It’s easy to recognize that pain located in the pelvic region might have a connection to the pelvic floor. But what if your pain is at your pubic bone, your tailbone, or your SI joint? What if it’s farther away than that—like your back, neck, or jaw? These aren’t related to the pelvic floor, right? Not so fast. Pelvic floor function can impact pain almost anywhere in the body, including all the locations listed above as well as at the hip, knee, foot, shoulder, even elbow. Let’s take a closer look at the why behind these connections.
The pelvic floor as an important part of your core
Most people think of their abs when they hear the word, ‘core.’ But imagine, instead, the Earth’s core, or even the center of a jaw breaker. The core of these structures is 3-dimensional in the same way that the original structures are. The core of a human is no different. It is not an isolated sheet of muscle on the frontside, but rather, a deep and 3-dimensional group of muscles located in the center of that human.
The deepest aspect of the human core includes the diaphragm, the pelvic floor, some tiny muscles in the back, and the transverse abs (the deepest of the four layers of ab muscles). These muscles work together to create a pressurized cylinder within the trunk.
How the core creates pressure
Pressure in the deepest aspect of our core is very closely related to respiration. On an inhale, the diaphragm can move downward from the bottom of the rib cage. This downward motion pushes the internal organs down on the pelvic floor and out against the abdominal muscles. This pressure creates an internal stiffness that allows the rest of the body to move over a predictable and stable trunk.
Likewise, on an exhale, the pelvic floor and the abs contract. They move upward and inward, respectively, pushing the internal organs up against the diaphragm. The diaphragm then rises and pushes air back out of the lungs. This reverses the direction pressure is generated, but it has the same effect of creating stability within the trunk.
In fact, for most people, exerting effort on the exhale is more powerful because the pelvic floor and abs can generate a greater contraction and thus, more pressure and stability than the diaphragm alone. Read this for more details on the basics of pelvic floor function.
Changes to how the core functions
Like most movements the human body can perform, we don’t all do them in the same way. Think about what it looks like when any two people run or throw a ball. It doesn’t look the exact same from person to person, and some of us have more variations than others. The same concept applies to the way we use this deepest aspect of our core.
The reasons for variation can range widely. Genetics, posture, or lifestyle can all play a role. So can previous injury, pregnancy, or delivery. There are more specifics about how the pelvic floor changes with motherhood here, but the diaphragm and the transverse abs also go through significant changes while growing a baby. This means that pregnancy has a big impact on 3 out of the 4 muscles of the deep core.
These changes are behind a lot of the big issues seen postpartum. Problems like incontinence, diastasis recti, and prolapse are all related to the management of pressure by the deep core system. But we often forget to consider the pelvic floor when it comes to pain located outside of the pelvis.
How pelvic floor changes can lead to remote pain
Before we talk about how the pelvic floor specifically relates to things that seem unrelated—like shoulder pain—let’s use an analogy.
If the pelvic floor were part of a house
Let’s imagine a home builder who’s not very good at his job. He clears a wooded lot, grades it, and lays the foundation for a home. But he doesn’t take the time to allow the ground to settle or the foundation to set. Instead, he hurriedly puts up a two-story house.
A year down the road, the ground has shifted, and the foundation is cracked. The grout in the upstairs bathroom keeps coming away from the tub. A good seal seems next to impossible. If you’re in the upstairs bathroom, you might be going through tubes of grout, trying to fill in the gap. But if you step back for a minute and look at the whole house, you realize you’re not fixing the real issue. The wall isn’t at 90 degrees anymore, and the house continues to shift. You will never have enough grout to solve this problem.
How to restore your own foundation
Hopefully, you can see that your postpartum body is a little bit like that freshly graded lot. Things are different than they were, and it’s important to go slow and lay a good foundation.
The diaphragm, the pelvic floor, and the abs endure a lot to grow a baby. If you layer your previous fitness routine on top of this altered foundation, you can end up with problems almost anywhere. Because if the floor of a house isn’t stable, it affects the walls and the roof. Not to mention that floor itself.
You end up needing to compensate for not having a stable inner core, and some other part of your body must take up the slack. Maybe you use your back more. Maybe it’s your legs. Or maybe you have an old injury that sets you up for asymmetry between the left and the right.
