Although the pelvic floor can be troublesome for anyone no matter their age or sex it can become a particularly troublesome part of the body for athletic females (Rebuildo, Faigenbaum and Chulvi-Medrana, 2021), dancers (Thyssen et al. 2002) and maternal women (Faubion et al. 2012). Evidence suggests that female athletes are three times more likely to experience pelvic floor dysfunction as compared to their male counterparts – throw the pre and postnatal journey on top of that; the maternal female dancer, is most certainly at risk of encountering pelvic floor dysfunction (PFD).
The pelvic floor can be particularly vulnerable during the journey to motherhood. Reasons that pregnancy and childbirth can influence pelvic floor function include:
1) A growing bump and widening pelvis will put stress and strain onto the pelvic floor muscles.
2) A long pushing phase or experiencing a tear can directly affect pelvic floor function
3) The overall postural changes and muscle imbalances that can occur during pregnancy can affect the function of the pelvic floor.
Pelvic floor dysfunction is NOT normal and should not be brushed under the carpet as a postnatal issue that’s part and parcel of becoming a mum.
Understanding the basic anatomy and function of pelvic floor, training it in the right way and getting support if needed should be part of every female dancers pre and postnatal journey. What’s frustrating, is that despite its very important functions, the pelvic floor isn’t an area of our body that we can readily see or even feel entirely comfortable talking about. Important functions include:
1) Spine and pelvis stability and support
2) Breathing and posture
3) Pelvic organ support
4) Continence (Urinary and faecal)
5) Sexual activity
The pelvic floor muscles are a group of muscles that together form a hammock at the base of the pelvis (Figure 1). If we were able to look down into the bowl of our pelvis (Figure 1) we would see that the pelvic floor muscles span the entire pelvis cavity – muscles attach to the pubic bone at the front, the coccyx and sacrum at the back and the ischial tuberosities/sitz bones at the sides.
There are a number of muscles that make up the entire pelvic floor, some superficial and some deep. The superficial muscles provide the squeeze which help with continence and the deep layer supports our pelvic organs (bladder, bowel, uterus). There is also a right and left side and a front and back to the pelvic floor. The right or left side can function or become dysfunctional independent of the other side, the same goes for the front and back and deep and superficial layers. In theory when contracting our pelvic floor we want our pelvic floor muscles to fire as a cohesive unit – just like our primary core muscles (internal and external obliques, transverse abdominus and rectus abdominal muscles). Also, similar to our core muscles, whilst we can consciously contract them, the pelvic floor should fire automatically to provide stability to the pelvis during movement.
Signs of dysfunction
Pelvic floor dysfunction (PFD) is a non-specific term that can encompass a wide variety of conditions. If a pre or postnatal dancer is experiencing PFD they might notice one or more of the following symptoms.
Urinary or faecal leakage; this could occur with jumps, coughing, sneezing, or lifting (stress incontinence)
Experiencing a very strong and uncontrollable urge to go (urge incontinence).
Pelvic pressure or the sensation of something falling out of your vagina
Urinary or bowel frequency/urgency (Having to “go” more often than every 2-4 hours during the day or getting up more than once in the night
Pain with urination or bowel movements
Incomplete bladder emptying (having to “go” again or dribbling a few minutes after urinating)
Pelvic pain (pain in the pelvic floor, lower abdominal, coccyx, pelvic region including urethral, bladder and anal pain)
Training the pelvic floor
Kegals – what are they and do they help?
A kegal or pelvic floor contraction is an exercise that isolates and contracts the pelvic floor muscles. A bit like a bicep curl – the exercise is targeting one specific area of the body. The idea of a kegal is to get someone to connect with their pelvic floor muscles and increase muscle volume and strength. Different versions of the kegal are designed to increase the responsiveness (i.e. exercises would include quick contractions and relaxations) and endurance of the pelvic floor (i.e. exercises would include holding a contraction for a period of time like 10 seconds).
Kegals are often thrown around as the solution to all pelvic floor dysfunction – the reality is that it will usually only be effective if the pelvic floor is hypotonic and lacks muscular tone. Sometimes Kegals quite simply might not help the PFD or in some cases (for example when the pelvic floor is tight or hypertonic) they might be making the issue worse. This is where the pelvic floor issue is NOT a pelvic floor issue and the pelvic floor is simply taking the hit for an issue somewhere else in the body. Because the lower extremity, hip, abdomen, pelvis, and spine are a connected kinetic chain, any dysfunction along this chain may cause overcompensation and dysfunction of other associated muscles, including the pelvic floor (Fabion et al. 2012).
Some of the major contributors of pelvic floor dysfunction might include
1. Incorrect response to increases in intra-abdominal pressure
2. Hip muscle imbalance
3. Function and strength of external rotators / turnout muscles
Incorrect response to increases in intra-abdominal pressure.
