The hips and the pelvic floor: friends or foes
Your poor pelvic floor gets all the blame when thinking about incontinence or prolapse. “My pelvic floor muscles are dead” or “I have no pelvic floor” are things I hear an awful lot in the clinic. While your pelvic floor may be weak it has NOT left your body or disintegrated into nothing. It is there, surrounded by many other muscles that probably need some love and attention too.
Did you know that your hip muscles make up part of the pelvic floor?
Yes, that’s correct! Your HIP MUSCLES are part of the PELVIC FLOOR complex!
Your hip rotators, which move your hip in and out, have direct connections to the pelvic floor. What happens at the hip can affect what happens at the pelvic floor and vice versa.
So, oftentimes, hip pain and pelvic floor dysfunction go together.
The Hip and the pelvic floor
The hip and pelvic floor are commonly assessed and treated as separate entities. You go to your pelvic health physiotherapist to assess your pelvic floor and you get your pelvic floor exercises to do, then you go to your other physiotherapists to assess your hip and get some hip exercises. Never thinking that the issues might be related.
Let me explain why your hip tightness and pelvic floor issue may be the same thing!
The pelvic floor and its anatomical relationship to the hip muscles
No muscle works alone. While a healthy pelvic floor can resist the pressure of daily life such as standing and walking; to generate enough force to withstand the forces of jumping and running the pelvic floor needs help from the surrounding structures. The additional support to meet these higher demands is proposed to come from your connective tissue, fascia and your outside muscle attachments, primarily contributions from the obturator internus muscle.
The obturator what you ask???
A lot of my working day is spent assessing and treating the obturator internus muscle.
The obturator internus muscle lines the inner surfaces of the pelvis (above your pelvic floor), so you can assess it internally!! Yes, your hip muscle can be assessed internally. It then exits the pelvis at the back and runs across the back of the hip joint to insert into your hip bone.
This muscle is a deep hip rotator, but it also has a role to play in augmenting pelvic floor muscle function, due to its strong connections to the pelvic fascia, where the pelvic floor muscles originate (neighbours and best friends).
Interactions between the pelvic floor and hip muscle function in healthy individuals
Pelvic floor force production increased by almost 50% after a hip-strengthening programme (Tuttle et al, 2016).
Did strength increase due to improved strength of the obturator internus muscle?
We don’t know but hip strengthening improves pelvic floor strength.
Hip function in those with pelvic floor problems
Women with bladder urgency or frequency were found to be significantly weaker in their hip muscles than women without lower urinary tract symptoms. However, there were no between-group differences in pelvic floor strength or endurance measured via vaginal manometry (an internal sensor), Foster et al, 2021.
Similarly, Hartigan and colleagues (2019) found that women with stress urinary incontinence had lower hip strength than women without stress urinary incontinence. They also found that there was no difference in pelvic floor muscle performance between the groups.
So they found a stronger relationship between hip weakness and incontinence, than pelvic floor weakness! So what happens when we train the hip muscles?
The effect of training hip muscles in those with pelvic floor problems
Jodre and co-authors compared a seated resisted hip rotation strengthening program, with a seated pelvic floor muscle training program in 27 women with stress urinary incontinence. They found similar improvements in symptoms of stress urinary incontinence in both groups, with the hip training group showing a slightly quicker improvement in reported leaks per week.
Another study assessed the ability of a hip exercise program to improve intravaginal squeeze pressure in 25 older women with or without stress urinary incontinence (Tuttle et al 2020). Participants exhibited an average of around 35% improvement in intravaginal squeeze pressure, with the authors concluding that ‘hip external rotation exercises may be effective as an indirect form of pelvic floor muscle exercise.’
So let’s get strengthening those hips!!
What above overactivity in the pelvic floor???
I see just as much overactivity as weakness of the pelvic floor musculature, and that overactivity and tenderness of the obturator internus (hip muscle) commonly co-exist with pelvic floor dysfunction.
Is the hip tightness a result of, or a contributor to, pelvic floor dysfunction? It’s likely that the relationship works both ways.
It’s critical that we consider the pelvic region holistically and recognise the close relationship between the internal pelvis and the outside structures.
That is why I have created the Pelvic Floor Revival. Focusing on just pelvic floor exercises does not cover the whole picture. The system in which the pelvic floor sits needs attention too. In The Pelvic floor Revival, you will reconnect with your pelvic floor, strengthen it but, not only that your hips will feel like new!
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