain can have severe effects on your tennis game! My go-to for thoracic spine rotation is the open book. This works well as a warmup exercise. As you rotate through the exercise, be sure to keep the knees stacked so that the rotate comes from the spine and not the pelvis turning!
Shoulder: Undoubtedly, shoulder strength is an important variable for efficient strokes but it can also directly affect elbow pain. Similar to the hip and knee relationship, if there is shoulder weakness then the elbow can take the brunt of the force. The rotator cuff is made up of four small muscles that stabilize the shoulder joint. Without strength of these muscles, the prime mover muscles then must take over for stabilization. When this happens, there will be less power production at the shoulder. Dysfunction at the shoulder can effect nerves passing through the area with may cause elbow pain. To keep the shoulder stabilizers strong and healthy, the exercise that will give you the most bang for your buck is the WY negative using a small band. This covers external rotation (cocking back before serving), overhead stabilization and posterior cuff control during deceleration. What was that last part? The muscles at the back of the shoulder work to slow the shoulder after the acceleration to hit the ball. A good indicator of dysfunction here is pain at the back of your shoulder.
Elbow: The elbow is effected so often by tennis that it was named after the sport! Tennis elbow, or lateral epicondylalgia, is pain at the outside part of the elbow. Its sibling, golfer’s elbow, is pain at the inside of the elbow. Despite the names, tennis players are susceptible to both. As mentioned before, it can be coming from up the chain- cervical spine or shoulder. The pain can also be coming from down the chain- wrist. The forearm muscles that move the wrist connect from the elbow and run to the hand. After hundreds of reps during a match or practice, forearm muscles can become irritated and tight. The triceps also crosses the elbow joint and can be a culprit with elbow pain. This muscle extends the elbow, so are very active with backhands and serves. Early on, the best focus of your time with elbow discomfort is soft tissue work using a lacrosse ball. After pinning down the ball in an area of tension, it is important to move the wrist and elbow to give the muscles a stretch.
If you are a tennis player looking to improve your game or ebb nagging pain, give these self-management techniques a try! By keeping the body mobile and strong you will have less pain and improved function. At Athletes’ Potential we work with multiple tennis athletes in all skill ranges that want to get back to the court quickly and feel better than ever. Not sure? Give us a call. We would love to chat with you and find the best fit.
Thanks for reading!
Dr. Jackie, PT, DPT, OCS, CSCS
Guess what? Physical therapists sometimes have pain and dysfunction too! We are only human. Often times, people will see me wrapping a voodoo band here and there, or digging a lacrosse ball into my shoulder. It usually strikes up a conversation starting with, “What would you do if…..?”
My ol’ volleyball knees tend to get creaky and achy sometimes, just as many athletes and patients often describe. So, what do I do if I have knee pain?
These are my 5 favorite “quick fixes” for knee pain. Obviously, management of knee pain is more comprehensive than 5 quick tips. However, these are for when you are in the middle of weightlifting, running, playing your sport and you get that nagging knee thing. Ideally, you would consult a PT or watch a video of yourself moving to see what is causing the knee pain. But understandably, sometimes we just need it to feel better RIGHT NOW.
#1 Modified Couch Stretch- This is a great stretch for the front of the hip! It is important that you stay tall and do not let the band pull your hips forward so that your back is banana shaped. Propping the foot up on a ball takes up more slack in the quad and intensifies the stretch. If you squeeze your booty, you will feel the stretch even more. Please kneel on something soft! Prolonged pressure on the front of your knee will only exacerbate the issue.
#2 VooDoo Band- Using a voodoo band, wrap your knee beginning below the knee and leaving a gap for your kneecap. Be sure it wrap it tightly! After it is wrapped, any knee movement will be beneficial. I like to do air squats and butt kicks to get deep knee flexion. You could also sit down and bend and straighten your knee. Leaving it on for up to 2 minutes will give you the best bang for your buck.
#3 Soft Tissue to quad- Often times, tension in the quad will cause knee pain right at the top of the knee cap or on either side. Pressure to the soft tissue in the thigh area can help the quad relax and allow more pain-free range. My favorite tool for this is the handle of a kettlebell. It allows more direct pressure than a foam roller and you can easily push down and then move it side-to-side for some release. Another option is a lacrosse ball. Just lie on your stomach, pin the ball on a sore spot on your quad, then bend and straighten your knee. Spend at least 2 minutes on this one.
#4 Knee Gapping- Everyone’s favorite! We like to use Yoga Tune Up Balls for this (as seen in the photo) but a double lacrosse ball or even a towel rolled up will work. Simply put the balls in the bend of your knee, then use overpressure form your arms to bring your heel towards your booty. This should feel good- like a stretch to your knee. Two minutes of oscillating between overpressure and releasing it will do the trick.
#5 Modify- Some days, the knees just aren’t on board. If you have completed a thorough warmup and tried some self-management but the knee still feels iffy--- modify, modify, modify. Don’t work through the pain! There are plenty of ways to change a workout that will still be beneficial but not aggravating to the knees. A great example is the box squat. If I have knee pain, it’s usually with heavy back squats- ol’ volleyball knees, remember? Box squats are a good option. I am still loading in the pattern I want, hitting the lumbopelvic muscle groups, but allowing my knees to stay back further so that the shear force is less.
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The Athletes' Potential Team
Dr. Danny and Dr. Jackie's views on performance improvement, injury prevention and sometimes other random thoughts.