The pelvis and its movements are complex. It’s difficult to learn about them on an exercise blog—almost as difficult as it is to try to teach in this format—so I’ve started with a basic(ish) model, because the simple lever systems of the pelvis should be understood before moving forward. I could get as technical and complicated as our bodies are, but I don’t think this is necessary when you’re trying to establish how well your big body parts are moving (or not) and if these parts might be players in any issues of the pelvis you’re experiencing. If you think you require or are seeking therapy for your pelvis or pelvic floor, there are physiotherapists that specialize in this area. Ask your health care team for a referral.
The Great Kegel Debates launched in 2008, with a quickie interview on Kegels I did with Kara Thom, a fitness writer with a blog for moms working on their fitness. As with all quick interviews, short online articles, and their headlines, volumes of information were left out for a short write-up. There was a flurry of response and debate the week after the article, and then we did a follow-up interview and a subsequent year of blogging and commenting responses, clarifying points in the modern fashion. You can find the highlights linked above, but to save you sitting in front of the computer, I’ve laid out the salient points below.
Folks kept wanting to boil everything down to a headline: “Kegels are bad, do squats instead.” Many people still think of this as the takeaway. But not only was this not a point of mine, the points I did intend were much more robust:
- Not all pelvic floors are weak due to being too stretched out; some will measure as weak due to too much tension
- The butt muscles (and other leg muscles too) are important when it comes to moving the levers of the pelvic floor. An all-Kegel or all-pelvic-floor approach will neglect much of the anatomy affecting a pelvic issue.
- Men also have pelvic floors and can have pelvic floors with disorders. All genders do and can.
- Being pregnant or having had babies is not the only risk factor for pelvic-floor issues; nulligravid (never had any babies in them) bodies can also have pelvic-floor issues.
There are many different issues of the pelvis and each is multi-factorial. They are not all created by a lack of movement, but they might all be affected by a lack of movement. Because we’re a sedentary culture, we don’t currently perceive and thus investigate sedentarism as an environment, and the exercise treatments we come up with are typically low in volume (minutes a day, for few days a week), which makes it easy to conclude, anecdotally or scientifically, that movement as a treatment doesn’t work.
My most important messages about the pelvic floor are also my most important messages about any parts of the body/the entire body not performing well:
- Sedentarism does not work for the body, and many of our musculoskeletal (and non-musculoskeletal) issues are local expressions of what happens when individual or many parts don’t move well or often.
- We need to move more, but we also need to move specific parts in a particular way. Physical therapy has emerged because small doses of movement in certain places make various ailments better, which is what makes movement similar in behavior to food: we’ve isolated chemical compounds (minerals and vitamins) that fix symptoms arising in their deficit; we’re using movement in the same way, as a medicine.
- In that way, exercises are like vitamin tablets, and taking only vitamins is not a sustainable, long-term approach to getting better and staying improved. The body needs a lot of movement, not only small doses of movement taken in a sedentary context. If we went to a nutritionist and only received supplements, we wouldn’t become as well as if we were given more direction on healthier eating, food shopping, and cooking. The same goes for movement. A handful of one single exercise won’t take us as far as many movement meals made of various movements.
- We’re not taught that the exercise-movements we “need” can be found in a non-exercise format. Imagine if we thought vitamin C only came in pills and never knew that we could get it from an orange! Exercises (movements done out of context) are not the necessary input. But when folks have multiple physical issues, they’re given a long list of “necessary exercises.” Our baseline well-being becomes entrenched in a medicalized, therapeutic model. Few people treating our ailments give the message that there’s a way to move through our life that gives us those necessary “exercises,” and countless more, to the same—even better—effect.
- When I say “even better effect,” what I mean is that the movement you need can be done while you’re also having more joyful interactions with others (#VitaminCommunity), green spaces (#VitaminNature), and the stuff you need for your everyday life (#VitaminTakeAWalkWithFriendsOrFamilyToGetGroceries). Your movements can be more nutrient-dense.
