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
Whether you are looking to PR your squat, want to squat without pain or are just sick of nagging lower extremity pain—this is where the change needs to begin.
This week I posted a picture on social media of a patient who started the session with a squat that deviated to the right and then after some mobility she was centered. This started a lot of conversation from athletes asking for help with this exact issue. First, check out your mobility. Remember: symmetry is important in a squat so be sure to check both sides and compare!
Pain and dysfunction in the back, hip and lower extremity can absolutely be caused by a laundry list of issues, but sometimes we make it more complicated than it needs to be. The best way to begin to decrease pain and improve function is to find the low hanging fruit and start there.
At Athletes’ Potential we use a group of movements to screen every patient with lower extremity complaints. The last movement is always a body weight squat. Not because every patient we treat is a weightlifter and wants to improve their squat, but because it is a foundational movement that everyone should have the requisite mobility and strength to perform.
The first two places to look for a mobility restriction are the ankle and the hip.
A few indicators of ankle restriction during the squat often comes in two forms: the people that feel like they will fall backwards if their chest is up any higher (pic 1) OR those who look like they have a solid squat but on closer look, their ankles are collapsed and spin outward (pic 2&3).
Ankle dorsiflexion is essential to have a deep squat with an upright torso. The best way to check your own ankle mobility: place your foot a hand width from a wall (in a lunge position), with the foot in that position drive your knee toward the wall making sure that your heel stays down. Can it touch the wall? If yes, move on to checking hip mobility. If no, your ankles are limiting your squat!
Our favorite ankle mobility drill uses a band to distract the ankle and then move it through range. Check it out-- Ankle distraction and dorsiflexion
Ankles can be a frustrating joint to mobilize because they are slower to change. It is important to work ankle mobility into your warm up and/or cool down as much as possible! As you begin to chip away at ankle restrictions, check out this older blog post about the best way for you to modify a squat until your mobility is improved: Is squatting bad for my knees? Part II
To self-check hip mobility there are a two hip movements that are important to check- hip flexion and hip internal rotation. When you are missing hip flexion and/or internal rotation, there may be a pinching sensation at the front of the hip during a squat or you have a “butt wink” at the bottom. To check hip flexion, lay on your back and pull your knee towards your chest. Ideally, you will be able to get your knee about a fists width from your chest. As you apply overpressure with your hand, you might notice your pelvis start to lift off of the floor. This is actually lumbar flexion, which is synonymous with a ‘butt wink’. The athlete below is experiencing this a bit, I think he was trying to show off for the camera. ☺
When checking internal rotation, sit on a table or box so that your feet are not in contact with the ground. Internal rotation is the motion when your foot moves outward from your body when your hips and knees are bent. We like to see 40-45 degrees, as in the picture below. Be sure that as you rotate your hip, you don’t bring your booty off the table and lean to make it go further!
Lacking hip flexion? Here is a great sequence to work through-- Hip Flexion Mobility
Is your internal rotation less than ideal? Is one side much less than the other? Give this a try-- Anterior Hip Opener with Internal Rotation
Maybe you check all of these areas and you have the ideal mobility. What else could it be??
Really bendy athletes are on an opposite end of the spectrum from more immobile athletes. In fact, banded mobility and banded distractions won’t help you at all! If this is you—stay tuned for Part II that covers the limiting factor of the squat for flexible folks.
Thanks for reading,
Since “retiring” from volleyball, my fitness regimen now consists of weightlifting, rowing, body weight movements, running (let’s call it casual jogging), and so on. What are all of these movements missing? Rotation! I have become very strong in the sagittal plane—cleans, jerks, rowing, squatting, pull-ups. No wonder when I play a pick-up game, I am sore as all get out!
This one goes out to those athletes who continue to be competitive in overhead rotational sports. Tennis players, softball-baseball-volleyballers, I’m looking at you! You guys hang out in the transverse plane a lot so this is where you need strength and control. This is why shoulder and spinal rotation is so vital for power and longevity in your sport and how to begin to maximize your performance.
The Anatomy of Rotation
Rotation in the thoracic spine is normally about 35 degrees but can be difficult to differentiate from lumbar rotation. However, the bony structure of the lumbar vertebra allow much less rotation than thoracic vertebra so we will focus there.
