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
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, PT, DPT, OCS, CSCS
What is your pelvic floor and why does it matter? The pelvic floor is a sling of muscles that runs inside the pelvis. It works dynamically with the diaphragm and abdominals to dictate pressure during breaths. The pelvic floor also has intimate connections to the sphincters of your urogenital structures. These structures are important for 3 vital human functions: peeing, pooping and sex.
Yea, I said it. The stuff that no one wants to talk about.
Some men and women experience incontinence or urinary urgency but think that is “just something that happens” with age or high level activity. This simply is not true. Others may have pelvic floor dysfunction symptoms including low back/hip pain, constipation, painful sex or feelings of incomplete voiding.
Every time you breathe, your pelvic floor is moving and contracting. The way in which you stand and move has a direct effect on the ability of the pelvic floor or contract and work in synergy with the rest of the deep core. What if you could change a few daily habits and have decreased pelvic symptoms? Check out these 7 common habits and see what applies to you:
1. Ab gripping- Whether it is to make your tummy look flatter, for stabilization during everyday movements or due to overtraining abs at the gym, ab gripping is adding constant and unbalanced pressure to your pelvic floor. When you are simply moving throughout your daily activities, your belly should be relaxed! I give you permission to fight the social stigma of a less-then-flat abdomen and give your pelvic floor a break. Let the belly go!
2. Preventive peeing- Many people have the habit of trying to urinate when their body is not signaling that they need to void, usually right before leaving the house or on a scheduled break at school/work. This “peeing just in case” can also lead to pelvic floor dysfunction or worsen existing issues. Your bladder will now have a different set point of when it thinks it’s full! Now the pelvic floor muscles never have to be coordinated to control a full bladder and fight the urge for 30 minutes before you get home.
3. Hovering- Believe me, I’ve been at music festivals and used a porta-potty that was so gnarly I didn’t want to touch the handle! What I am about to say does not apply to that situation--I would not recommend that you ever sit in that. However, when using the restroom in public, many women will hover over the toilet while urinating. This is not doing your pelvic floor any favors. Remember, the hip musculature and pelvic floor have connections so while you are holding an isometric air squat, do you think your pelvic floor is relaxed? Hell no, it’s holding on for dear life. Take your time when peeing and try to sit whenever possible. Most bathrooms these days have those little paper covers for the toilet seat. Use that! And take your time, giving your pelvic floor time to relax and the bladder to completely empty.
4. Breath-holding- As I mentioned before, the diaphragm and the pelvic floor work together. So breath holding will also increase pressure on the pelvic floor and increase the likelihood of leaks. Those who use breath holding as a strategy while moving light object or bending over, usually do so to avoid a leak or feeling of urgency. However, this increased pressure increases the likelihood of a leak! I understand that there are times breath holding is essential- lifting heavy weights. There are alternate strategies to avoid leaks in these situations—outside the depth of this post!
5. Butt clenching- This goes right along with ab gripping- relax! Deep hip muscles have fascial connections with the pelvic floor, so a tight booty = a tight pelvic floor. But tight means strong, right? No, in this sense I mean tight as in over-recruited. Your pelvic floor is on high guard all day from increased pressures and over-recruitment. Then you expect it to hold on tighter with a violent sneeze or a couple dozen box jumps? It is tired! The pelvic floor function and intimate relationship is more about timing and synergy than strength. Ladies- be careful when are trying to look sassy in those heels on Saturday nights. High heels can also cause women to unconsciously hold their pelvis in a tucked position or butt clench.
6. Poor posture- So I have said a lot about pressure, particularly imbalances and increased amounts. However, posture is often the prequel to the alternate recruitment strategies discussed above. If your diaphragm and pelvic floor are not stacked on top of each other, then they are at a disadvantage for working together. In appropriate synergy = pelvic floor dysfunction. The best way to check this is to look at your posture in the mirror or have a friend take a picture. You want your rib cage and your pelvis in line. Poor posture indicators are your lower ribs poking forward, nipple trajectory pointing upward rather than straight, hip bones much further forward than your lower ribs.