When it comes to PFD we often need to retrain the natural function of the pelvic floor (Zivkovic et al. 2012). With each inhale the pelvic floor should relax and spread and with each exhale the pelvic floor should gather and contract (Bartelink, 1952). The pelvic floor, should, in theory work in synchrony with the respiratory diaphragm and the muscles within the abdominal cavity (Figure 2). Training the co-ordination of this is essential for good pelvic floor function.
Without training this natural synchrony we might hold a constant level of tension or tone in the pelvic floor – our inhales might not be accompanied by a relaxation or lengthening of the pelvic floor. Holding tension in a muscle will introduce fatigue, hypertonicity (tightness), weakness and ultimately poor function. Another consequence of poor synchrony is that an exhale, in particular a forced exhale (i.e. during a cough or laugh) which rapidly increases intra-abdominal pressure could cause a bearing down on the pelvic floor, instead of it gathering and contracting. This puts the dancer at risk of stress incontinence (i.e. leaking) or pelvic organ prolapse.
Training good synchrony in breathing patterns is essential so that when it comes to effort we can increase abdominal pressure without pelvic floor failure. Dance can be a high impact, high intensity activity and dancers need to put effort into movement – they need to leap, jump, pirouette, run, lift and transition in and out of the floor. Dancers are therefore constantly increasing intra-abdominal pressure in response to effort – having good natural function of the pelvic floor means that it will be ready to gather and contract during these moments of increased effort.
Hip muscle weakness / muscle imbalance
The hip muscles are often used as a window into the pelvic floor. Hip muscles include the adductors, the hip flexors and extensors and the internal and external rotators (Figure 3).
Many of these muscles have been found to work synergistically with the pelvic floor (Halski et al. 2017). They work together to provide pelvic stability. Imbalances and weaknesses within the hip complex can therefore contribute to changes in the orientation of the pelvis and the musculoskeletal balance of the hip, this can therefore directly affect the function of the pelvic floor muscles. Specifically, research findings have revealed a relationship between pelvic floor tightness, dysfunction and abnormal pelvic alignment (Tu, Holt, Gonzales and Fitzgerald, 2008). In addition, research has shown that hip muscle strengthening benefited the pelvic floor in individuals with stress urinary incontinence (Marques et al. 2020).
Function and strength of external rotators / turnout muscles
When it comes to dancers, a very important consideration in the hip and pelvic floor relationship are the hip external rotators. The obturator internus, a turnout muscle is a pelvic floor muscle and the remaining external rotators are fascially connected to it – the dancers’ turnout muscles are their pelvic floor and therefore the function of these muscles are directly important for good pelvic floor function (Tuttle et al. 2020, Baba et al. 2014). Foster and colleagues (2021) found weaker hip external rotators and abductors in women with increased urinary urgency and frequency (signs of pelvic floor tightness).
But can we not assume that all dancers who use turnout have strong, functioning external rotators?Personally I’m not convinced and research has recently found that many dancers rely on floor friction to hold external rotation (Duncan et al. 2020) – this finding suggests that the function and strength of these muscles might not be what we need it to be and better training and understanding of the external rotators themselves is required.
For good functioning external rotators (ones that can contract and relax) we need correct positioning of the hip socket, good pelvic alignment and balanced strength between the internal and external rotators – these very specific things can be altered during pregnancy and therefore might need attention postnatally – especially if PFD is present. If a postnatal dancer, with PFD is suddenly (or has always been) more comfortable standing in external rotation – the chances are that their external rotators and therefore their pelvic floor could be overworked, tight and weakened. Organising the strength and balance within the hip will be an important factor in improving pelvic floor function.
Pelvic floor dysfunction is NOT normal and should not be brushed under the carpet as a postnatal issue that’s part and parcel of becoming a mum.
Pelvic health physiotherapist
A pelvic health physiotherapist is best placed to provide you with a clear picture of why you might be experiencing pelvic floor dysfunction. Through internal examination, they can gain a full understanding of your pelvic floor and what is and isn’t functioning as it should. Understanding whether it’s a prescribed programme of kegals that is required or whether the problem could be stemming from another part of your kinetic chain is key. Pelvic health physiotherapists can also administer manual therapy (trigger point massage and myofascial release) to the pelvic floor – this is a very effective treatment for a hypertonic (tight) pelvic floor (Faubion et al. 2012).
Postnatal corrective exercise specialist
A postnatal corrective exercise specialist is well placed to train the function, strength and balance of your body whilst considering and integrating the correct function of the pelvic floor. Whilst returning to dance and intense physical activity it is key to understand, train and strengthen the body in a way that targets the postural changes and muscles weaknesses that can occur during pregnancy and ultimately affect the function of the pelvic floor.
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