The Pelvic Floor: An Extensive Guide for Pre-, During-, and Post-Pregnant Runners
Updated: Oct 18, 2022
Of all the pregnant-running questions I get, most are about the pelvic floor. It is very exciting.
I also want to disclaim: the following are suppositions I've made based on internet research I've done and tested out. I am absolutely open to the idea that I'm wrong about some of this.
I'm no doc, and recommend you talk to yours for REAL and customized information. Hope this leads you down the right path.
By the way... there's a secret for anyone who isn't pregnant yet at the very bottom.
What is the Pelvic Floor?
No need to re-write what's been written a million times. Here's a great vid with a great accent describing the pelvic floor. Watch then come back here.
common issues with the pelvic floor
There are a few main concerns that pop up from a good percentage of women I talk to:
When pelvic floor muscles are weak, you pee on accident
Risk for organ prolapse down the line
Fear of damaging the pelvic floor permanently
Pain or pressure in the pelvis during and after runs (SPD)
Fear of separating abs (diastasis recti)
I hear all these for good reason: it's pretty scary to project what life could be like with a permanently malfunctioning body - especially a part of your body as central as the pelvis.
Let's break this down as simply as we can.
How do Pelvic-floor issues arise?
If you've never been pregnant, this info may be foreign to you. If you have been, it's something you've almost certainly thought hard about.
The cause of most pelvic-floor issues is pregnancy, specifically the "opening up" of your pelvis during pregnancy/delivery as the hormone relaxin loosens your pelvic joints and ligaments. Picture loosening the pelvis screws on your health-class skeleton a bit.
Your pelvic muscles also loosen throughout the process, and pressure from the weight of your growing uterus presses on the bladder, which is why it's too easy to pee durning and after pregnancy. When the muscles have to work harder to fully contract, your ability to stop the flow decreases.
You've lived and run your whole life to this point with a virgin pelvis (#birthvirgin), and suddenly the whole thing becomes flopsy dopsy to fit a baby through - restrengthening of those muscles is needed.
Not shocking that your pelvis doesn't snap right back to the firm bowl it once was. It'll take 4-12 weeks to do that as progesterone levels decrease, relaxin backs off, and you recover.
Concern 1: Accidental urination
For long runs during my first pregnancy, I had a 3-mile loop that centered on the only public bathroom open during Covid, and I used it often. One time it was locked while people were passing, and I drained liquid first from my eyes, and then down my leg - there is no holding it.
Pelvic floor muscles will slacken, but you can mitigate that slackening with - say it loud with me - KEGALS.
There's some kind of psychological threshold, below which people don't like doing easy things. I'll lift 200 lbs. for four sets of 10 reps, but it takes a lot of mental effort to do 10 mins of kegals.
No matter how easy they are, 90% of you won't do them. My challenge to you is to be the 10%. I used an app that gamified them for me - worked like a charm.
Dr. Stacy Sims also recommends two other useful exercises here.
***It should be noted: Athletes sometimes have over-strengthened pelvic floor muscles, which can lead to other problems during delivery - trying to fit a baby's head through a ring of perpetually-tight muscles can be difficult - and even problems with excessive pressure on the bladder (ever peed your pants during a race? Me too). If you're an athlete, you'll need to learn strengthening techniques AND lengthening techniques.
In speaking with a pelvic floor therapist, she says, "We need a strong pelvic floor for pregnancy and during late third trimester actually need to learn how to lengthen pelvic floor to prepare for labor."
I'm no expert on either strengthening or lengthening the pelvic floor, so I highly recommend you speak with a pelvic floor PT about this.
Concern 2: Risk of Organ Prolapse
Though uncommon in women of birthing age, I was surprised to hear that 1 in 2 women experience pelvic organ prolapse surrounding menopause. This is when the uterus, bladder or rectum drop into the vagina due to lack of pelvic-floor strength and support.
You're likely not at high risk of this if you've just had a baby, but you'll want to spend these youthful years working to prevent it so you can stay on this side of the 50% of women who don't suffer from this.
How? *whisper* KEEEGAALLS.
Girls - come on. Do your kegals. Doing kegals is like contributing to your pelvic floor 401k. Invest now, reap the benefits later, (and now actually).
Concern 3: Fear of Permanent Pelvic Floor Damage
You just felt a twinge of pain again on a run four months after delivering. This pain is familiar, and it's getting ever so slightly more common. You think, 'I don't want to bother my OB, I'm sure it's fine.'
Just get it checked. It's not worth permanent damage. This type of pain is called Symphysis Pubic Dysfunction (SPD): generalized pelvic pain often due to stiff joints or uneven hip bones. It's easily diagnosed by an OB, and great to know about if you intend to fix it.
