You don’t have to be a runner to have pelvic floor dysfunction but runners are more prone to pelvic floor dysfunction. The reason is that all parts that are involved with the pelvic floor or influence the pelvic floor area are heavily used when running. Think about it, pelvic floor muscles are like a hammock attached to the pelvis which includes the ilium and sacrum. The spine at the lumbosacral area and the hips are attached to the pelvis and therefore any issues related to their functionality directly impact the pelvic floor muscles and contribute to potential pelvic floor dysfunction.

What is Pelvic Floor Dysfunction?

Pelvic floor dysfunction can show up in different forms but unfortunately, we live in a society that instead of looking at the person as a whole, we tend to ‘chop’ people into pieces with each piece given to a different specialist to treat. These symptoms are like different chapters of the same story and should not be looked at as separate stories by themselves.

Pelvic Floor Dysfunction can show up as:

  • Urinary incontinence
  • Fecal incontinence
  • Hemorrhoid
  • Pelvic pain
  • Painful intercourse
  • Lower back pain
  • Sacro-iliac joint pain
  • Hip pain
  • Weak abdominals
  • Weak lower back
  • Forward posture
  • Side to side sway of the pelvis in walking or running

It contributes to knee pain, ankle issues, and even plantar fasciitis given that failed or dysfunctional posture is the ‘feeder’ of these problems.

It is important to realize that weak pelvic floor muscles are a part of pelvic floor dysfunction so it is possible to have no incontinence or pelvic pain and still have pelvic floor dysfunction.

Basic Facts of the Movement Apparatus in Runners

My specialty is postural neurology and neuro-kinesiology: the neurology and mechanics behind posture and movement. When I watch people run, I don’t see them only run! I analyze their run and try to predict what sort of problems are present, or they may be encountering in the near future. To get into this more in-depth, we need to go over certain anatomical parts and muscle fiber types.

We are going to divide the body into 2 parts:

  1. Stabilizers: Your stabilizers are the muscles that comprise your body excluding the arms and legs. So imagine a rectangle that is consisted of the top (the line connecting the shoulders to each other), the bottom (line of the hips to each other), and the shoulders to the hips being the sides. Of course, there is a front, back, and sides to this so it is more of a rectangular cube that we are talking about. Your neck is now connected to it and it should be looked at as if it is a part of this rectangle.

Stabilizer muscles are the type of muscle fibers that don’t fatigue easily so they can do their job for much longer. The muscles of your body (excluding your arms and legs) are responsible for that portion of your body and are well equipped to do an amazing job. The problem arises when they are used to facilitate movement in the arms and/or legs. A great example is when I ask patients to move their shoulder blade back and they stick their chest out or ‘shove’ their arm back in the socket to move the shoulder joint back! Pay attention to this video to see what I am talking about.

2. Extremities (arms and legs):

This is self-explanatory but one thing to know is that the type of muscle fibers of your extremities is fast-acting, precise but easily fatigued. That is why for instance you play darts with your arms. When it comes to running, our conditioning and training is to increase the strength in the muscles to run faster and not get tired.

In many instances, when rehabbing a runner, I can see how despite a ‘flat’ stomach, the lower ab is weak. That means to stabilize that portion of the spine and pelvis, the hip flexors will have to pick up the ‘tab’ to stabilize that corner of the rectangle example I gave above. So when the same muscles are to run AND to stabilize, we end up with a problem and the beginning of a decline that collectively is referred to as pelvic floor dysfunction as an example.

Pelvic Floor Dysfunction Signs in Runners

  • Too much rotation of the torso is a sign of instability of the stabilizers:

This typically happens when there is too much forward flexion of the shoulder joints. This is the work of biomechanics since the shoulder joint is a forward shoulder that is not centrated and with running, the arms swing back and forth. This less than ideal positioning of the shoulder joint leads to early fatigue of the body trying to assist the shoulder movement (stabilizer doing the extremity job) and becomes fatigued and unstable itself.

