Pelvic floor strength is not just a topic for postpartum ladies these days, and it’s not all about doing kegels. The pelvic floor is a dynamic sling of muscles that connects the entire bottom of the pelvis. Take a moment to think about this – it’s the base for your entire torso, it stabilizes your pelvis and it keeps your organs in your body – now that’s an area worth looking at!
The sling of muscles that make up the pelvic floor work in conjunction with the kinetic chain just like other muscle groups in the body. After reading Coach Dan’s blog, you know that the rotator cuff must work in conjunction with the muscles of the scapula to properly support the shoulder. Weak scapula muscles can lead to shoulder issues. The pelvic floor is no different. It integrates with the diaphragm above, the abdominal wall in the middle and the hips below to create dynamic strength. If your hips are not rotating properly or your diaphragm is not functioning correctly then your pelvic floor will not be living up to its full potential. A weak pelvic floor is a contributing factor in low back pain, pelvic pain and SI Joint pain, as well as incontinence issues.
“Gray242” by Henry Vandyke Carter – Henry Gray (1918) Anatomy of the Human Body (See “Book” section below) Bartleby.com: Gray’s Anatomy, Plate 242. Licensed under Public Domain via Commons – https://commons.wikimedia.org/wiki/File:Gray242.png#/media/File:Gray242.png
More muscles make up the pelvic floor than you might imagine. To keep it simple I’m going to lump muscle groups together for this quick anatomy review.
When people think of the pelvic floor muscles, they think of the deepest layers called the pelvic diaphragm. Think about these as your hammock muscles. They stabilize as well as hold up your organs and control bowel and bladder function. The muscles here are:
Yes, the piriformis is part of the pelvic floor. Crazy right? When is the last time you heard someone talking about their piriformis pain being a pelvic floor problem? This is a huge consideration when treating piriformis syndrome.
Take a closer look at the anatomy: In the picture below you see the levetor ani as well as the coccygeus labeled on the pelvic floor but you also see the piriformis. To finish this up, if we move laterally, we find the gamelus and glutes and medially, we find the adductors. Anything in the kinetic chain with the adductors and glutes is bound to have a significant role.
“Gray404” by Henry Vandyke Carter – Henry Gray (1918) Anatomy of the Human Body (See “Book” section below)Bartleby.com: Gray’s Anatomy, Plate 404. Licensed under Public Domain via Commons – https://commons.wikimedia.org/wiki/File:Gray404.png#/media/File:Gray404.png
Let’s take a closer look at the interactions of the kinetic chain with the pelvic floor.
#1 Dynamic Diaphragm
Think about your core as a pressure canister. The lid is the diaphragm, the sides are the abdominal wall and the bottom is the pelvic floor.
In order for this canister to hold the proper amount of pressure all the systems must work correctly.
Take a deep breath- feel your ribs expand out and your diaphragm down making room for the air to fill your lungs. The diaphragm expanding down puts pressure on your pelvic floor, making it relax and expand down too. On the exhale, your diaphragm will naturally retract up, as will your pelvic floor. Try this a few times till you get the hang of it.
Now imagine a shallow breather, they never tap into their diaphragmatic system. Instead of the work coming from deep diaphragmatic breathing it’s coming from their pec minor and scalenes. This person is constantly complaining about their tight neck and rounded shoulders.
If the diaphragm never expands, then the strength potential for stabilizing your pelvis and core is never reached. Want to lift heavier? Make sure your internal system is working properly.
Focus on proper deep breathing and diaphragm expansion to turn on and coordinate the pelvic floor. Once you have achieved this in sitting try something a little more challenging, like hands and knees blowing up a balloon.
Think of the balloon as weight lifting for your diaphragm.
To start: Tuck your chin and ground your toes. Give me a pinch of a flat back by lifting from your belly not by pulling from your hips.
Exercise Credit: Postural Restoration Institute
Relax your glutes and hamstrings. I want your abdominal wall holding you, not the clinching of your glutes.
Normally I’m a stickler for neutral spine, but I can’t argue with the fact that some slight rounding, in a gravity friendly position, really gets the diaphragm going. If you are prone to disc herniations, use caution with this one.
Congratulations! You are now on your way to having a dynamic diaphragm. The next step to getting the pelvic floor stronger is coordinating the hip rotational muscles and adductor muscles.
#2 Rotation at the Hips
To make this interesting let’s take a closer look at how piriformis pain (a hip rotational issue) can be related to pelvic floor strength.