The giant "sedentary" vacuum
The pelvic floor sits beneath the weight of all your internal organs and is moved when you move. The pubococcygeal contraction is called a Kegel when it’s performed as an exercise, but this same contraction should be occurring to varying degrees when you get up and get back down again, and with every step as you walk. When you move (change positions) infrequently, the pelvic floor gets little opportunity to feel and adapt to the load above. Like any muscle not being used most of the time, your pelvic floor loses strength and the joints stiffen as they adapt to not getting much movement. So when you do move, or create a bigger load (jumping, running, laughing, sneezing) the lever systems can’t generate the leverage necessary to deal with this sudden onset.
So, what’s the best solution? Should we keep mostly sitting down, and just add an exercise (Kegels) that simulate how the pelvic floor moves as the body changes position? Or should we work to changing the body’s position more frequently, in a way that stimulates a variety of loads to the pelvic floor muscles, so they begin to respond reflexively?
I do get the need for therapeutic/corrective exercise (I teach many of these exercises and I think they are great), and I even see a place for Kegel exercises as a beginning step to moving pelvis-parts more. But my main point in the great Kegel debates is this: a single exercise to competently train an area of the body with so much depending upon it won’t cut it, and thinking that one small exercise will suffice is the approach a sedentary culture will keep trying to take, an approach that will keep getting poor results. We must talk about this giant sedentary vacuum, sucking out all the movement from our lives. If we can’t get our culture moving, human movement will be reduced to a list of therapeutic exercises to be done to improve a part/symptom (a part suffering or symptom arising often from a lack of movement), from here on out. We won’t see movement as part of the medicine wheel of our lives. We won’t understand that movement—whole-body, whole-life movement—is as essential to our health and vitality as water or air.
Movement as nutrition
So many people are already exercising or looking for how to move their whole body around well. Often, once people start moving their body around more, it becomes clear that the pelvis isn’t keeping up. Exercise can be the period of time where you experience urine leakage, or organ prolapse, or pain. It might make you wonder, HOW IS MOVEMENT HELPING AGAIN?
In these cases, it’s helpful to consider movement as nutrition. Food is good in general, but maybe there are some foods you can’t tolerate (they make you ill) or maybe you’re just taking in too much of one food. Even the most nutritious food will leave you sick if you only eat that food. You need a range of nutrients, as they all work together. So, what’s your entire movement diet? Is your exercise mode (running, biking, lifting, Pilates, etc.) the only movement-food you eat? Are you balancing your bout of concentrated movement with a host of other movement nutrients throughout the day that support and strengthen your parts, including your pelvic floor? Or, are you movement starved, from head to toe?
Your pelvis is a part in an entire body, so it’s possible the widespread pelvic issues we’re experiencing as a group have something to do with general (and specific) movement malnutrition.
Which parts do you need to get moving?
I don’t automatically view pelvic ailments as being isolated to the pelvis; there are simply too many moving parts outside of our pelvic anatomy that affect how pelvic anatomy works. The pelvis is the junction of many parts, including those seemingly far away (e.g., did you know that there are muscles connecting your pelvis to your shins? In this way, movements of your knees and shin bones are moving your pelvic-floor muscles!). Your pelvis parts are affected by all sorts of whole-body movements—and not only obvious movements like running or jumping, but breathing movements too.
This isn’t to say that all pelvic issues are a result of a lack of one specific type of movement. In all physiological issues there are environmental, psychological, biochemical, and biomechanical factors. We just tend to leave those biomechanical stones unturned, so as biomechanist I turn them, and offer a broad understanding of the mechanics of how all your parts move together. It’s important to understand all the moving parts of and connected to a pelvis when we’re troubleshooting what’s happening there.
There are multiple leverage systems affecting the pelvic bowl; many are listed below.
The bony levers:
- Two (one right and one left) os coxa, or “hip bones,” each having three named areas: ilium, ischium, and pubis
- a sacrum
- a coccyx
- two femurs
The muscles, connective tissue, and nerves that collectively make up what’s commonly labeled the “Pelvic floor.”
- tissues of the levator ani (which is made up of the pubococcygeus, iliococcygeus, puborectalis muscles)
- tissues of the coccygeus muscle
There are also muscles that are not included in the “pelvic floor group” but they still make up the pelvic walls that seal the bottom of the bony pelvis. These below are classified as hip/leg muscles, but the hips are also part of the moving parts of the pelvic floor even though they’re not included in the pelvic floor group list.
