Experts explain why a strong pelvic floor is so important for runners, plus what to look for to make sure your muscles can withstand kilometrage.
Maybe it happened during the final sprint of a big race, or on a cross-training day as you knocked out a series of double-unders with a jump rope: You suddenly realise the wetness you feel in your shorts isn’t sweat, it’s urine. Certainly, it’s an embarrassing turn of events, but stress incontinence (the loss of urinary control in response to a stressor, like exercise, laughing, or sneezing), is an incredibly common problem that’s a frequent sign of a weak pelvic floor.
But it’s not the only sign, and having a weak pelvic floor can negatively affect your life—and the enjoyment of your sport. It’s important to know what symptoms to look out for so you can identify any pelvic floor problems and then take steps to correct them.
Most Common Sign of a Weak Pelvic Floor
Urinary incontinence is by far the most well-known symptom of pelvic floor muscle weakness.
When these core muscles (yes, the pelvic floor muscles are considered part of your core) are weak, they have more difficulty contracting and supporting the bladder and other pelvic organs to prevent leakage. This is particularly true when the muscles and the bladder are placed under stress, as happens with sneezing or jumping up and down, for instance.
While rates of urinary incontinence vary widely by population and age, data compiled in StatPearls in 2022 indicates that 24 to 45 percent of women over the age of 30 experience stress urinary incontinence. This is largely due to pelvic floor dysfunction which may be attributed to weak pelvic floor muscles. And even more to the point, a study published in 2017 found that, when analyzing 245 women between the ages of 18 and 40, those who participated in high-impact sports or who registered a high volume of sports-related training were more likely to experience incontinence, compared to who were less physically active or who selected lower-impact activities.
While not all urinary incontinence can be attributed to weak pelvic floor muscles, it’s important to acknowledge that this is a major symptom of weakness and that it’s not something to simply ignore. Just because stress incontinence is common among women, particularly among active women, that doesn’t mean it’s “normal,” or that there’s nothing you can do about it.
3 Less Common Symptoms of Pelvic Floor Weakness
To understand why weak pelvic floor muscles may contribute to other problems, it’s helpful to understand the function of the pelvic floor.
“The pelvic floor serves five main functions: to support the pelvic organs housed within the pelvis, to open and close to allow for healthy urination and bowel movements, for sexual penetration, stability for the trunk with movements, and as a ‘sump pump’ for the lymphatic system,” explains Laura Calko, a pelvic floor occupational therapist and owner of Calko Pelvic Rehabilitation and Wellness in Canfield, Ohio. “A weak pelvic floor can cause one of these vital functions to stop doing their job, sometimes leading to conditions like urinary incontinence, constipation, pelvic organ prolapse, or pain with sex.”
Because the pelvic floor plays a role in many functions of the body, symptoms of weakness can show up in other ways:
One of those five main functions that shouldn’t be underestimated is the role of core stability with movements. “The pelvic floor is the connection between your upper and your lower body and between the right and left sides of your body,” says Kathleen Kilburg, M.P.T., A.T.C., a specialist in pelvic health and the owner of The Bladder Coach. “It is the crossroads of many muscles, nerves, and blood vessels and it is integral for the stability of your pelvis and lumbar spine, especially during higher-level activities.”
If you have poor core stability, you may be at greater risk of injury. This is because you need to stabilize your trunk to maintain balance and move smoothly and in a coordinated fashion, transferring energy between your lower and upper body.
If your pelvic muscles are weak, and your trunk is less stable, you’re going to be more likely to have inefficiencies in your biomechanics or muscular compensations that negatively affect the way you move. One bad or awkward movement, or chronic muscle or joint compensations that place increased stress on areas that aren’t intended to support such movements could be the reason you end up injured.
“Pelvic floor muscle weakness can contribute to orthopedic conditions. Most people aren’t aware of this very important connection,” explains Heather Jeffcoat, D.P.T., the owner of Femina Physical Therapy in Los Angeles and president of The Academy of Pelvic Health Physical Therapy. “When your pelvic floor is weak, it can contribute to low back pain, hip pain, and pelvic girdle pain.”
Active individuals are often no strangers to low back or hip pain, but they may not immediately connect it to pelvic floor dysfunction, so it’s important to be cognizant of the fact that they can be connected. “It’s important to reflect on how your activities impact these symptoms, especially if you notice they get worse. It’s a red flag for pelvic floor dysfunction, and a work-up with a urogynecologist and pelvic floor physical therapist are your next steps to developing a solid treatment,” says Jeffcoat.