Common Scenario*: Patient is referred for piriformis pain. This patient can do kegels and bridges till the cows come home but needs to run to the restroom before lifting, has some minor SI instability as well as pain in their piriformis. After evaluation, I generally find them lacking in eccentric hip rotation strength. This patient has plenty of pelvic floor strength upon command, but the strength isn’t integrating automatically. The pelvic floor has gotten lazy. They also usually present with decreased foot strength, but that’s a discussion for another day.
What helps to turn the pelvic floor back on so the piriformis pain goes away?
The piriformis, obturator, gamelus, adductors and glutes all work to control rotation at the hip, with their close connections to the pelvic floor, these muscles tell the pelvic floor that it needs to work harder to help out. Remember the pelvic floor provides a sling of muscles on the bottom that help stabilize the SI Joint by holding onto the coccyx and pubic bones. So, if we get the rest of the pelvic floor to turn on as well as the adductors and glutes the piriformis will not have to work as hard and everyone will be happy. We do this by working eccentric rotation in the transverse plane. A transverse plane torque stresses the pelvic floor, asking it to get stronger and respond quicker. The rotation will also target the glutes and adductors. Now, I’m not talking about side lying clams. I’m talking about applying forces that are a bit more functional!
One more factor to look at is that patients with weak hip rotational muscles (accompanying piriformis pain) will often present themselves as glute clinchers. They are stuck in a low level state of firing, with their glutes holding on for dear life. This can contribute to a weak pelvic floor and piriformis pain. Getting the hips to eccentrically lengthen allows the glutes to stop clinching and therefore get stronger.
Strong glutes = a strong pelvic floor!
What we don’t overload will only get weaker. Holding a kegel as our only line of defense against a weak pelvic floor is not functional. This direction of thinking was inspired by Gary Grey and his preaching to make it functional. Pelvic floor control must be dynamic and automatic.
There are many exercises to target eccentric hip rotational strength, but one of my favorites is rotation in a lunge position with band or cable resistance.
All of the motion is coming from rotation between your femur and pelvis. It will feel weird at first because we are so used to locking our pelvis and lumbar spine in place to lift and pivoting on our toes. Try not to let those toes pivot or knees move instead focus on the hip rotating in the hip socket.
Keep the range small to start. I promise your adductors and glutes will be sore.
(Warning: If you have anterior impingement you need further PT to get the femur moving back in the socket before attempting this exercise.)
Strengthening the pelvic floor should be dynamic and fun rather than sitting around doing a bunch of kegels. They have a place for building some basic strength, but we shouldn’t stop there.
Other exercises that I love for the pelvic floor: Deep squats, Dead Lifts, Chops and many more, but only if you can execute the lifts with 100% perfection. You may have been performing these lifts for years, but the next time you do them, take the time to incorporate breathing deeply. Have some fun keeping all planes of motion alive in your workout routine!
About the author: Sarah Duvall is a physical therapist and adventure sports athlete at heart. She takes functional training to a whole new level. In her unique approach to treating patients she believes in teaching. Fully understanding every aspect of the injury is a necessity to complete healing. When she is not hanging off the side of the mountain Sarah enjoys writing and presenting at www.coreexercisesolutions.com and discovering new ways for her patients to continue pursuing their dreams and lead an adventurous life pain free.
Sarah has created an excellent product which goes much more in depth about training the pelvic floor. If you want to:
Then I highly recommend her product. You can find the link HERE:
Varuna Raizada, M.D. and Ravinder K. Mittal, M.D.. PELVIC FLOOR ANATOMY AND APPLIED PHYSIOLOGY. Gastroenterol Clin North Am. 2008 Sep; 37(3): 493–vii.
J. J. M. Pel, et al. Biomechanical Analysis of Reducing Sacroiliac Joint Shear Load by Optimization of Pelvic Muscle and Ligament Forces. Ann Biomed Eng. 2008 Mar; 36(3): 415–424.
Ashton-Miller JA and DeLancey JO. Functional anatomy of the female pelvic floor. Ann N Y Acad Sci. 2007 Apr;1101:266-96.
Hodges PW, et al. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-71.
Bordoni B and Zanier E. Anatomic connections of the diaphragm: influence of respiration on the body system. J Multidiscip Healthc. 2013; 6: 281–291.
Hsiu-Chuan Hung. et al. An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Man Ther. 2010 Jun; 15(3):273-9.
Talasz H. et al. Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor. Eur J Obstet Gynecol Reprod Biol. 2012 Oct;164(2):227-33.
*The opinions presented here are from my personal clinical experience. More studies are needed on the subject to acquire definitive diagnostic and treatment protocols.