Pelvic pain. A pain in the bottom. Pain “down there” that, unlike other areas, doesn’t seem to have a magic cure (because the Kegels everyone told you would keep everything together don’t seem to be working).
While it’s estimated that 38 out of 1000 women between the ages of 15-73 will experience chronic pelvic pain, it’s not just a gender-specific issue.1 Between 2% and 14% of men worldwide visit the doctor each year for pelvic pain issues, 90% of which don’t seem to have a specific cause.2 In addition, there are all of the people walking around with a literal pain in the butt that, when asked, will probably tell you it’s a hip thing. (I see this a lot. New client comes in and says, “I have some hip pain.” “Okay,” I respond, “show me the general area it bothers you.” Client points to the outside center of her bottom. Explanation of where the hip joint is located ensues.)
The Nickel Tour of Pelvic Anatomy
Before we dive into the various options available to treat pelvic pain from an exercise perspective, let’s take a moment to look at what the pelvis is and how it functions with the rest of the body.
When you look at a skeleton, the pelvis is the big, bowl-like bone at the bottom of the spine. It’s made up of three bones: the ilium, ischium, and the pubis. The long upper leg bone, the femur, connects to it; so does the sacrum, a bone which consists of five fused vertebrae at the end of the spine. We can think of the pelvis as a place where forces are transmitted, from the leg to the torso, and the torso to the leg.
There are several muscles that attach in and around the pelvis. They do things like stabilize the femur in the hip socket, transfer load between the torso and lower extremity, and maintain stability and movement in the pelvic floor. When you inhale and the diaphragm moves down, for instance, the pelvic floor also descends. When you exhale and the diaphragm recoils up, the pelvic floor also moves up.3 The pelvic floor is often considered the body’s second diaphragm, because of the way it mirrors the actions of the respiratory diaphragm.
The pelvis (like most structures in the body) has the ability to be still and move. In a well-coordinated individual with strength and adequate mobility, this happens naturally. However, too much rigidity can be problematic. Always moving in a specific way, placing the structure under high loads without giving it time to adapt (like beginning a daily running program when you haven’t run in 20 years), or having limited ranges of motion in the hip and torso can lead to a sense of discomfort. When pain is present in the body, the muscles “guard,” or become rigid. Introducing gentle, pain free mobility can help the muscles relax and restore normal function in the area.
On the flip side, if you are a very bendy person, with a lot of flexibility and not as much strength to support that flexibility, the pelvis may move a lot, and have a difficult time remaining still. Increasing overall strength and introducing a sense of stability is appropriate in this situation.
Let’s break this down into three components: teaching awareness of where the pelvis is and how it moves, improving stability, and improving mobilization.
How to Build Pelvic Awareness
The first step to improving intermuscular cooperation (a very fancy term that I just made up), is to have a very clear understanding of your pelvic location and how it is different from the low back or hip.
For instance, if we think about a standard quadruped rock back, it can be initiated from the pelvis or the hips. The difference between the two will be reflected in whether the low back position appears to remain the same throughout the movement, or if it arches or rounds. If there is a change in pelvis position during the movement and a coach gives you a cue to keep the pelvis neutral, can you actually perform that cue, or do you just think you are performing the cue?
The same thing is frequently seen in the squat. As you move down, do you arch your back more to accommodate movement in the hips? Or does your pelvis round at the bottom, not because of poor hamstring length, but because of a lack of pelvic control? (They are different). And if asked, can you consciously control the position of the pelvis throughout the movement?
If you are unsure where you fall on the spectrum of maintaining pelvis control, video yourself performing a quadruped rock back or the side view of a squat. If you tell yourself to move from your hips, what happens? Does your low back arch or round, even if you’ve told yourself to keep your pelvis still?
If the answer is yes, then improving your sense of awareness will probably benefit you. You can’t change what you can’t feel, and if you can’t feel your pelvis moving when you tell it not to, establishing a stronger mind-body connection should help.
The two short sequences below are designed to bring awareness to the different ways the pelvis moves. One is done in a supine (lying down) position; the other takes place in a seated position. Awareness drills make it easier to sense what’s happening when you are moving.
How Well Do You Breathe?
Before we move into stability, let’s talk about breathing. Earlier, we talked about the relationship between breathing and the pelvic floor. How can you assess your breathing?
During quiet breathing (e.g., when you are sitting on the couch watching Netflix), the inhale leads to expansion while the exhale leads to softening. What I mean by that is during the inhale, the ribs gently expand in all directions, like a ball being inflated with air. During the exhale, the ribs and belly sink a little bit, as though air were being let out of a ball. Nothing hardens, and the movement is subtle, not forced.
A quick test is to lie down on your back with your knees bent, your feet flat, one hand below your belly button, and one hand on your chest. Close your eyes and observe your breathing. When you inhale, do you feel movement underneath your hands? When you exhale, do your hands sink down a little bit? If you shift your attention to the back resting on the floor opposite your hands, what happens? Is there any movement you can feel? What about the lateral parts of your body? Do they fill with air?
Finally, bring awareness to how you are breathing. Do you inhale through your nose or mouth? How do you exhale? Is your inhale longer than your exhale? The same length? Shorter? What feels most natural for you?
Make a few notes to yourself. If you felt a lot of movement under one hand and not much under the other, or you couldn’t feel movement in any other parts of yourself (back, ribs), that might indicate you could improve your method to get a fuller breath. If you felt your abdomen harden when you exhaled, that’s not a very relaxed way to breathe under circumstances that should be low stress; decreasing bracing and rigidity during breathing will influence what’s happening in the pelvic floor.
Below is a breathing sequence designed to increase your breathing options.
