Back pain is such a common complaint that we treat, but what if I told you that back pain can be caused by pelvic floor dysfunction? First, it is important to remember that pain does not equal damage. Second, it is not unusual to experience pain in a different area from where the dysfunction lies. This could be referred from another area or a secondary effect to moving in a weird way due to the dysfunctional area.
Cause and effect in this case is very similar to asking “Which came first, the chicken or the egg?”. What we can state confidently, is that your back and your pelvic floor go hand-in-hand. Studies show that folks with low back pain have decreased pelvic floor function compared to those without back pain. Could this be pelvic floor inhibition due to the back pain? Can weakness or over-tension or control issues of the pelvic floor be causing the back pain?
For many, the pelvic floor is very nebulous. What is it anyway? Where is it? What does it look like? Do only women have them? Males do have pelvic floors, but the anatomy is different. For this post, we will referring specifically to the female pelvic floor. But guys- you too can have pelvic floor dysfunction! This image below is a great look at the female pelvic floor and it’s close relationship to the other pelvic and lumbar spine architecture.
The pelvic floor helps to support the weight of your organs, helps with toileting and sexual function, and influences posture and control through pressure within the core. Weakness, over-tension, spasm or damage to the pelvic floor will change the support of the sacroiliac (SI) joint and the forces that we create through the lumbar spine.
If you have addressed your lumbar spine without much change in symptoms, go a different route! Keep in mind, there are other signs of pelvic floor dysfunction, other than leaking urine or back pain. They include painful sex, frequent constipation, the feeling of heaviness in the vagina with jumping/running/bearing down etc.
Addressing the Pelvic Floor
There are 3 areas to cover that address your pelvic floor in a functional way -- position, breathing and bracing. All of these can be applied to any athlete in any setting.
Position- Keeping the ribcage stacked over the pelvis is an important position to maintain, regardless of activity. This sets the canister (“core”) up for optimal function- meaning the diaphragm, pelvic floor, abs and back muscles can work harmoniously to lift the most weight, support the spine and minimize pressure on the pelvic floor.
Breathing- Diaphragmatic breathing is essential for pelvic floor function and decreasing pain around the low back. The pelvic floor mirrors the movement of the diaphragm, so it is a simple way to relax a tight pelvic floor. Also, two major muscles that run from the ribs to the pelvis also have connections to the diaphragm. So deep breaths can work as a gentle mobilization!
Bracing- How do you prepare for heavy loads or challenging positions? If you simply hold your breath and go, you are missing an opportunity to create more tension! Or if you are holding your breath for a position that should not require that much power, you are increasing the workload on your pelvic floor and back for no reason. For example, preparing to lift a couch versus preparing to lift a pencil.
Put simply, if you are lifting something heavy, holding your breath is fair game. IF you do it correctly. If you experience symptoms- low back pain, leaking, heaviness- then do not hold your breath until you seek help for how to correctly brace. Knock the weight down or the mileage down to a place that you do not have symptoms and work there until your tolerance improves.
If you notice you are holding your breath with lifting a small object, such as your purse, then let’s talk breathing. Breathing out on exertion for a task like this will help the pelvic floor contract reflexively and can keep symptoms at bay. Try it out!
Big picture: Back pain does NOT equal back injury. It is very likely that back pain can be decreased and function improved with addressing the pelvic floor as it work with the low back muscles. Check out these simple ways to check your position, breathing and bracing. Often times, pain is a product of HOW you are moving.
If you take a crack at it yourself but just can’t seem to find improvement, reach out to us at Athletes’ Potential. We work with people like you every day to get them back to high functioning lives without pain and with a better understanding of how to move their body.
Thanks for reading!
Dr. Jackie, PT, DPT
It’s been well researched and well documented that surgery is over utilized in the United States. Whether for your knee, back, shoulder, or ankle, it is far too common for people to rush to the operating table when, in many cases, conservative treatment (physical therapy) has been shown to have equal or better outcomes. Let's look at back surgery as an example. If you take 3 random people off the street who have absolutely no back pain, one of them is going to a “herniated disc” show up on an MRI scan. This means disc herniations may not always be the cause of someone’s low back pain, yet 500,000 people opt to have back surgery every year, often times with minimal or no relief.
That being said, there is obviously a time and a place for surgery. Depending on a number of different variables (age, activity level, mechanism of injury, etc), sometimes surgery can absolutely be the best treatment option for you. What most people fail to understand though is that surgery is the easy part...all you have to do is get stuck with an IV and the next thing you know you wake up in the recovery room. Returning to your previous level of performance is the hard part, and it’s the hard part primarily because of the incredible amount of muscle atrophy (loss of muscle mass) that occurs after a surgery. In as little as two weeks a surgically repaired limb goes into a state of anabolic resistance and protein synthesis shuts down, leading to a 30% loss of muscle mass in that limb. Because of this rapid and extreme loss in muscle mass, muscle atrophy has a profound impact on a patient's rehabilitation, and sometimes patients never fully recover.