7. Sitting all day- Sitting is just bad for you, plain and simple. But it has particular effects on the pelvic floor from both a myofascial and alignment standpoint. The glutes and your pelvic floor are buddies, they like to work together. When you sit on your glutes all day, the fascial layers become compressed and unable to slide as easily. As far as alignment, who can actually sit with good posture for 8 hours? Not me. I don’t think I would trust someone that could- they are probably an alien. Those deeper hip muscles that have connections to the pelvic floor can become tensioned and tight which could lead to a tighter pelvic floor- remember tight doesn’t equal strong! That being said, as you sit slumped over a computer, your alignment of ribs over hips is likely disrupted. Then we are back at the beginning with an imbalance of pressure. Don’t you see, it is a never-ending cycle?!
** Allergies/coughing/sneezing- Ok, so this isn’t a habit per se but worth noting on this subject! Women and men with persistent allergies causing frequent cough and sneeze episodes may also see increased pelvic floor dysfunction due to the frequent pressure changes. If this sounds like you, be sure to find some medicine that works for you or talk to a physician about possible allergies. If the coughing is from smoking, well that is absolutely a habit that you can direct effect!
I think it’s safe to say everyone could find at least one habit that applies to them. Take some time to be more aware of your posture and how you are holding your muscles when they should be relaxing! Stress urinary incontinence and urgency is not normal but it is common. You never know, a few simple habit fixes may resolve your symptoms. If not, reach out to us at Athletes’ Potential, we would love to help!
Dr. Jackie Varnum PT, DPT
Many people are willing to go the extra step to increase their efficiency and function when it comes to their sport: the latest and greatest running shoes, wrist wraps and weight belts to hit a PR or a personal trainer for the extra push. What if we could improve our function and decrease pain for free? I think I would have your attention.
As we spend hours each week training, two very important muscle groups are ignored: the diaphragm and the pelvic floor. It is not for lack of use; every time you take a breath the diaphragm contracts and lowers to help fill your lungs. The pelvic floor works double time; these muscles are firing like crazy to keep you stabilized with each breath and during movements. If they work all day long, they should be strong - right? Not always the case.
Often times the “core” and “abs” are used interchangeably. The abdominal muscles that you see in a six pack are just the most superficial muscles of the core. The deep core is comprised of the diaphragm, pelvic floor, transverse abdominis and multifidi. These four muscles make up the “canister” of the inner core. As you see in the picture below, the glottis is also included in this as it has direct function with the diaphragm, and thus the pelvic floor. The transverse abdominis is a deep core muscle that is often referred to as a corset. It attaches to your pelvis and lower ribs and even has connections to the diaphragm through fascia. The multifidi are small back muscles that attach your vertebra and also connect to the pelvis at the lower levels. See how it is all connected? It is important to keep in mind that these are endurance muscles.
The diaphragm is the second largest muscle in the body! It attaches from the chest bone, to the ribs and down to the upper three lumbar vertebra. The pelvic floor is a group of smaller muscles that act as a hammock in the bottom on the pelvis. They attach from the sacrum to the inner ring of the pelvis. The diaphragm and pelvic floor have an intimate relationship of synergy during breathing. With inhalation, the diaphragm draws down and the pelvic floor drops simultaneously. It is essential that they have the endurance to move with each breath, but the pelvic floor must also have the strength to withhold increases in intraabdominal pressure.
When the diaphragm and pelvic floor are stacked one on top of the other, you are able to more efficiently breathe and manage the pressure in your core. This is best achieved through optimal posture. When you are unable to manage the pressure, it will push towards the weakest area: often the pelvic floor. This leads to stress urinary incontinence, or peeing during jumping, running, laughing, sneezing, etc. This can be exacerbated by poor postures.
Can you imagine how each of these poor postures affects your canister? Both sway back and increased lordosis move the core out of the optimal stacked position. Thoracic kyphosis, rounded upper back, puts your diaphragm in a shortened position, thus making it less efficient.
Breaking or bending the canister is easily identifiable in poor overhead lifts and poor running form. The picture below shows that with a poor finish overhead, her diaphragm and pelvis are no longer stacked. This affects her breathing efficiency, the internal pressure and work of the pelvic floor. Not to mention, this puts her big movers, specifically the lats, at a disadvantage and can cause back pain. You have probably also observed runners moving their core out of the optimal position. Those who run bent over at the waist or those who lean their torso back as if running downhill are essentially bending the canister.