Pelvic Stability Exercises
Remember the assessment from earlier, where you checked your quadruped rock back or your squat? That was a way to assess if you could consciously keep the pelvis still during movement. We will refer to this as keeping the pelvis stable.
The hip joint allows the leg to move in many different ways. It moves forward, backwards, side to side, in and out, and around in circles. It is suggested by researchers that one way to increase intermuscular coordination is through maximizing controlled movement options at a joint.4 This would mean the hip could move all of these different ways without requiring help from other body parts.
If we think about the breathing drills we did above, I mentioned the sense of the ribs coming in and down. Maintaining this more expiratory rib position tends to make it easier to isolate hip movement from movement at other areas. To demonstrate, let’s look at two hip mobility exercises:
- Lie on your back, with your knees bent, and your feet flat on the ground. Pretend like you are lightly holding a throw pillow between your knees so your feet can be completely flat and grounded. Reach the right leg all of the way out as you exhale. Feel the ribs coming towards your pelvis in the front and the spine getting long on the ground. Maintain this position as you inhale and lift the straight right leg up as high as you comfortably can. Exhale, control the movement as you lower down. Perform this sequence four times, and on your last one, keep the leg up in the air. Breathe for three breaths. Notice your rib position and observe that it hasn’t changed since you took the initial exhale. Your pelvis should feel fairly level against the floor.
- Next, come into a tall kneeling position. Notice the position of your pelvis. You might even take your hands to your two front hip bones. They should feel fairly even. Exhale, feel the ribs softening down. Now, maintaining the sense of the two front hip bones staying in line and the ribs staying soft, step your right foot forward. Your left knee will remain under your left hip, so it won’t be the full lunge position you traditionally see for stretching the hip flexors. Keep the set-up as you strongly press the left knee into the mat, creating a sense of length in the front of the left hip. Hold for four breaths, and switch sides.
The muscles that stabilize the bottom of the pelvis, specifically the hamstrings, also play a role in pelvic stability. The hamstrings can flex the knee and extend the hip;5 they also posteriorly tilt the pelvis, or provide stability, depending on how you want to look at it. If you struggle with a sense of pelvis instability and you are a regular yoga practitioner or spend lots of time passively stretching your hamstrings, consider adding a regular lower extremity strength component to your routine that includes things like hip hinging (with weight). Rather than emphasizing the feeling of stretching, work to resist gravity and use the strength of your muscles to get into various positions. Remember, finding a balance between strength and flexibility is paramount for efficient movement.
Move Those Hips
Let’s say you feel like you have a lot of pelvis stability. In fact, you feel like your pelvis stays pretty still, well, almost always. You might need to work on mobility.
During regular gait, the pelvis moves in a way that allows load to be transferred into the torso and enables one leg to move forward while the other leg is back.6 Short of twerking or finding a burlesque dance class, what’s a guy (or gal) to do?
We explored this a little bit in the awareness section through gentle movement. Other ways to improve mobility in the area involve incorporating different positions into your warm-ups and cool-downs. Various lunge positions, different squat stances, and active stretch positions such as the prone frog are all ways to improve pelvic mobility. Many of the standing yoga postures, such as triangle pose and warrior II, allow the legs (and therefore the pelvis), to be in different positions. One of my favorite positions to improve multi-directional pelvic movement is seated 90/90 and variations, including shifting from side to side. Give yourself permission to explore these types of movements gently and slowly as a way to increase both awareness and mobility.
Move Different, Feel Better
Whenever you struggle with discomfort in a specific body part, after you’ve done physical therapy and are cleared to return to your regular physical activity, it’s important to evaluate your program and make sure you strike a balance between strength and mobility. The occasional novel position does the body good; so does a progressive strength conditioning program.
While pelvis pain might feel like it should be treated differently than other body parts, it really boils down to “can the area contract? Can the area relax? Can the joint move? Can the joint stay still?” When in doubt, ask yourself these four questions, and let their answers help you discern where you should bring awareness, and what you should work on to improve total-body coordination and athleticism.
Finally, remember pain is multi-faceted. When recent research on male pelvic pain was reviewed,7 the authors concluded that chronic pelvic pain could be triggered by food sensitivities, psychosocial factors, and exercise; what we do in the gym is just one important piece of the puzzle.
Is your chronic pain somewhat further north?
The Neck Pain Troubleshooting Guide
References:
1. Latthe, P., Hills, R., Mignini, L., Gray, R., Hills, R., & Khan, K., (2006). Factors predisposing women to chronic pelvic pain: systematic review. British Journal of Medicine, 332(7544), 749-755.
2. Lin, G., Reed-Maldonado, A.B., Lin, M., Xin, Z., & Lue, T.F., (2016). Effects and mechanisms of low-intensity pulsed ultrasound for chronic prostatitis and chronic pelvic pain syndrome. International Journal of Molecular Science, 17(7), 1057.
3. Bordoni, B., & Zanier, E., (2013). Anatomic connections of the diaphragm: influence of respiration on the body system. Journal of Multidisciplinary Healthcare, 6, 281-291.
4. Borsch. F., (2016). Strength Training and Coordination: An Integrative Approach. 2010 Publishers: Rotterdam.
5. Valle, X., Tol, J.L., Hamilston, B., Rodas, G., Malliaras, P., Milliaropoulos, N., Rizo, V., Moreno, M., & Jardi, J., (2015). Hamstring muscle injuries, a rehabilitation protocol purpose. Asian Journal of Sports Medicine, 6(4), e25411.
6. Hungerford, B., Gilleard, W., & Lee, D., (2004). Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers. Clinical Biomechanics, 19(5), 456-464.
7. Smith, C.P., (2016). Male chronic pelvic pain: an update. Indian Journal of Urology, 32(1), 34-39.
