I talk a lot about the pelvis and the pelvic floor. It’s pretty important to all people, especially pregnant ones, and especially pregnant or postpartum folks who want to maintain or return to fitness or high level athletics. But is it fair to talk ONLY about the pelvis when considering pelvic floor strength and function? The pelvis attaches to muscles above and below, and the length-tension relationship of these muscles contributes to what is happening to the pelvis and its muscles in the middle. And so, since the pelvis is pushed and pulled upon by everything connected to it we need to extend our discussion of pelvic alignment and pelvic floor health to the whole body.
Before we go on, what is a “strong” pelvic floor? Certainly a strong pelvic floor is one that provides good control of the bladder and bowel and does an adequate job of supporting all of the organs that sit above it. A strong pelvic floor is appropriately responsive to the demands of your daily life and sports. A strong pelvic floor is not synonymous with a “tight” pelvic floor and the pathway to a strong pelvic floor is not a million isolated pelvic floor contractions (“kegels”). It is also important to note that not only is a “tight” pelvic floor not a super strong pelvic floor, but it’s one that comes along with a range of unpleasant symptoms such as pelvic pain, incontinence, constipation and painful sex. I think you’ll agree that those are outcomes we’d like to avoid.
Throughout this post, we’ll talk about factors, spanning the whole body, that play a role in supporting optimal pelvic floor strength and function. Three great starting points are pelvic alignment, rib cage placement and breathing. But, in order to achieve these desired starting points and capitalize on their setup, we have to look beyond the pelvis and discuss a few more structures that attach to the pelvis from above and below.
Getting started – the big three.
First, let’s talk about pelvic alignment. In other posts, I’ve talked about ‘alignment’ in the context of the whole core. In that context, I’m often referring to a “stacked” or “ribs over hips alignment” that puts all of the core musculature in an optimal position to work as a team. But if we narrow in on what the pelvis is doing within that stacked alignment, we find that it should be in “neutral” in order to set up the rest of the team for success. Neutral can be defined in a couple of different ways. I think the easiest way is to pretend your pelvis is a bowl, tip it forward and backward as if to dump out the water, and then find a spot in between where the water is level. This approach should yield a gentle curve in your lower back (you’ll watch that curve become flattened and then exaggerated as your rock your pelvis back and forth).
If you want to get more technical, you can align the two bony points of your hip bones and the bony point of your pelvis along your midline in between and below your hip bones (this is your pubic symphysis, technically a cartilaginous joint). The two hip bones and the pubic symphysis should align vertically relative to one another.
After pelvic alignment, we also need to consider rib cage placement. Julie Wiebe, PT describes rib cage placement using an analogy to a bell. If your rib cage is thrust up and back, your bell is rung up. If it’s rounded down, it’s rung down. And if your bell is rung up or down, it’s noisy. In order to achieve good rib cage placement, that will enable optimal coordination between the diaphragm and pelvic floor, you want your bell to be quiet.
Once you have found a good stacked alignment with a neutral pelvis and quiet rib cage, the next step is to consider how you breathe. During a normal breath cycle, the pelvic floor mirrors the diaphragm (check out the animation below). The diaphragm contracts (and ideally descends towards your pelvis) to draw air into the lungs and the rib cage should expand 360 degrees. In response, the pelvic floor lengthens and descends. On exhale, everything reverses; the diaphragm and pelvic floor rise.
This diaphragmatic breath cycle is important for many reasons, but with respect to the pelvic floor it puts the muscle through a contract and relax cycle with every breath you take. The “relax” portion of that cycle is super important. By giving the pelvic floor an opportunity to relax during each breath, we can begin to counteract a lot of the tension thrown its way through stress, frequent sitting, heavy lifting or other factors. But a lot of us miss out on this built-in "relax" cycle for a range of reasons and tension or tightness can accumulate. If you happen to be pregnant or postpartum, you have probably gotten out of the habit of taking nice big breaths that expand the rib cage all around and send the diaphragm through it’s full range of motion (down towards your pelvis). Even if you wanted to breathe deeply, you can’t; there is (or was) a baby in the way! But since the pelvic floor mirrors the diaphragm you can imagine that if the diaphragm is not fully expanding on inhale, the pelvic floor is not going through its full lengthening and relaxation either. Even if you have not been pregnant, if your rib cage is rung up or rung down, chances are good that you too are not taking full advantage of your diaphragmatic inhale.
In summary, your pelvic floor is set up for success when your pelvis and rib cage are both aligned in a neutral position and your core and pelvic floor are set up for optimal coordination and function. Your rib cage and pelvis are most likely to be in neutral when everything attached to them from above and below are at their optimal length-tension relationships as well. Unfortunately, all of the bits that attach to the pelvis are frequently either too tight or are stretched out, and as a result our pelvises are being nudged out of neutral.
In Part 2 of this post, I will dig into the stuff above and below the pelvis that impacts pelvic floor tension by influencing pelvis and rib cage alignment. I’ll also provide some practical suggestions that you can incorporate into your fitness routine to improve your pelvic floor function. Stay tuned!