By Natalie Sterner, PT, DPT
Running is a common activity that many women and men enjoy daily. Frequent runners typically have a pre and post workout regime consisting of stretching for hip and knee musculature, foam rolling, and even icing in order to reduce pain and inflammation in various joints or muscles. One thing that is often left out of these routines is the pelvic floor – a vital component in core stabilization and injury prevention with exercise, particularly running. Many runners will seek out treatment for common orthopedic issues – plantar fasciitis, hip pain, ITBand dysfunction – which may be stemming from the pelvic floor and will not see complete results with therapy due to only being given “core” exercises without addressing the pelvic floor as well. Statistics show that at least 1 out of 4 women report having one or more pelvic floor related disorders such as urinary/fecal incontinence, pelvic pain, and pelvic organ prolapse (POP). A study by Thyssen in 2002 found 44% of young female athletes leaked during sports.
The pelvic floor is just as important as our other external musculature in proper running mechanics. The pelvic floor is part of the deep core muscles which are our anticipatory muscles. They stabilize our body by contracting prior to movement. Other muscles in this group are the transverse abdominus, multifidi, and diaphragm. The pelvic floor works during both phases of running. During the flight phase it works eccentrically or lengthens. During heel strike of the stance phase the pelvic floor and deep core muscles work concentrically meaning they shorten to allow for stability. Thus we need the full range of the pelvic floor for optimal mechanics during running.
Pelvic floor dysfunction can present in various signs/symptoms. Some common dysfunctions found in athletes/runners are listed below:
- Urinary/fecal urgency: This symptom is often caused by myofascial trigger points within the pelvic floor muscles which triggers neurogenic bladder symptoms. These trigger points can become active during running and lead to the feeling of immediate voiding! This can be extremely frustrating for runner who may limit their paths or routes to make sure a bathroom is close by or even needing to stop mid-run to not lose urine or feces.
- Urinary/fecal incontinence: Urinary or fecal leaking can be a very common occurrence with runners. In a study by Leitner in 2016, it was found that 41% of female athletes have experienced urinary leaking with running. This can range from a small dribble to fully soaking through leggings and running down legs. Running is very stressful on the pelvic floor muscles that work to support all the pelvic organs while maintaining continence. If leaking occurs, the pelvic floor is not able to tolerate this pressure. This could be caused by myofascial trigger points, muscle weakness, and/or decreased coordination.
- Pain: The pelvic floor muscles work just like any other muscles – they contract and relax and can become tight or weaken. Pelvic floor muscle trigger points can develop as well if not allowing lengthening to occur in the muscle. Common pain referrals from the pelvic floor are the lower abdomen, hip, buttock, posterior thigh. Pain may also be coming from external hip muscles as well. The adductors, our inner thigh muscles, can also refer pain to the pelvis. It is important to have both strength and flexibility in all of these muscle groups.
- Heaviness or pressure: This can be a potential sign of pelvic organ prolapse (POP) which is the downward descent of the pelvic organs. This can involve the uterus, bladder, and/or rectum. The pelvic floor muscles need to provide enough support with the increase of intra-abdominal pressure that occurs during running. If there is weakness and not enough support, this can lead to pulling on the ligaments and connective tissue leading to possible prolapse.
What can we do to ensure that the pelvic floor is working appropriately to reduce the risk of these symptoms? Breathing is the first step. When exercising we want to ensure that the diaphragm is moving properly. When we inhale the diaphragm should move down into our abdominal cavity allowing the rib cage to open and the belly to expand rather than just breathing using our chest. This will allow the pelvic floor and transverse abdominus muscles to lengthen. During our exhalation the diaphragm moves upward as the pelvic floor and transverse abdominus return to their prior position. The diaphragm and pelvic floor muscles move in tandem like a piston and generate good tension in the trunk which creates more stability while we run. Coordination of this is important.
Try not to hold/grip the abdominals or pelvic floor. This will limit trunk rotation and the ability to use the abdominals effectively. Same with the pelvic floor – there needs to be some absorption of pressure and holding can lead to overactivity of the muscles. We want all of the deep core muscles to work together in balance.
Posture is important for running as well. Proper running posture consists of leaning over so that your rib cage is on top of your pelvis in order to keep your head looking forward. This will allow better mobility through the hips and will keep your body over your heel as you land reducing the pressure through the body. Increasing your cadence, the number of steps you take per minute, can also decrease the forces through your body leading to less impact through the pelvic floor as well.
Making sure that your body is taken care of while doing what you love to do is important so that you can keep doing it! The demands of running are intensive and repetitive. It is important to specifically train the pelvic floor to meet these demands just as you would strengthen your back, hip and knees for fitness. If you feel you are having any of these issues the pelvic health therapists at Pelvic Health Solutions can assess you individually and work with you to continue with the sport that you love to do!
Leitner M, Moser H, Eichelberger P, Kuhn A, Radlinger L. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurology and Urodynamics. 2016;36(6): 1570-1576. Doi:10.1002/nau.23151
Thyssen HH, Clevin L, Olesen S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J Pelvic Floor Dysfunction. 2002;13(1):15-7.