When you lift something, the deep back and abdominal muscles will contract for stabilization and the pelvic floor should slightly lift to help secure the lower abdominal organs. However, if you hold your breath and bear down, the pressure pushes the pelvic floor down. This can make you more susceptible to leaking or pelvic pain. So I should never hold my breath? No, you absolutely must hold your breath or brace with certain athletic movements. Especially lifting heavy weights!
How to Brace:
Bracing or breath-holding is common for many athletes. Learning how to properly brace will ensure success in the movement and the proper distribution of tension throughout the body. Many times, tension is increased but only in the superior and inferior directions, or up and down. Remember the picture above: this means that the diaphragm and the pelvic floor are receiving most of the force. Luckily our diaphragm is big and smart, it knows that in order to live it must work. Unfortunately, the pelvic floor then becomes the weakest link and may be overtaken by the pressure. This results in SUI, or leaking during exercise. Focusing on sending the tension in 360 degrees will be helpful to reduce this downward pressure. Rather than just bearing down through your thorax, add tension to your hips and shoulder girdle.
But what if you’re a runner? Obviously you do not want to hold your breath throughout a long run or even periodically. Then it is important to either down train or strengthen your pelvic floor, depending on your issue. If you experience problems with bounding or impact such as a box jump, exhaling on the landing will help to decrease the pressure in the thorax and load on the pelvic floor.
Whether you have an underactive, overactive or normal pelvic floor, learning to properly brace with the diaphragm and pelvic floor engagement is important. By spreading the tension throughout your body, you are able to sustain more tension for greater loads.
Pulling it all together:
As you train, don’t neglect two important muscle groups: the diaphragm and the pelvic floor. They are often forgotten since you cannot see them in the mirror. But if you optimize their function, then your workouts will improve! Maintaining optimal posture is a great start; this applies to quiet standing, as well as during workouts. When you brace, be sure to spread tension throughout your body to avoid pushing it all to the pelvic floor.
If you continue to experience issues or wish to have someone closely screen your movement with breathing and bracing, come by and see us at Athletes’ Potential. This is just the tip of the iceberg!
Thanks for reading,
Dr. Jackie, PT, DPT
Previously, we talked about safe exercise during your pregnancy. But how do you know when and
where to start after having your baby? As always, consult your doctor before beginning an exercise
program. Complications during labor or other factors, such as diastasis recti, can change your return-to-exercise timeline.
Before I list a few suggestions for exercise, it’s important to review the guidelines:
Protect your joints- effects of the hormone relaxin can last up to six months postpartum. Your
ligaments will have more laxity and range of motion will be increased. It is important that you
control your movement throughout the entire range and avoid loading your joints at the end
range. An example that I use a lot is crashing into the bottom of a squat—avoid that! Mobility
exercises, specifically distraction, with bands should not be used directly after pregnancy and added conservatively after a few months.
Ease into exercise- you may find that beginning with low impact exercise is more comfortable,
such as swimming, biking, light weight training. Just as during your pregnancy, listen to your
body and avoid going to exhaustion right out of the gates.
Stay hydrated- especially if breast feeding, it is important to remain hydrated. The
cardiovascular changes that took place during pregnancy will begin to level off. So drinking
plenty of water and maintaining electrolyte levels is important for the health of you and your
Mind your belly- diastasis recti is the separation of your abdominal muscles during pregnancy.
Depending on the amount of separation, different exercises should be avoided. Not all women
experience diastasis recti but it important that you communicate with your care provider to
determine if it affects you. If so, abdominal crunches, planks and sit-up variations should be
avoided until it is healing and closed to a certain degree.
Pelvic floor health- many factors during the pregnancy will make your pelvic floor vulnerable to
dysfunction: pressure from the baby, altered posture during the pregnancy, episiotomy or
spontaneous laceration, vaginal delivery. It is important to check in with your pelvic floor and
decide if it needs some attention before returning to exercise. Pelvic floor dysfunction can lead
to a slew of issues; three very common issues are urinary stress incontinence (peeing when you
sneeze, jump, etc), low back/hip pain and painful intercourse. If any of these issues persist, see
a pelvic floor physical therapist and they can get you back on track. These are all common but
Keeping the guidelines in mind, work through these exercises and find your weaknesses.