When your pelvis's axis is off, you take misaligned steps while running to compensate on one side. That builds muscles that perpetuate the misalignment, and the problem gets progressively worse, causing more and more pain. It also causes other injuries from compensation, see below.
If you know your alignment is off - either by feel or your OB told you so - go to a physical therapist who knows running form. She'll likely assign you some strength exercises with the intention of strengthening the side you've been nursing. That's because you've unintentionally been forcing the other side to work harder. I'll provide some exercises I use below.
We'll call the pelvic floor the bowl, and the surrounding muscles (hip flexors, glutes, piriformis, etc.) the halo. Strengthening of this halo, and balancing their symmetrical force output will help your bowl straighten out, and eventually take away all that unnecessary pain.
Just so you're aware, pelvic misalignment is VERY common. I'm dealing with it myself right now, and if I'm not doing the right exercises (see below), pregnancy + relaxin will only magnify any problems I'm facing.
If I head these issues off, however, they are much easier to manage during and after pregnancy. Same should be true for you.
Concern 5: Diastasis Recti
Your rectus abdominis is divided into two halves that run from the bottom of your ribcage to the top of your pelvis, and it's connected in the middle by a ligament.
As a baby grows from avocado to watermelon, she pushes those two halves apart, stretches the ligament, and can even tear it - especially in post-term pregnancies.
Let me be clear: this is not the end of the world, and will likely not even effect your running, but if tendons are stretched, your abs may not contract as well for other types of movement, and some women prefer to avoid it.
The truth is this: A majority of women will experience a separation of the linea alba at around 40 weeks, and you simply can't guarantee its prevention even with a perfect exercise regimen. These things (DR) just happen. And guess what. You still look good, mama.
That said, the right exercise can reduce your risk of DR, and if you know the right ones to do, you'll give yourself a chance of strengthening the right muscles to be used as your "internal corset."
The transverse abdominis muscles (TVA) are likely the most important in relation to DR. They run horizontally to the torso, keeping everything together. Strengthen the TVA before, and throughout your pregnancy.
Again, I don't see any point in reinventing the wheel here, and I'm not dying for SEO points, so go watch this video for exercises that I'd do myself.
My overall pelvic-floor philosophy
If you want the plain truth, I'm pretty sure I got away with a healthy pelvic floor that allowed me to run during my entire pregnancy and within two weeks of delivery because of a combination of luck, kegals, weight lifting and activation exercises.
Lifting weights (mostly Olympic lifting) will do more than keep your pelvic floor and the halo that surrounds it in check, it will also mitigate any downstream issues that would be otherwise caused by these imbalances.
Pelvic Floor: Downstream Effects
Oh but what do you mean by downstream issues, Makenna?
Your ankle hurts on every run? You think, 'It's probably only an ankle injury... for now. I just need ice and rest.'
Well the ankle injury probably originated somewhere north, around your hips, and as a result of an inequality. Your calf is tightening up and won't back off? Probably an imbalance higher up.
Pelvic Floor Exercises
Practice fast and slow contractions as well as holds at the top, and squeezing as hard as possible. Also practice while moving if you want to be able to stop the pee while running. Practice sitting and standing. Also practice pushing out and holding - the opposite of squeezing, as if you were trying to pee. Try spending 10 minutes on them, 2x per day.
The great thing about kegals is that you can do them in line at the grocery store, on a roller coaster, in a negotiation for a million-dollar deal, at a red light or while watching The Office, season 4. Just pick a cue you see consistently, and which triggers you to do them consistently. Again, I used an app.
Pelvic Halo Exercises
I won't write out a whole workout regimen here, but I try to do the following 2-3x per week, and 4 sets of 6-10 reps of each.
Plank variations (point your toes toward your head so you tuck your pelvis correctly)
These are the exercises that I really profess to do before and sometimes after every run, but really, with life, usually only happen before long runs, and hard workouts.
Glute bridges (band optional, and preferred)
No need to wear yourself out with these before a run. Just pick two, do them until you start to feel a little burn, then do both again (two sets). Honestly anything that gets your glutes firing will do the trick.
Another disclaimer: I'm no pelvic-floor expert, and some people are. They might have better exercises for you, or slight variations to help you with your specific imbalances. Do your research.
Last Thing - A secret for the pre-pregnant
If you've made it this far, and you're not pregnant yet, I'm fairly certain another key for me personally was that I didn't wait to get pregnant before doing the above exercises. Because of that, I reaped benefits of strength and proper weight balance my whole pregnancy, and afterward.
Ben Franklin was right: "An ounce of prevention is worth a pound of cure."
May your pelvises be tight and level forever!