The two major anterior rotators are the external and internal obliques. The external oblique (EO) attaches to the last 6-7 ribs, to the upper fibers of the serratus anterior and lateral fibers of the latissimus dorsi (on the right in picture). Due to these connections, you see how rotation strength would also affect shoulder stability. It acts to cause contralateral rotation; so the left EO turns your trunk to the right. The internal oblique (IO) acts to rotate the torso ipsilaterally, or to the same side (on the left in picture).
Another muscle group that we cannot forget about is the multifidi. These small muscles live on the posterior vertebra and have short connections at each level. Rather than acting as a strength muscle that creates movement, they are stability muscles that control rotation. So as my torso rotates left, my right side fires more than my left to control the amount of rotation allowed.
Training these muscles for strength and motor control are important to maximize power through rotation and decrease the rotational load on the lumbar spine. Rotation at your hips, trunk and then arm are the secret to a powerful throw/swing and minimize damage at these joints. If your thoracic spine is not mobile, the hips and shoulders will take the brunt of the force. This often results in early rotator cuff damage and impingement as well as issues up and down the kinetic chain in the elbow, back, hips and knees.
Spinal mobility and strength is the foundation of overhead sports.
Check your thoracic mobility: kneel on the floor, hands and knees. Put one arm behind your head and then rotate your shoulder and torso on that side up toward the ceiling. How far do you get? For an overhead athlete, it would be ideal that you elbow and shoulder could be straight up. Be sure not to just crank your elbow back, its more about the thoracic spine and shoulder position!
“Wow, people can really rotate in this position?”--if that’s you, then it’s time to begin some thoracic mobility work! Check these out:
Better Upper Back mobility: This one is great for those who sit the majority of the day or who tend to have poor posture (that should have covered 98% of us!) All you need is a double lacrosse ball or Yoga Tune Up balls like those that Danny has in the video.
The thoracic rotation mobility drill is great to perform as part of a warmup. Beginning in position A, take a deep breath and open up the shoulders, lowering the top shoulder down towards the floor to reach position B. On exhalation, try to sink further into the stretch. Stay there for about 5 seconds then back to A. Move through this with your breath 10 times in each direction.
“That was easy!”—if you said this then let’s focus on your strength and control. Try these versions a Pallof Press. This exercise as described in the video is great for anti-rotation. The picture depicts another form that works on anti-extension. Just be sure that when you move your arms overhead, your ribs remain stacked above your pelvis. We want to avoid overextension of the back and the ribs poking forward. What I mean by “anti-“ exercises is that you are resisting the band tension that is trying to pull you into rotation and extension, thus working the muscles we highlighted earlier.
As I mentioned before, thoracic mobility and torso strength are just the beginning to a successful and long career as an overhead athlete. Hip complex rotation and shoulder rotation will be highlighted in later posts! But for now, it all starts here!
All of this overhead sport talk has me missing volleyball. So for that, here’s a #ThrowbackThursday.
Thanks for reading!
This used to be me, minus the 16 year old Asian kid part.
Like most kids in the United States, sports were a huge part of my life growing up. If you would have asked the 10-year-old me what I wanted to be when I grew up, it wasn't a physical therapist, it was a professional baseball player (that obviously didn't happen).
When I do look back on my athletic career (I guess you could call it that), it's riddled with injuries. Here's a list of the major injuries I have sustained playing sports to include, football, baseball, basketball, soccer and dabbling in military combatives.
-Broken right ankle at the growth plate age 15.
-Non-contact related right meniscal tear requiring surgery age 16.
-SLAP labral tear right shoulder age 18.
-Torn disc lower back L4-5 causing nerve root compression for 6 months age 24. (High volume deficit dead lifts with poor technique, my own damn fault)
-Torn disc neck C5-6 causing nerve compression for 3 months age 26.(Army combatives, accidents happen)
Looking back all the injuries that I have sustained it's a fairly long list. Some people would say that I'm injury prone, others may blame it on my genetics. I blame it on my horrific lack of mobility!
When I was in elementary school, I can remember taking the President's Physical Fitness Test. It was a big deal to me back then, mainly because I was sure I would be a professional athlete one day. I did great on all of the events and went into the last event with my confidence at an all time high. The last event was the sit and reach and I failed it! I could not for the life of me reach forward and just touch my damn toes. I was an emotional train wreck, my whole life revolved around sports and I couldn't even pass a national standard. That's a tough pill for a 10-year-old to swallow.
I think back to that test and I think of something different that could have come out of that. An educator, my parents or a coach could have seen that as a red flag or a warning sign. Sadly, the reality is that mobility is often overlooked and brushed aside as just being "tight". If you are making all-star teams and progressing in your athletic skill sets, who cares if you are a little on the tight side, right? Wrong, that's a big mistake and it needs to change.