Hollow Rock Regression- this exercise is great to begin to regain midline control. Do not do this if you have diastasis recti.
Air Squat- slow and steady, controlling your speed on the descent. If you are having hard time with
control, squat to a box!
Monster Walks- the deep rotators of the hip have fascial connections with the pelvic floor so they
directly impact its function.
Diaphragm Reset- it is important to practice breathing with proper posture- ribs over hips. In the later stages of pregnancy, the exaggerated lumbar lordosis (sway back) puts your diaphragm at a
Starting with these foundational exercises will make your transition back to higher level exercise as seamless as possible. Keep those precautions in mind and communicate with your healthcare provider if you have any questions. If pelvic floor dysfunction seems to be sticking around, seek out a pelvic floor therapist. This is something that can be treated and resolved!
Thanks for reading,
Dr. Jackie, PT, DPT, CSCS
Should women train differently than men? The answer to this question is far from black and white.
There are some principles of strength and conditioning that remain constant whether training a male or female. However, the biological makeup of women causes some factors to be different than a man.
First I will address the YES, or why women should train differently.
NO- Reasons why women should not train differently than men
So what do you do with this information? For most of you, continue to train as you were. However, it will behoove you to add some extra warm-up drills, “core” exercises and closely analyze your motor control. However, do not cut yourself short on the intensity. Remember, women can perform more reps at higher weight and yes you will maintain a feminine figure! Keep the intensity high for greater metabolic impact and don’t skip the weights.
Thanks for reading!
-Dr. Jackie, PT, DPT, CSCS
Mata, John D et al. Sex Differences in Strength and Power Support the Use of a Mixed-Model Approach to Resistance Training Program. Strength and Conditioning Journal 38:2 April 2016.
Tuttle, Lori J et al. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 40:1 2016.
Many active women wish to continue their lifestyle even through pregnancy. Aerobic activity and resistance training are fantastic for maintaining fitness while keeping the baby healthy. Of course, always consult your doctor after becoming pregnant to make sure that it is safe to exercise at various intensities.
The general guidelines are to accumulate at least 20 minutes of moderate intensity almost every day of the week. For those of you who look for more intense activity, 3-5 days of vigorous activity is suggested for 20-60 minutes per bout.
Baby Bumps & Barbells guidelines:
As the baby bump grows and the center of mass is moved forward, your posture will be affected. The lumbar lordosis, or curve of the low back, will increase drastically throughout the pregnancy. Often times, your thoracic spine will flatten. Although postural changes are expected and normal, it is important to continue to maintain the best posture possible. Continuing upper body strength training and focusing on proper posture are key.
Another group of muscles that is greatly affected during pregnancy is the posterior chain. I’m talking specifically about the glutes and the hamstrings. Any barbell work to strengthen these areas should be continued throughout, keeping the baby bumps and barbells guidelines in mind. Lunges and squats remain some of the best and most simple workouts to target the posterior chain with little risk.
Birddog- if achieving this position proves to be too difficult, you can keep your knees down and extended just one arm at a time. Then you can progress to extending just one leg at a time before combining for an arm and a leg simultaneously.
As mentioned earlier, pregnant women are inherently more bendy than they were pre-pregnancy so stretching may seem unwarranted. However, most of these stretches are aimed at relieving areas of pain or tension from the growing bump and new posture.
Child’s pose- as the baby bump grows, this can be modified by having your arms and hands out-stretched on a workout ball, chair, or any other elevated surface. A large ball will give you the option of small rotations right and left with your arms to feel the stretch intensified along your sides.
Seated Hamstring Stretch- as the bump grows it may be necessary to use a bed sheet wrapped across the bottom of the foot and held with the hands.
Hip flexor stretch- while standing at the bottom of a staircase, place the lead foot two or three steps up. Keeping the back leg on the bottom with a slight bend in the knee, shift the weight forward to the lead foot to the point that you feel a comfortable stretch in the front of you trailing hip.
Cat Cow- a great way to stretch the lower back and get the thoracic spine moving throughout the entire pregnancy.
Pigeon- if you are unable to achieve or maintain this position, adding a firm pillow under the upper thigh of the back leg and buttock area of the front leg may be more comfortable.
