“Oh I have to cross my legs and clench every time I’m about to sneeze.” She laughed - half comedically, half self consciously. This was our first appointment together.
I nodded and smiled. “You’re not alone in that. It’s nothing to be embarrassed about.” I could see the tension fall away from her shoulders.
“How often do you squeeze your legs or clench your pelvic floor every day?” I asked.
“Oh, all the time,” she said without hesitation. “I mean, I’m trying not to leak, you know?”
We smiled at each other again. One of my favourite parts of my work is being able to normalise these conversations - no judgement.
“That’s a lot of work for your pelvic floor, in isolation,” I said. “Especially given that it only works properly when the other muscles that work on the same neurological loop work with it.” I held up a diagram of the loop of muscles (pic below).
“Doing all of these squeezes without connecting to the rest of the core can really wear the pelvic floor out.” I said.
She looked alarmed. “Am I making it worse?” she asked.
“In the long run, you could be.” I replied sympathetically. “Squeezing all of the time, without a proper release can lead to a hypertonic pelvic floor - where the overly tight muscles compress the bladder and other pelvic organs, creating urgency for the toilet and feelings of irritation.”
“Now that you say that, I do get that a lot - but I thought it was because I wasn’t squeezing enough!!” She shook her head.
We smiled at each other - the road to healing had begun.
2 out of 3 women experience bladder leakage at some stage in their lives, after having had their children.
It can get worse with time, not because of age - but because of a decrease in function.
If someone who leaks is squeezing their pelvic floor in panic (understandably so) in order to avoid an accident, over time this can overwork and shorten the pelvic floor muscles.
The lower belly that is meant to integrate with the pelvic floor isn’t included in these squeezes, creating an imbalance between the abdominals and pelvic floor.
And usually, because the squeeze is a panicked one, it’s so intense that women tend to brace or push out through the abdominals instead. This is doing the opposite of what we need the lower belly to do -which is gently bring everything up and in.
When the deep transverse abdominis isn’t integrated with pelvic floor contractions, the lower belly tends to push outwards, looking distended or more rounded than the rest of the abdomen.
If you stand up for a long period of time on the spot, and find that you end up clenching your glutes in order to stand there - you aren’t using your lower abs.
Over time the glutes fatigue and atrophy, because working as postural muscles isn’t their primary function. This can look like a flatter butt (mum jeans anyone?) which we can blame age on - but it’s usually a functional issue.
The posterior chain of our body comprises the hamstrings, lower back (lumbar erectors) and gluteal muscles.
If the lower belly and butt muscles aren’t contributing (as mentioned above) the lower back takes a lot of pressure - feeling compressed, tight and sore.
Our thoracic spine (the mid and upper part of the back) needs to be able to extend and twist in order to use the shoulders and neck correctly. If it’s stiff, it limits the range of motion we have at the shoulders to lift things overhead, which can result in shoulder impingement.
Over time, we typically end up extending at the neck - coming into too much extension, resulting in a forward head posture which can create shearing through the cervical vetebrae and place pressure on the discs.
We’re not often told how our lower belly and butt muscles connect to the rest of our body, but over time these small compensations tend to make neck pain, upper back tightness and lower back pain (including sacroiliac joint pain) much worse.
The great news though, is that while it can feel as though we have 10 issues going on - often when we heal the core properly, connecting the pelvic floor to the other essential muscles how to work in an- it doesn’t just fix one issue, it fixes all of them.
Learn how to activate pelvic floor (rather than clench it) alongside the lower belly muscles, and more importantly - master the release. Every muscle needs to return to it’s original length after a contraction, otherwise over time it loses function.
These are the diaphragm (through our breath), our deep transverse abdominis along with the internal obliques, and our multifidus muscles, which are deep in our back (see loop pic above).
These are the large ones (see image). A lot of the time women focus on the smaller external rotators by doing exercises like clams. If your largest butt muscle isn’t working, this isn't the place to start - as it can create issues like irritating the piriformis muscles.
Kristy Ahale is an Exercise Scientist who has specialised in orthopaedic rehabilitation for over 15 years.
Her Core and Pelvic Floor Program uniquely combines elements of rehabilitation, strength training, and women’s health.