- internal and external obturators
- piriformis and other deep hip rotators (gemellus superior, gemellus inferior, quadratus femoris)
- the “lateral hip muscles” (tensor fascia latae, glute medius & minimus)
These are other, large tissues directly connected to the pelvis, but also not classified as pelvic muscles, so they’re easily off the “troubleshooting my pelvis” radar:
- the gluteus maximus
- Latissimus dorsi (These are one of the reasons TIGHT SHOULDERS can affect the pelvis!)
- thoracolumbar fascia
The gluteal muscles pull the sacrum in opposition to the pull created by the pelvic floor, as (crappily) diagramed below. The green arrow indicates glute-pull (and to a lesser extent, a pull from the latissimus dorsi) and red arrows indicate pelvic-floor pull. You can read more about this here.
But consider what the pelvis does: it bears the burden of the abdominal and pelvic contents, and it helps facilitate breathing and coughing (both helpful when it comes to keeping the lungs clear). And consider how weights, pressure, and leverage are all influenced by position. It becomes obvious that we must expand our list of levers and pulleys affecting the pelvis; we have to include those that tilt or tuck the pelvis. So, here are more even more muscles (and their nerves and surrounding connective tissue) that affect pelvic position or loads:
- rectus femoris (one of the quadriceps that connects the pelvis to the shins)
- adductors (muscles of the inner thighs)
- psoas major (via flexing the lumbar spine)
- quadratus lumborum
- muscles of the abdomen (abdominals, diaphragm)
When we acknowledge how many other parts are involved in moving the pelvis and its parts, then the list of exercises we need to do to maintain our pelvic health can quickly get longer and longer.
How to start moving your pelvis parts
Clearly we need to move our entire body more, and there are many parts in your body to get moving—so where to start? The short answer is, I don’t know the right answer for you, mostly because I don’t know who you are, how you’re moving now, what your specific issues are, and what movement protocol will fit into your life. That said, I’ve worked with so many people on their pelvic floor issues, and most of them have benefitted by working in this order: 1. Small corrective exercises, 2. Everyday alignment adjustments, 3. Start STACKING your movement, 4. Walking more 5. Hanging. Note: You don’t have to complete a category before moving on to the next (you can start walking more now, too!), I just want to stress that getting your individual parts moving is the first step to getting the larger movements to benefit your pelvic floor more directly.
1. Small corrective exercises
Whether you exercise a lot or not at all, it’s possible to have pelvic-affecting parts that don’t move. When we go to move parts that have been stiff for a long time, we tend to move around them. How we move around them isn’t always easy to see, which is why we at Nutritious Movement use such specific form. You might already have a favorite calf stretch, and you might also look at our strap stretch and think that you’ve been doing something similar for years, but what we offer are not novel exercises, so much as a way to evaluate your own movement while you do exercises, to tell if you indeed have “sticky” spots that aren’t budging.
For example, I’ve seen multiple clients (scores of them, even) that have been told their hamstrings aren’t tight or affecting their pelvic-floor issues because they can easily bend over and touch the floor. But you can bend over and touch the floor by using excessive lower back movement and no hamstring movement at all. Being able to touch the floor doesn’t mean your hamstrings are mobile; instead you have to watch how far the pelvis can move over your thigh-bones. If you’re watching your hands instead of your pelvis, it’s easy to miss poor pelvic movement.
Start by checking how the individual parts listed out above are moving. Begin with your hamstrings! They’re not that difficult to check; you just need this article and a mirror.
Then read through the articles and try the moves I’ve listed on Our Best “Healthy Pelvis” Resources to find out where you’re mobile and where you’re not. The best part is, you won’t just be measuring your movement; by paying attention to form, you will also be moving the muscles of your legs, hips, and pelvis more.
2. Everyday alignment adjustments
Once you’ve gotten parts moving a bit, start learning the simple adjustments to body position (on that same resource page) that can quickly change pelvic loads throughout the day. Back your hips up, make sure your ribcage isn’t lifted, and make sure your shoes aren’t pushing your pelvis around. The exercises will make adjusting your position easier, and adjusting your position actually uses your parts more all day, making the exercises easier and, over time, less necessary. It’s all very cyclical, and you might find that exercises and adjustments you can’t do right now become more available over time by doing the ones you can.