What this means for pelvic pain
The pubic bones, the tailbone, and the sacroiliac (SI) joints are all located on the pelvis. Pain at any of these is like having a crack in the floor of your house. Unlevel ground might have caused the crack, but it’s hard for the floor not to be affected. The same is true with the pelvic floor muscles. They might not be the cause of your issue, but they’re affected by their attachment to the pelvis.
Pain in these locations often relates to asymmetry elsewhere in the body. This is most obvious with pain at one SI joint and not the other. But it’s also true with pubic or tailbone pain. In this case, an uneven pull from muscles can create excessive movement where there is normally very little.
How the pelvic floor is a part of the hip
The hip is a ball and socket joint, where the ball is the top of the femur and the socket is at the outer aspect of the pelvis. Because the hip has lots of mobility available, there are also lots of muscles that help to control this motion. Some of the bigger, more superficial muscles control the actual movement, while deeper, smaller muscles provide stability to the joint.
Some of these deeper, smaller muscles are also part of the pelvic floor. When the pelvic floor is weak or overworked, it changes how well the ball centers in the socket. This then causes some hip muscles to work harder, while others are underutilized. Over time, with enough repetition, this can result in hip, or even, back pain. As an example, here’s a study exploring the relationship between gluteus maximus (a hip muscle) and low back pain.
What this means for the rest of your leg
What happens at the hip affects the position of the femur. Although the top of the femur is part of the hip joint, the bottom of the femur contributes to the knee joint. If the femur is poorly controlled at the hip, it can manifest in symptoms at the knee. Without a specific trauma to the knee, hip strength plays a role in most varieties of knee pain, and can even be a factor in some cases of trauma.
As an example, the gluteus maximus is the largest muscle in the human body. One of its jobs is to create outward rotation of the femur relative to midline. If glut max is weak, the femur tends to spend more time rolled inward. This creates a greater inward angle at the knee, and this position makes the knee more vulnerable to injury. Research links this position to increased rates of arthritis as well as ACL injury.
Likewise, for the foot, hip strength and control changes the position of the body as it moves over top of the foot. When the hip and the trunk above it are not well controlled, excessive force can be transferred downstream to the foot. What happens at the hip and pelvic floor have the potential to influence issues such as bunions, tendinitis, and arch function.
The effect of the pelvic floor on the upper body
The pelvic floor impacts the upper body in two significant ways. The first is its close relationship with the diaphragm. When pelvic floor function improves, so does diaphragmatic function. Since the diaphragm attaches to the rib cage, this can affect any of the upper body muscles that also attach there.
The second way relates to some sort of asymmetry. As an example, let’s say that you have a history of repeated ankle sprains on your right ankle. After injuring it so many times, you have altered the way you use that entire leg, and now, your right hip is weaker in addition to your right ankle.
We know that hip function links to pelvic floor function, so this means there is a good possibility your pelvic floor is weaker on the right, too. The right side of your body just doesn’t seem as reliable as the left side, so you tend to use the left more because you can count on it. Then, you start to get left shoulder pain. What happened?
Let’s go back to the house analogy I used previously. If the right hip and pelvic floor aren’t working well, this is like the bottom of the house being unstable. It then affects the walls of the house, or the trunk of your body. And over time, you can start to see issues at the windows, the roof, the bathtub. The human body works in the same way.
Where do you start with solving this kind of pain?
If any of this sounds all too familiar, you might be wondering how to put an end to it, especially if you’ve already tried every other solution known to man. If traditional rehab methods don’t seem to be working for you, it might be time to start over, from the inside out.
Learn how to reconnect your breathing pattern to your pelvic floor. Begin to notice when your pelvic floor is contracted and relaxed, and identify how these aspects of your deepest core affect your pain. You often need to change the alignment elsewhere in the body, so that you can unload or strengthen the area where your symptoms are.
Sometimes, these steps will fall neatly into place, while other times, it can require the guidance of an expert in human movement. The best professional for this situation is a pelvic floor physical therapist. There are plenty of joint aches and pains that are not related to the pelvic floor, but if you have pelvic floor issues, you almost always have joint pain elsewhere as well.