Pelvic Floor: The Truth is Out There

By Guest Ninja Ann Wendel, PT, ATC, CMTPT

Hello, growing Ninja Army!

The pelvic floor is having a moment in the health and fitness world. While I couldn’t be happier that issues south of the belly button are finally getting some attention, I have to point out that not all information on the Interwebz is accurate. Just this week I was alerted to this article on the website for the National Association for Continence. I had high hopes as I saw the title, “Integrate Kegels into Your Daily Workout Warmup.”  While pelvic health physical therapists don’t typically use the word Kegels any more, it’s a word that the general public recognizes, and I was excited that someone was talking about how to incorporate the pelvic floor into activity. The article started out just fine, stating, “Whether you’re jogging, running, hiking, biking, or playing a contact sport, warming up is crucial to your exercise plan, so why not incorporate Kegel training into your daily routine to help strengthen your pelvic floor muscles?”A few weeks ago, Mark sent me an email to ask if I would speak to you on a topic about which I’m very passionate: pelvic floor dysfunction. If you’ve been following me in social media or online, you know that I am a physical therapist whose mission is to empower you to live an amazing life. I have a special interest in how the deep central stability system of the body provides the foundation for movement and continence. I touched on this issue here, in a guest post back in 2013. Today, we’re going to delve deeper into the topic, because wearing a big old pad to workout is not sexy.

Unfortunately, the article went downhill from there, as it proceeded to state that you should “walk for 3-5 minutes and then take a break and do 10 pelvic floor holds” and “do jumping jacks for 30 second intervals, practicing 10 Kegels between intervals.” At that point, I had a moment where I got that look on my face like, “Whatcho talkin’ bout, Willis?” It seems that we have a long way to go to educate folks about how the pelvic floor muscles work as a part of the deep central stability system. So, let’s start at the beginning.

What Are We Really Talking About Here?

Leaking urine during exercise (called Stress Urinary Incontinence or SUI) iscommon, but not “normal.” In the U.S., the national average of women who experience incontinence is 1 in 3. Incontinence is very prevalent in the athletic community, yet most women do not seek treatment because they are either embarrassed or they assume it’s normal because everyone else they know has the same issue.

Leaking urine is a sign that the whole system is breaking down, and the pelvic floor is just the place it shows the most at the time. SUI is only one way that pelvic floor dysfunction may show up. Other clues are: low back pain, hip pain, pain in the buttocks, or pain in the pubic symphysis (where the pelvis joins together in the front). Although pelvic floor issues tend to be more common in women, men struggle with these issues too.

Taking Stock

As part of my initial evaluation, I ask every woman if they ever experience any incontinence. Over half of the women will say no, until I press, and then they admit that they do. What they don’t understand is that pain in the knee may be related to weak and/or uncoordinated pelvic floor, diaphragm and hip muscles. Chronic groin strains, IT Band Syndrome, Trochanteric Bursitis, low back pain and Patellofemoral Syndrome are a few of the common diagnoses that female patients seek treatment for – an integrated approach is necessary to identify the root cause of the issue and to successfully treat the problem.

If you experience incontinence with running, box jumps, deadlifts, or double unders, STOP. Seek help from a qualified women’s health physical therapist, even if your GYN states that you don’t need physical therapy. Be an advocate for yourself and seek treatment. The Section on Women’s Health of the American Physical Therapy Association has an index of providers.

There are many factors that can lead to SUI and/or pelvic pain, including weakness of the pelvic floor muscles, overactive (hypertonic) pelvic floor muscles that cannot generate a good contraction because they can’t relax, and uncoordinated contractions of the diaphragm, pelvic floor and deep abdominals.

Seeking Qualified Help

It is important to work with a therapist who can evaluate your specific condition and treat you with appropriate exercises and manual techniques. The answer to pelvic floor issues and SUI is not always “more Kegels.” If the muscles are hypertonic or the issue is with breath holding, Kegels in isolation won’t solve the problem. Central stability (commonly called core stability) requires a balance of muscular strength and a neuromuscular strategy for engagement to meet physical demands. The respiratory diaphragm, deep abdominal muscles, spinal stabilizing muscles and pelvic floor need to work perfectly together while we do functional activities.

Helping women (and men!) with pelvic floor dysfunction often requires a team effort. Women and men with SUI/pelvic floor dysfunction need to seek treatment. I encourage anyone with these issues to have an evaluation with a gynecologist/urologist and/or a physical therapist specializing in pelvic health. Through evaluation, we can identify what is causing your issue and work with you to treat it.

We know that for any muscle in the body, there is an optimal length/tension ratio; the pelvic floor muscles are no different. We also know that a muscle needs to relax fully in order to then generate a strong contraction – we wouldn’t walk around with our biceps flexed all day, so the notion of constant firing of the pelvic floor (Kegels all day long) or “sucking your belly button to your spine” is incorrect.

Exercises and Strategies

Constant tension in the pelvic floor muscles is just as problematic as weak muscles. Learn to completely relax your pelvic floor. I teach my patients to develop a strategy where the breathing is coordinated with the pelvic floor.

Prior to starting this exercise, be sure that your ribs are lined up over your pelvis and your head is in a neutral position as you stand (use a mirror or have a partner watch you). When you inhale, your belly and pelvic floor should be relaxed. As you exhale, pretend you’re fogging up a mirror with your breath, making a gentle “haaaaaa” sound. You should feel your deepest abdominals firing gently and your pelvic floor slightly lifting when you exhale this way. Practice this until you can feel both the relaxation and the contraction of the abdominals and pelvic floor.

As you start to feel the way the whole system works together, you can try this breathing strategy in different positions with different exercises. Try it in sidelying with a clamshell – begin to exhale gently as you lift the top knee, then relax and inhale as you let the knees come back together. Try it in supine as you do a bridge.

Bodyweight squats with integration of breathing and relaxation of the pelvic floor muscles can be done daily, several times a day even. Just inhale and relax the belly and pelvic floor as you sit, then exhale and lift through the pelvic floor as you stand (same breathing pattern as you would use for a squat, you’re just bringing in the extra awareness of the pelvic floor).

Once you can successfully use this strategy, then you need to integrate the motor pattern of being relaxed on inhale and contracting the pelvic floor on exhale into your functional activities – lifting children or lifting heavy bags of dog food, etc. For some women, strength may show a measurable increase after several weeks of training (provided that the correct techniques are utilized – this is where evaluation by a professional comes in to play).

With treatment, you will be able to get back to doing the things you love to do; but, for now, please avoid the exercises that cause the leaking to occur. Training your pelvic floor is just like beginning any other exercise routine: you need to start by building a strong foundation and then progress appropriately. Take the time to have a thorough evaluation and work with a women’s health physical therapist to develop the correct personalized plan to treat your specific issue. We will give you strategies to use during your workouts so you can PR all over the place (instead of peeing all over the place!) and we’ll have you back to wearing those booty shorts in no time.

Ann Wendel, PT, ATC, CMTPT

Ann holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT).

Over the past two decades, Ann has continually developed as a health care professional. She started her career working with high school, college and professional athletes, and later went on to work at an area hospital treating patients with a wide variety of Orthopedic and Neurological conditions.

Ann received her CMTPT through Myopain Seminars in 2011 and now utilizes Trigger Point Dry Needling as a treatment modality, along with Pilates, weight lifting, and nutrition/lifestyle consulting.  Ann owns and operates Prana Physical Therapy in Alexandria, VA. She can be contacted through her website:


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