We as coaches, parents and physical therapists have to prioritize movement first. That comes down to two components, motor control and mobility. Motor control is the ability to perform a movement correctly aka technique. Mobility is having enough available range in your joints and tissues to perform that movement optimally and safely. You need both to have proper movement, one without the other is worthless.
For me, mobility was my greatest obstacle to achieve better movement. Working on mobility sucks! I know, both as an instructor and from personal experience. Shit, two years ago I couldn't even touch my toes and now I teach Movement and Mobility courses across the country. It's very humbling for me to teach these courses for CrossFit and it's because I know first hand how much it can change people's ability to perform at a high level and stay injury free. Since adding MWOD concepts into my training I have not been injured once. I did get hit in the face with a surfboard that broke my nose a couple years ago but no amount of mobility/technique would have changed that. Some injuries are unavoidable but they are very rare.
Here's my advice for all my CrossFit athletes in Atlanta. If you suck at something, you need to focus on trying to improve that weakness everyday. This is not what most people want to hear. If you're flexible, you will enjoy yoga. If you're strong, you will enjoy powerlifting. The reality is, that super flexiblity yoga practitioner would benefit a hell of a lot more from doing some heavy squats than working on her pigeon position.
Find your flaws, chase them down, go for the throat and don't let go until your weakness becomes an asset!
Often times, external rotation is the focus in athletic movements. When the shoulder is externally rotated, it can be packed into the back of the capsule to improve stability and congruence. It also rotates the humerus in a way that the anterior structures of the shoulder have room to move without being pinned between bones. Many of the stretches people gravitate towards for the hip involve external rotation: sitting figure 4 stretch, pigeon, etc.
What is internal rotation and why do I need it?
Internal rotation is one of the movements of a ball and socket joint, such as the shoulder and hip. In the shoulder, it allows you to reach behind your back and pull your wallet from your back pocket or tie your bikini behind your back. More importantly for athletes, it allows you to keep the bar close to the body during Olympic movements and arrive at the bottom of a ring dip safely. Hip internal rotation is needed for athletes for proper biomechanics during any form of a squat or while running. Without full internal rotation, you will likely have a “butt wink” or your low back will slightly round at the bottom of the squat. It is also important for runners to have full internal rotation, coupled with extension, to allow correct biomechanics in the trail leg.
During internal rotation, the ball of the joint (humeral head and femoral head) will glide posteriorly and roll anteriorly. This movement can be restricted with a tight posterior capsule or muscles around the joint. Unfortunately, many people will have issues here due to increasingly sedentary lifestyles and desk jobs. As you sit all day, the hip rarely reaches full extension, allowing the posterior capsule to become tight. This in turn decreases the posterior glide and thus decreased internal rotation. The same deal happens at the shoulder when you sit all day at the computer with terrible posture.
Interestingly, hip internal rotation deficits have been correlated with low back and sacroiliac pain. It is better to start improving internal rotation now rather than trying to manage back pain!
How to check internal rotation
It is easiest to accurately check internal rotation of the shoulder with a buddy. Lay on your back, arm straight out to the side and elbow bent (as in the picture below). Your buddy should provide solid but comfortable pressure to the front of your shoulder to avoid it from raising off of the ground. Now move your palm down towards the ground. Ideally, you would be able to get at least a fists-width from the floor! Be sure to check both sides because noting an asymmetry is important. Also, be sure to do this same test after practicing the mobilizations below!
To check hip IR, lay on your stomach and allow your feet to drop out to the side. Again, we are looking for asymmetries and major deficits. Ideally, your leg will move about 40 degrees or roughly halfway down toward the floor.
Mobilizations to Improve Internal Rotation
Below are a few mobilizations for the shoulder and hip to improve internal rotation. They are by no means an exhaustive list but merely a starting point.
Bully stretch- used to mobilize the humerus into the back of the shoulder capsule, which increases internal rotation.
Pec smash- nearly everyone has a tight pec minor due to the poor postures we often keep throughout the day. This muscle is located in the front of the shoulder, so if it’s tight it can easily restrict the posterior glide!
Internal Rotation Stretch- start with your foot flat on the ground and the other leg crossed over. Slowly walk your foot out to the side until you feel a strong but comfortable stretch in the hip. You should feel this in the bottom leg.
Lateral Hip Opener- this does not have to be banded if you do not have access to one, you will still feel a stretch!