Historically, muscle atrophy has been a battle that physical therapists, athletic trainers, and strength coaches alike have struggled to win. Just the other day I was working with a patient who is extremely active and fit, but had a knee surgery over 15 years ago and still had a significant side-to-side difference in leg size. However, there’s a revolutionary piece of equipment that is taking the world of physical therapy by storm, on that’s allowing healthcare professionals to prevent this initial 30% loss of muscle mass from even happening in the first place, Personalized Blood Flow Restriction Training.
I go more into detail about what exactly Personalized Blood Flow Restriction Training (PBFRT) is in my previous article, but in a nutshell PBFRT is the use a modified surgical tourniquet to occlude a percentage of the arterial flow into a limb to trick your body into thinking it’s doing something much harder than it actually is.
So why is personalized blood flow restriction training so revolutionizing when it comes to surgery? It prevents the significant muscle atrophy from even happening in the first place.
In normal circumstances it takes 8-12 weeks of high intensity strength training (>65% of your one rep max) to get improved strength and muscle size from, you can see how this would be an issue for someone recovering from a surgery. When you have a surgery, you’re going to go through a period of time where it simply isn’t feasible, nor safe, to lift the weight required to increase muscle size. This is where PBFRT comes in.
Say you’ve torn your ACL. With an ACL reconstruction, for the first few weeks the “strengthening” component of your rehabilitation will include simple exercises like seated knee extensions, mini squats, and heel raises. None of these exercises are going to make you a stronger functioning human, because none of these are at a high enough intensity level to cause the biological responses needed to increase muscle size and strength. However, if we put on a blood flow restriction device, and do these exact same exercises, we cause the following:
There are about 200 published research articles in 15 different countries that have demonstrate the benefits of personalized blood flow restriction training and we are seeing those benefits every day here in the clinic. Whether it’s helping someone who has years of atrophy as a result of surgery or we’re preventing the atrophy from even happening in the first place, the results we’re seeing are simply incredible. If you’re living in Atlanta, and you’ve had surgery or are struggling to get your strength back after a surgery, we’d love to help you. Give us a call at 470-355-2106 or fill out the contact request form and we’ll contact you.
Thanks for reading,
-Dr. Jake, PT, DPT
Shoulder volume: This is the first thing that comes to mind with I have the opportunity to work with youth swimmers. A typical club or high school swim team will average around 40,000 to 60,000 yards in a week of practice and the average athlete will have a stroke count of about 12-15 strokes per 25 yards, giving you a range of 19,200 to 36,000 strokes per week...that’s a TON of volume on the shoulders!
With such a high demand on swimmers’ shoulders, injuries are incredibly common, so common in fact experts coined the term “swimmer’s shoulder” as an umbrella diagnosis. That being said though there are a number of steps you can take to prevent injury, the most crucial of which being to improve your movement efficiency. Movement efficiency is key to not just preventing injury, put to improving performance. Think of it this way. Performing 36,000 strokes a week with poor mechanics is like trying to drive a Ferrari with the handbrake on; sure, you’ll still be able move and potentially even move pretty damn fast, but you’re going to leave a ton of performance on the table and you’re going to break down way quicker and more often.
In order to know to know where a deficiency is happening, you must break down each stroke into its component parts. For the sake of this article, we will focus on freestyle. Each freestyle stroke can be broken down into five main phases:
When looking over all the different component phases that make up a freestyle swimming stroke, something becomes abundantly clear… internal rotation is crucial. From the catch phase all the way through the recovery phase, internal rotation is necessary in order to perform the freestyle stroke effectively and efficiently. That’s why you’re always hearing your coaches scream out cues like “keep a high elbow”, “drag your fingers”, “point your elbow to the the ceiling”, all those are various cues for internal rotation.
The problem is though, we see a ton of swimmers who are missing adequate internal rotation. When you’re missing internal rotation and you try to go into a “hang position” (see picture above) you will compensate by dipping your shoulder forward. This is big problem because when you dip your shoulder forward you’re putting your rotator cuff in a weakened position, putting unneeded stress on your biceps tendon and labrum, and decreasing your power output. Add all that together and multiply it 36,000 strokes you're doing in an average week and it becomes easy to see why this is a recipe for disaster.
So how do you know if you’re missing internal rotation and what can you do if you are? Well, check out the video below to assess your shoulder range of motion and see if you hit the minimum of 70 degrees of internal rotation we like to see our athletes to hit. If you don’t have the needed range or it is a struggle to get there, check out the following two videos for a couple of our favorite ways to improve your shoulder rotation.
(Internal Rotation Self-Assessment):
(Internal Rotation Superfriend Stretch):
(Banded Internal Rotation Stretch):
Lacking internal rotation is one of the main reasons why we see swimmers, especially youth swimmers, in our clinic in Decatur, GA. However, the shoulder is an incredibly complex joint and there could be a number of reasons in addition to a lack of internal rotation causing pain in a swimmer’s shoulders. If you’re still struggling with shoulder pain or noticing a decrease in performance after working on your shoulder internal rotation you live we’d love to help. Simply give us a call at 470-355-2106 or fill out the contact request form below and we’d be happy to contact you.
Thanks for reading,
-Dr. Jake, PT, DPT
Dr. Danny and staff's views on performance improvement, injury prevention, and sometimes other random thoughts.