By Natalie Sterner, PT, DPT
Interstitial cystitis (IC) is a chronic pain condition that affects more than 12 million Americans. It is typically 2-3 times more common in women than in men and research has shown the risk of IC increased with age. IC is characterized by both pelvic pain and urinary symptoms. Patients will experience sensations of pain and pressure in the bladder area as well as lower urinary tract symptoms. It is typically diagnosed by unexplained pain and ruling out other health conditions that may cause similar symptoms. 85% of people with IC also have pelvic floor dysfunction.
Pain is often the most common sign along with pressure of the bladder. The bladder pain may increase as the bladder fills. Pain may also be experienced in other areas of the pelvic region and low back. The muscles of the pelvic floor attach to the front (pubic bone), back (tailbone), and sides of the pelvis and help to support all of the pelvic organs as well as coordinate between contraction and relaxation to allow for proper bladder and bowel function. Often times with IC, these muscles are tight or in spasm which causes trigger points to develop. Inflammation will arise and persist due to the chronic nature of IC. Muscle tightness, trigger points, and inflammation can irritate the nerves that run through the pelvis and refer pain to other areas such as pelvis, thighs, buttocks, lower abdomen, and perineal area.
Frequency of urination is also a common symptom with IC. Typical daily voiding ranges between 5-7 times a day with no night time voiding. A patient with IC will go the bathroom to urinate more often during the day as well as at night. This can also lead to urinary urgency. Some patients will feel the urge to urinate that does not even go away after they have voided. Other symptoms that may occur with IC include burning with urination, pain with intercourse, difficulty starting/maintaining urine stream, and constipation. Symptoms may be exacerbated by various reasons. Certain foods or drinks, such as spicy foods or caffeine, may be more irritating to the bladder. Stress both physical and mental can be an irritating factor. Some women may notice symptoms vary around their period as well.
Only a fraction of patients with the key symptoms of IC (urinary frequency, urgency, and pelvic pain) have ulcers within the bladder (Hunner lesions) and many are found to not have any sort of bladder pathology at all. Thus the muscles of the pelvic floor as well as external hip/pelvic musculature are important to assess as they may aide with decreasing and managing symptoms related to IC. The American Urological Association has given pelvic floor physical therapy a grade “A” and is recommended as the first line of medical treatment for IC. Other bladder treatments and oral medication are often needed to be continued indefinitely to provide benefits if they work. Physical therapy can provide lifestyle changes and techniques for sustained relief. One study in 2013 showed that 63% of patients had significant pain improvement with pelvic floor physical therapy.
As always, a thorough initial evaluation would be completed prior to beginning treatment as everyone is individual. This would include both an external assessment of the hip/pelvic/back muscles and an internal assessment of the pelvic floor muscles. The goal of physical therapy is to restore normal function of the muscles, prevent irritation of the nerves that cause pain, and clearing inflammation from the system. Release of trigger points in the tightened muscles helps to clear inflammation in the fascia which can restore better blood flow and reduce reoccurrence of trigger points. This can help with disrupting the nervous system’s pain feedback loop. Other treatments include relaxation of the pelvic floor and hip muscles and education for self-care at home such as deep breathing, stretching and self-release of pelvic floor muscles.
Our skilled therapists at Pelvic Health Solutions can evaluate and provide individualized treatment plans for patients with IC. For more information on chronic pelvic pain or other pelvic dysfunctions, call us at (561)899-7747.
Bedaiwy MA, Patterson B, Mahajan S. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med 2013; 58: 504–510.
By Katie Usher, DPT
Diastasis Recti is a term used to describe separation of the abdominal wall muscles that typically occurs during pregnancy. Abdominal muscles are made up of 4 muscle groups. From superficial to deep, they are named rectus abdominis, external obliques, internal obliques, and transverse abdominis. These muscles, under normal circumstances, meet in your midline called your linea alba. During pregnancy, these muscles are stretched laterally as the belly grows to make room for baby, which is completely normal. In fact, there is recent research that sites that 100% of women will have some sort of diastasis by 36 weeks of pregnancy. This separation can become problematic on the postpartum side if the tissue doesn’t heal appropriately and continues to stay separated.
Our abdominal wall functions to hold in intestinal contents and stabilize the body during movement. It is also part of our core, along with our diaphragm, pelvic floor and back muscles. If there is dysfunction in the abdominal wall, it can lead to problems such as umbilical hernias, pelvic floor dysfunction, breathing problems and poor movement strategies.
When a health professional assesses for diastasis, they will ask the person to do a partial curl up off the surface. The practitioner is looking for any doming or dipping through that midline tissue called the linea alba. They measure the width and the depth of the tissue using their fingers to assess the severity of the separation. Typically, they will then ask the patient to engage through their transverse abdominis and retest to see how well the abdominal wall can produce tension.
If there is a diastasis present, physical therapy is typically indicated. Therapy options include manual therapy to promote bringing the tissue back towards midline, education on proper engagement of core muscles, education on proper breathing mechanics, and instructing the patient how to properly recruit the muscles during functional movement. We also provide education on exercises and movements to avoid that may increase the intra-abdominal pressure and strain through the abdominal tissue. The biggest indicator for improvement is the ability to correctly produce tension through the core, as the tissue will often remain separated. In some rare and severe cases, surgery may be indicated.
If you feel you have a diastasis recti, you should be evaluated by an appropriate health care provider. It is important to know there is something you can do to help yourself. Our experienced and well trained pelvic health physical therapists here at Pelvic Health Solutions are available to treat any issues with diastasis recti.