September 10 2018
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As a pelvic floor physical therapist, I often see athletes who struggle with pelvic pain. This pain can be debilitating, causing some to leave the sports they love. Pelvic pain presents itself in a number of ways, such as pubic bone pain or pain in the vagina or rectum, but it can also masquerade as low back pain, hip pain, glute pain or groin pain. Fortunately, the source of these ailments is often treatable. Having a better understanding of what can contribute to your pain as well as how to manage it can make all the difference.
Pelvic pain is often elusive, presenting itself differently from person to person; this makes diagnosing the source of pain challenging. As a result, athletes often seek treatment that appears unsuccessful.
A case study written by Podschun et. al. in 2013 demonstrates this very struggle. The article describes a 45-year-old runner who had been sent to physical therapy with hamstring pain, which had begun several months earlier. This pain not only forced her to stop running, but also made it difficult for her to sit for extended periods of time. She was diagnosed with bursitis and hamstring syndrome and underwent physical therapy treatment focused on strengthening her glutes, improving her posture and educating her on movement patterns. Despite weeks of this, her pain did not abate. A reassessment of her pelvic floor led to a diagnosis of pelvic floor hypertonic disorder, or tightness in her pelvic floor muscles. Following physical therapy treatment for the tension in her pelvis, she returned to running and sitting, pain-free.
This is exemplary of many cases that I see. Your pelvic floor is a group of muscles that stretches from your pubic bone to your tailbone, and from sit bone (ischial tuberosity) to sit bone. This group of muscles can affect the mobility in your hips and your lumbar spine, as well as the strength of your core.
If these muscles are tight, or spasmed, they can cause pain. This pain can present in any of the regions previously mentioned. To understand this better, I like to use the example of a fist. If I clench my fist tightly for hours, eventually my fingers will hurt, my wrist will hurt, my forearm will hurt and so on. But because I can see my fist, I can recognize that clenching my hand may be causing pain, and I can stop clenching. We don’t have the same luxury in our pelvic floor; we cannot see these muscles, and often times we don’t realize we are holding them in a contracted state. Because these muscles contribute so much to our strength and stability, we contract them throughout our day and even more frequently while performing our sport. This lack of awareness and tendency to contract subconsciously can lead to a cascade of pain in a number of places.
Exercise is great for the body. If done correctly, it can make our muscles and bones stronger, give us more energy, make us happier, help promote weight loss—the list goes on. If done incorrectly, unfortunately, it can hurt.
In order for muscles to be strong and functional, they first need to be flexible. This is called the length-tension relationship. If your muscles are spasmed, they may not be capable of giving you the kind of support you need. In part, this is why stretching after exercise is important. The trouble for the pelvic floor is that most of us don’t know how to stretch it or notice that it is getting tight.
When we exercise we co-contract multiple muscle groups. In the case of running, your pelvic floor is actually contracting alongside your quadriceps, hamstrings and glutes. Additionally, muscular guarding during sports is very common. Our bodies use muscular contraction to protect themselves from impact and pain, and over time this chronic tensing can lead to shortened muscles. This can make achieving a completely relaxed state much more difficult for the body, leading to discomfort.
It’s easy to picture this when you think of a “tight” hamstring. If you don’t stretch the day after a long run, you can expect to feel tight the following morning when you wake up. The next day maybe you’ll do some gentle stretching or go to yoga and feel like a new woman afterwards. When our hamstrings are tight, it can make running and our regular movements uncomfortable. We need to stretch, frequently and consistently, to achieve any long lasting change in muscle length and comfort. The pelvic floor is no different.
The difficulty with the pelvic floor is that these are muscles that we can’t see or touch, and often times we lack control of this area. These muscles are also locked in your bony pelvis, meaning available stretches are even more limited.
Some options for gentle relaxation of the pelvic floor include common yoga poses such as child’s pose, happy baby pose, and deep gorilla squat. Deep belly breathing in these positions will further enhance the stretch. However, these stretches may not be enough. If you feel like your pain may be stemming from your pelvis, consider seeing a pelvic floor physical therapist.
A pelvic floor physical therapist will be able to assess what is happening with your pelvic floor. Are your muscles tight or weak? The physical therapist will be able to guide you through exercises that work best for you specifically to help manage your pain.