  • Uneven arm swing:

There is more to this observation than most realize. The arms swing in an opposite pattern to the legs; in other words, your left arm swings forward with the right leg and vice versa. When there is an uneven swinging of the arms, the leg and arm movements are not in sync and it can be a sign of the right and left sides of the brain not talking to each other like they should. This connection in babies starts with crawling and is absolutely necessary for balance and coordination of movement. Any lack there, in a runner, means imbalance, weak pelvic floor muscles, and the beginning of pelvic floor dysfunction.

  • Uneven sound of heel strike when running:

This is one of the reasons why I suggest running without listening to any music. The sounds our feet create at toe-off and heel strike provides valuable information about our biomechanics. The symmetry in picking them up off the ground and allowing the feet to touch the ground requires absolute coordination and synergy of movement of the lower extremities with the flexors and adductors being the primary focus in runners.

When the pelvic floor muscles start getting weak, it is the adductors that start overworking to provide more stability to the area. With the overworked adductors, the feet hit the ground on the toe side of the foot more, and with over-worked flexors, there is a ‘thump’ sound at heel strike. This evaluation is much easier with walking or slow jogging and worth assessing in all runners.

This picture shows the role of hips on the health of the pelvic floor biomechanics and alignment of the structure.

pelvic floor dysfunction physical therapy


  • History of Plantar Fasciitis:

Plantar fasciitis is a foot pain but not a foot problem! When your hip flexors don’t do a good job lifting the lower extremity, the ankle joint does more flexion to clear the foot and toes and gets fatigued as a result; the plantar fascia at the bottom of the foot gets rigid and painful. Anyone with a history of plantar fasciitis is at risk for pelvic floor dysfunction.

  • Side to side sway when running:

When it comes to the movement of the pelvis, there are 3 bones to think about:

  1. The sacrum
  2. And 2 Ilia (ilium) that connect in the back of your body to form 2 sacroiliac joints.
Pelvis bones

Pelvis bones (courtesy of https://orthoinfo.aaos.org/)

Each ilium and sacrum move opposite of each other so for instance when you step forward, your ilium flexes while the sacrum extends. The hip and pelvic stabilizers limit the side-to-side movements since this movement in excess leads to a lack of balance and potential for injury. When there is a movement dysfunction in the pelvis the side-to-side movement becomes more prevalent and is a tell-tale sign of pelvic floor dysfunction in the works.

Gait assessment, therefore, is a big part of my examination when evaluating all patients especially the runners which give a detailed story of what is happening, what has been happening, and what is about to happen if untreated.

  • Rotation of thigh bone or knees inward or outward:

This gets missed quite a bit and is looked at as a knee pain treatment when in reality with an exception of an insult to the knee joint directly, all knee problems are a result of dysfunctional biomechanics. When walking or running, the knee joint is to flex and extend; if there is a rotational component of the joint, the issue stems from the lack of stability at the hip joint which in turn leads to pelvic floor dysfunction.

The correction of all knee issues has to include both the hip and ankle mobility assessment and evaluation without isolating those joints to rehabilitate them. This means that most therapies done for the injured joints in my opinion are not going to be long-lasting because after all, none of our joints function alone and need to work in synchrony with the rest of our body in movement. Here is an example of what an ankle mobility exercise should look like:

Best Treatment for Pelvic Floor Dysfunction in Runners

In all pelvic floor dysfunction presentations at our clinic, a thorough assessment of the patient includes Postural Neurology, Developmental Kinesiology exam, and external assessment of the pelvis to determine the extent of weakness or tension of the pelvic floor muscles.

Once the corrective exercises based on Developmental Kinesiology start, at some point if the pelvic floor muscles are weak, we use our FDA-approved machine, Emsella Chair to strengthen the floor by creating 400 Kegels a minute which this machine is designed to do.

Emsella Chair

Emsella Chair

In the case of a non-relaxing pelvic floor, internal manual treatment is performed to address the trigger points and tension that may exist in the muscles of the pelvic floor. Visceral manipulation may or may not be necessary but is certainly among the arsenal of treatments available to those in need.

As a runner with pelvic floor dysfunction as a result of a horse riding injury, I appreciate the passion involved with this sport and how important it is to continue running. If you think you suffer from pelvic floor dysfunction or wish to be evaluated for it, contact me.