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Running with Pelvic Pain, Common Does NOT Mean “Normal”



As I wrote about in a prior blog, pelvic pain or dysfunction can be a common complaint within cycling populations. I talked about how the pelvic floor muscles can be a part of the onset or maintenance of this dysfunction and how Pelvic Physical Therapy can often help! You may be wondering if runners can also experience pelvic floor dysfunction? The answer would be a resounding- YES!


In my blog about cyclists, I talked about the idea that pelvic pain and related issues can be present in those that identify as female, male, or in non-gender binary ways. In female athletes, pelvic floor dysfunction has been identified as being present in up to 80% of individuals (Donnelly, 2023). Though less well studied, pelvic floor dysfunction could also be present in male athletes and could manifest as stress urinary incontinence, erectile/sexual dysfunction, or pelvic pain (Giagio, 2021).


Risk factors for pelvic girdle pain in pregnant individuals from an extensive research review (Clinton, 2017) include:

· History of prior pregnancy

· History of orthopedic injury

· Work dissatisfaction

· High BMI

· High number of areas of pain near or at the pelvis

· Belief that their pain will not get better with conservative treatment


Many runners, triathletes, and active individuals often wonder what types of activity are safe and healthy to continue to engage in during pregnancy. It is important to be mindful of the potential risks of exercising during and after pregnancy without completely refraining from exercise (in most cases).


Even after pregnancy, getting back to running can take some work! Following pregnancy it is common for runners to exhibit dysfunctions (Christopher, 2020). These could include posture and biomechanical faults such as excessive low back lordosis or upper back rounding (kyphosis), muscle weakness in hip and core muscles, and flexibility deficits such as tightness in hip flexors and/or hamstrings. Furthermore, a high percentage of women returning to run after pregnancy have pain in the low back, pelvis, or hip areas and in by some estimates this could be as high as 90% of women (Christopher, 2020)! Having some guidance and knowledge on how to get back to running and exercising safely can reduce mental anxiety and also keep you on track to pursuing health and reducing injury risk. Some general guidelines on returning to running and activity that come from the British Journal of Sports Medicine are shown in the diagram below:




Figure Above From Donnelly, 2020


For more detailed information on factors to consider for running during and after pregnancy, check out this blog from Dr. Kate Mihevc Edwards Running for Two: What to Know About Running During Pregnancy and her related book: Go Ahead, Stop and Pee: Running During Pregnancy and PostPartum.


You may have questions about getting back to strength training after pregnancy and potentially related pelvic floor symptoms such as stress urinary incontinence. In a sample of recreationally active post-partum individuals (CrossFit participants), over half reported symptoms of urinary incontinence (Prevett, 2022). As you can see, pelvic floor dysfunction in runners and active populations is very common, but that does not make it NORMAL or acceptable. This is where Pelvic Physical Therapy can really help and can address YOUR individual needs better than any general medical advice can.


Strength training can be one important component of rehabilitation for runners before or after pregnancy looking to return to run, but is it safe?! Research and clinical experience suggest that it is but that it must be progressed safely and ideally with the help of a trained medical provider such as a physical therapist. It is important to note for many people, returning to running and high-level activity is a great possibility after pregnancy. In fact, researchers conducting a study on elite female marathoners and their performance after pregnancy report, “When age is considered, maternity does not have significant impact on performance development. World’s most competitive marathoners can still perform at their best level after pregnancy,” (Forstmann, 2022).


Why Pelvic Physical Therapy is Great for Runners


As discussed above, there are many reasons that Pelvic Physical Therapy can help runners during and after pregnancy including treating posture and biomechanical faults, strengthening weak muscles, improving flexibility and mobility, etc. There are also benefits of pursuing Pelvic Physical Therapy as a runner who is not peripartum. Runners have high incidence of musculoskeletal injuries in the areas of hip, knee, and low back, which as I’ve suggested could all be related to some underlying (or comorbid) pelvic floor dysfunction. These injuries could come with weakness in hip, core, back, and leg muscles; flexibility or mobility limitations, and/or poor running mechanics not to mention the various related issues that are seen with pelvic floor dysfunction such as muscle hyper tonicity, weakness, and/or breathing dysfunction.


These are all variables that Pelvic Physical Therapists are specially trained in and can help address (remember: “Common” does NOT mean “Normal”!). Pelvic floor dysfunction is not always addressed in orthopedic rehabilitation and physical therapy “as usual.” But, it can often be the missing ingredient in unresolving hip, buttock/posterior thigh, and back pain! In one case report, a runner experiencing persisting pelvic pain while undergoing physical therapy for hip and buttock pain had a full resolution of symptoms once pelvic floor muscle dysfunction was addressed in physical therapy (Podschun, 2013). As you can see, it is almost always a factor and of great importance to consider the role of the pelvic floor in cases of low back, hip, and upper leg pain when getting a runner back to pain-free activity and running!


*NOTE: this blog is not intended as individual medical advice. If you are in need of medical care, please seek out the advice and guidance of a medical doctor.


REFERENCES:

1. Christopher SM, Garcia AN, Snodgrass SJ, Cook C. Common musculoskeletal impairments in postpartum runners: an international Delphi study. Arch Physiother. 2020;10(1):19. doi:10.1186/s40945-020-00090-y

2. Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Womenʼs Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Womenʼs Health Physical Therapy. 2017;41(2):102-125. doi:10.1097/JWH.0000000000000081

3. Donnelly GM, Moore IS. Sports Medicine and the Pelvic Floor. Curr Sports Med Rep. 2023;22(3):82-90. doi:10.1249/JSR.0000000000001045

4. Donnelly GM, Rankin A, Mills H, De Vivo M, Goom TS, Brockwell E. Infographic. Guidance for medical, health and fitness professionals to support women in returning to running postnatally. Br J Sports Med. 2020;54(18):1114-1115. doi:10.1136/bjsports-2020-102139

5. Forstmann N, Meignié A, De Larochelambert Q, et al. Does maternity during sports career jeopardize future athletic success in elite marathon runners? European Journal of Sport Science. 2023;23(6):896-903. doi:10.1080/17461391.2022.2089054

6. Giagio S, Salvioli S, Pillastrini P, Innocenti T. Sport and pelvic floor dysfunction in male and female athletes: A scoping review. Neurourol Urodyn. 2021 Jan;40(1):55-64. doi: 10.1002/nau.24564. Epub 2020 Nov 2. PMID: 33137211.

7. Podschun L, Hanney WJ, Kolber MJ, Garcia A, Rothschild CE. Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. Int J Sports Phys Ther. 2013 Aug;8(4):462-71. PMID: 24175132; PMCID: PMC3812833.

8. Prevett C, Kimber ML, Forner L, de Vivo M, Davenport MH. Impact of heavy resistance training on pregnancy and postpartum health outcomes. Int Urogynecol J. 2023;34(2):405-411. doi:10.1007/s00192-022-05393-1

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