3. Start STACKING your movement
Our bodies needs a lot more movement/diversity of movement than they are probably getting, but we’ve set up our lives in a way where there’s no more time for movement! Good news: you can start layering movement into other things you’re doing (I call it “stacking”) by making a few simple changes.
Sitting on the floor can give you the timespace to do whatever else you’re doing (working, watching TV, reading, hanging out) while also doing one of the leg-moving exercises above. I’m not going to say you can’t take a Zoom conference in Psoas Release, but maybe opt for a V-sit to move your hamstrings while on camera, or if you’re in an actual office, just cross a leg over the other while in your desk chair and move your piriformis on company time. Stack your evening reading with Legs on the Wall.
Then, stack further by picking whole-body movements that move many of your pelvic (and other!) parts at once. Once you’re able to work on the larger movements with good form, you’ll need fewer individual exercises.
Walking is basically the best thing you can do for your entire body as it’s free, functional, and it moves a lot of your parts at once—pelvic floor included. Even before you’ve started all the little exercises above, walking is an excellent low-impact way to move. Once you’ve checked in with your parts and gotten them moving more, you can refine your walking time so that it’s even more nutritious. First, tune in to how much you are walking. Break up bouts of sitting on your pelvis with walking your pelvis around and using your pelvic floor. Aim to increase your walking by ten minutes a day, and then slowly add more over time.
Take a longer walk each day as you can (stack it with running errands or visiting with a friend on foot), but also look for places where a short, 3–5-minute walking session can fit in. If you think of walking as your pelvic-floor-activity time, then every minute you’re breaking up a sedentary position counts.
Check out your walking-movement diet. Are you always on flat-and-level sidewalks? Look for bumpy terrain, hills, and steps that move your legs (and pelvis) more. Carrying things while you walk will expand your abdominal-movement diversity.
I’m not going to take much time to address why/how the upper body is so important to the pelvic floor because it’s already written out in some articles and in Diastasis Recti. In short, the movements and tensions of your shoulder girdle (and abdomen) are important when it comes to intra-abdominal pressure being high, which is part of what can be pushing down on the organs of the pelvis. Also, the tension the latissimus dorsi contributes to the stabilizing movements of sacrum (in opposition to the pelvic floor). In shorter short, your arm movement matters too. You can find both individual-part exercises here and a more stacked version of these exercises in Hanging and Swinging 101.
Movement permaculture for the pelvis
Once you’ve taken a survey of the “sticky spots” in your body and figured out how to isolate them, you can add your stacks, restoring the pelvis while you restore movement back into your life. Consider the movements that can make up a lifetime: getting up and down, walking, running, bending over, carrying stuff, climbing, and even sitting and SQUATTING for rest. They all hold the potential for moving your pelvic parts more (and they also can facilitate some other, non-exercise benefit as well). This is movement permaculture. By tending to the soil of your life, you can simultaneously reap the “healthy plant” of a pelvis that works better for you.
The pelves, they are a-changing
It has been over 10 years since the Great Kegel Debates, and while the “Squat or Kegel?” headlines might linger, a short literature review reveals that in the years since a little interview dropped onto the interwebs, the questions being asked in investigations are more robust and now include more pelvic parts and descriptions of pelvic issues.
We are still lacking deep investigation into a shared mechanism between chronic low back pain and disordered pelves, as well as how these can affect gestation, birthing processes, and outcome. Also, we don’t yet have widespread appreciation for movement as a natural phenomenon; we mostly know movement as exercise. Exercise movements, while being a poor substitution for movement, help so many bodies. That can give us a sense of the power movement contains. Movement could work so much more if we could just see how much bigger than exercise it gets.
My pelvic position in 2020 is dynamic and hopeful. Folks are becoming more aware of the importance of movement and also the breadth of the pelvis’s inner workings, and this is wonderful news for all people potentially affected by the pelvis.
WHICH IS EVERY PERSON.
If you think you require or are seeking therapy for your pelvis or pelvic floor, there are physiotherapists that specialize in this area. Ask your health care team for a referral. For more information on pelvis movements, including lots of exercises, visit Our Best “Healthy-Pelvis” Resources. If you’re just starting and want a simple and gentle program to get your whole-body pelvis-parts moving more, check out our Healthy Pelvis DVD or download.