Deep Squat- a great stretch for your hips and pelvic floor during the pregnancy. **Caution – in the third trimester, ask your doctor before trying this stretch as it may induce labor **
Remaining active will lead to a healthier and happier pregnancy. Keeping the posterior chain strong can ward off back pain for mom while exercise activity increases blood flow for the baby. Remember, it is important to always listen to your body and consult healthcare professionals when questions arise.
Thanks for reading!
-Dr. Jackie, PT, DPT, CSCS
R Artal, M O’Toole. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period.
Photos: FitPregnancy.com, tfwropestone.com, fusionwellness.com, themusicmommy.com, alimcwilliams.com, momjunction.com
Midline stabilization is heralded as the foundation of safe and successful weightlifting. But have we been ignoring a part of the “core”? The pelvic floor is a topic that tends to be avoided. Most people do not casually discuss urinary frequency over coffee or admit to their coach that they pee every time they perform double-unders. Men- if you think this one is just for the women, stick around!
I only realized the prevalence of leakage after CrossFit HQ posted a video following regionals. All of these women were saying “It’s ok, I pee during workouts too. It’s normal!” Please do not confuse normal and common. Urinary incontinence may be common in certain populations, especially of heavy lifters, but it is absolutely not normal.
The pelvic floor includes a group of muscles that attach from your coccyx (tail bone) and sacrum to your pelvic ring.
These muscles are important for bowel and bladder function, organ support, and stability of the pelvis. Although pelvic floor dysfunction (PFD) was thought to be largely a problem of women, it is becoming apparent that men have similar issues. The pelvic floor may seem very foreign and uncomfortable to discuss, but when it properly functions it can improve your workouts. Here’s how:
I like Mary Massery’s description of the core as a “soda-pop can”. The front of the can is the abs, the back is the multifidi, the pop top is the glottis and the bottom of the can is the pelvic floor. The core pressure is maintained by a functioning glottis and pelvic floor, with the diaphragm acting as a pressure regulator.
When you take a breath in, the diaphragm descends. This requires the pelvic floor muscles to descend and lengthen. When you exhale the diaphragm rises and the pelvic floor rises and tightens.
In fit individuals, (notice I said individuals and not just women), a common pelvic floor problem is overactive muscles. Very strong back or abdominal muscles can cause increased inward pressure. It’s been shown that when your deep abdominals contract, so does your pelvic floor.
Imagine squeezing the can from both sides with the pressure maintained. The bottom and top will have to withstand more pressure and bulge. If your abdominals are always squeezing in then your pelvic floor is always pushing up to withstand the pressure. It’s overworked! The diaphragm is pretty darn good at its job. If it does not work, we have a bigger issue on our hands.
So often, when something’s ‘gotta give’- it’s the pelvic floor. When all of these muscles work in concert, your canister and the force it can produce is maximized. Thus, your workout improves.
A conversation about breathing techniques regarding the glottis and diaphragm is essential to training the entire core. Here I am simply touching on one contribution but remember it does not work alone.
Keep in mind, PFD can also manifest in ways such as pelvic pain, painful intercourse, low back pain, urinary frequency or even the dreaded butt wink. It is not just urinary incontinence.
“ Pelvic floor pain is only caused by pregnancy, right?”
Wrong. There has been no correlation shown between PFD and post-partum women. Sure, some moms experience issues but again, it is not normal for any population. Weakness and/or tightness of the pelvic floor can be caused by poor postural habits, extended periods of sitting, over training of the abdominals and pregnancy. Excluding pregnancy of course, men are susceptible to all of the other risk factors.
“Ok, so I pee on myself at the gym and it’s not normal. What do I do to stop it?”
Thanks for reading!
Dr. Jackie, PT, DPT, CSCS
Sapsford, Ruth R, Hodges, Paul W. Contraction of the Pelvic Floor Muscles during Abdominal Maneuvers. Physical Medicine and Rehabilitation, 2001, Vol.82(8), pp.1081-1088.
Presentation at CSM 2016 by Mary Massery: referencing Massery 2005 & 2006.
Dr. Danny and staff's views on performance improvement, injury prevention and sometimes other random thoughts.