I hope this gives you a better understanding of what internal rotation means, how we achieve it and why it is needed. More importantly, I hope these videos give you a good idea of how to begin to manage internal rotation deficits!
At Athletes’ Potential we want to help every athlete remain healthy and meet goals. You don’t have to be in pain to come see us. If you find asymmetries with tests such as these or know you have movement deficits, we can help you with proper movement and self-maintenance. We also have recovery options to further augment your fitness and health. We look forward to hearing from you!
Thanks for reading,
If you're in Atlanta and you have questions about our Physical Therapy or if you're frustrated with your current situation, contact us and let us help you!
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, DPT
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
Flexibility is an important aspect of fitness, along with muscular strength and endurance, and aerobic capacity. However, it is not uncommon to find athletes who are unable to bend over and touch their toes! This is most likely due to sitting most hours of the day and attempting to reverse the changes by ten minutes of stretching at the gym.
In the past decade, there has been much discrepancy in recommendations about stretching: how long, what kind, which muscles? Does it depend on your sport of choice? Before or after a workout?
There have been countless studies published, even in the past year, with varying results. However, they all agree on one thing: Do not perform static stretches prior to exercising.
Static stretching alters the (microscopic) length of the muscle which can alter, and likely decrease, its firing potential. Stretching may also activate tendon structures that inhibit muscle action. Both of these proposed mechanisms will decrease power output.
“Then how should I warm up?”
Warm-ups are essential to performance and injury prevention. They are useful for increasing the core temperature to decrease stiffness of muscles and alerting the neurologic system to the events about to take place. This should be achieved with specific, dynamic exercises rather than static stretches or laying on the foam roller.
Runners—Studies found that a dynamic warm-up increased performance of endurance runners, meaning they ran longer without exhaustion1. This warm-up consisted of movements such as high knees, butt kicks, leg swings and hopping. Total time: 4 minutes.
Notice, I said nothing about running. Those athletes warming up with running had comparable results to those not warming up at all. Check out Dr. Danny’s post specifically addressing running warm-ups.
Weightlifters—Other studies found that just ONE set of static stretches decreased 1RM performance by 5.4%2. That would decrease your 400 lb back squat by 21.6 lb!
When performing sets for reps, static or ballistic stretching decreased amount of reps by 17-20%3. That’s 2 less reps in your 10 rep set. The most effective was a specific warm-up of 20 reps around 30% 1RM, then appropriately building to working weight.
For Olympic Lifts, additional dynamic warm-ups may be warranted, specifically for the overhead movements. One of my favorite drills is thoracic rotation4, performed in between light warm-up sets:
CrossFitters—You fall somewhere in between; Choose your warm-up type based on the workout of the day. The same theme holds true: specific, dynamic warm-ups!
Sport-Specific Athletes—Dynamic, sport specific warm-ups are the most effective to prepare for practice or competition. This includes running, cutting, jumping, ball handling, throwing or whatever your sport demands. Begin at a slower pace and then work up to competition speed movements.
Your workout is over, you ran your fastest 5K, PRed your back squat or scored the winning goal... NOW you stretch.
To address the earlier question: When, how long, what kind, which muscles?
To receive any benefit, hold static stretches for at least 30 seconds but 2 minutes may show better results. Static stretches can work but they take a few weeks for sustainable differences.
PNF (proprioceptive neuromuscular facilitation) stretches have been shown to be superior to static stretching. These can be done with a buddy or by yourself using bands or straps. A common form of PNF to increase range of motion is contract-relax. You have likely seen it before:
This would also be the appropriate time to work with the foam roller or PVC pipe on the muscles that are sore or may be lacking flexibility.
Of course, the cartoon at the top is wrong. Touching your toes IS everything. Every athlete should have the flexibility to bend over and touch their toes whether or not they are warmed up. Inefficient muscle length can lead to compensation by other muscles. This causes joint pain, tendonitis, faulty movement patterns, poor form and then decreased performance or injury. Stretching is also great to incorporate into rest days. A light warm-up, then your favorite stretches or maybe your least favorite if you have some restrictions.
Self-management is 100% possible when it comes to flexibility and recovery! Take the time to take care of your body and it will perform better. Remember, at Athletes’ Potential you can supplement your stretching and take recovery to the next level with full-body cryotherapy and NormaTec compression boots. Call us anytime to schedule an appointment!
Dr. Danny and Dr. Jackie's views on performance improvement, injury prevention and sometimes other random thoughts.