3. Gastrointestinal Problems
If you’re constantly dealing with constipation, or you can’t keep yourself from passing gas, these may also be symptoms of pelvic floor weakness.
The thing is, a strong pelvic floor is designed to help control and assist with opening and closing the sphincters of your anus. If you lack control, or you don’t have the strength or range of motion to help support these movements, you may end up with embarrassing gastrointestinal problems from constipation to gas incontinence (not being able to stop yourself from passing gas) or even fecal incontinence. And here’s the catch—it’s possible to have tight and weak pelvic floor muscles which can further complicate the problems.
“Just because your pelvic floor is tight does not mean it’s strong. Oftentimes, I see clients who have high-tone pelvic floors but are unable to contract their pelvic floors well because they lack the full range of motion of the pelvic floor muscles,” Calko explains. “Signs of a weak or dysfunctional pelvic floor may include constipation that doesn’t go away with diet changes.”
Why Runners Should Take Note of Weak Pelvic Floor Muscles
The thing about pelvic floor weakness is that it can directly influence a person’s sports participation, particularly when stress urinary incontinence is present. “Urinary incontinence can be a primary reason people leave their sport, including running. Whether it’s an elite athlete or a new mom struggling to return to exercise, many patients just stop running, and in doing so, lose one of their primary coping mechanisms for stress and mood,” notes Jeffcoat.
Beyond urinary incontinence, the biomechanics of running inherently increase the risk for other symptoms when a weak pelvic floor is present. “Running is a series of single-leg stance positions done repeatedly. Without pelvic floor strength, your hip mechanics may be altered, putting increased strain on the lateral hip, leading to hip bursitis or iliotibial band syndrome. It can put increased pressure on the medial knee, causing knee pain. It can also put extra strain on the foot and ankle,” says Kilburg.
In other words: If you want to run healthy and pain-free, you need to pay attention to the pelvic floor.
Populations Most at Risk of Weak Pelvic Floor Muscles
While women are certainly at a higher risk of pelvic floor dysfunction than men, that doesn’t mean men can’t be at risk, too. “No one is immune to pelvic floor dysfunction—it can happen to anyone, as we all have a pelvic floor,” says Jeffcoat.
That said, those at highest risk are women who fall into specific categories. “Folks who have been pregnant and are entering menopause or post-menopause are typically the higher risk groups,” says Jeffcoat.
Elite female athletes in higher-impact sports, like gymnastics, soccer, or CrossFit, are in a high-risk group for urinary and bowel incontinence. And more than 50 percent of elite track and field athletes have also reported urinary incontinence symptoms during training and competition, Jeffcoat adds.
Unfortunately, those aren’t the only groups who demonstrate a higher risk for pelvic floor weakness. Jeffcoat notes that individuals who have a history of straining to poop or pee are constantly straining their pelvic floor, which can increase the risk of dysfunction.
Also, it’s not just women who have been pregnant who are at risk—the number of pregnancies and size of the babies can make a difference, as well as other lifestyle factors. “Having multiple pregnancies or large babies during pregnancy, and individuals who are obese or who live a sedentary lifestyle are also at risk,” says Kilburg.
If you fall into any of these categories (or several of them) and you’re experiencing stress-related urinary incontinence, it’s likely time to schedule an appointment with your doctor or a pelvic floor therapist.
What Should You Do About a Weak Pelvic Floor
If you’re experiencing symptoms associated with pelvic floor weakness, it’s important to have an evaluation. While you may have heard that knocking out a few sets of kegel exercises is the solution for a weak pelvic floor, it may not be appropriate right off the bat.
“It’s typically not appropriate to start with pelvic floor strengthening,” says Jeffcoat. “What is more often found are tight or overactive pelvic floor muscles, which are still weak, but strengthening will only feed into the dysfunction, making them shorter and tighter. The more appropriate treatment plan is to work on flexibility of these muscles, guided by a pelvic floor physical therapist, then progress to pelvic floor coordination, and finally, strength training.”
Running can also impact the proper course of action when it comes to assessing and addressing the underlying causes of pelvic floor weakness. “Addressing a weak pelvic floor goes beyond just strengthening it; it also means assessing and potentially altering one’s running posture, the force of impact, and where the foot strikes. All of this impacts how much force is repeatedly placed on the pelvic floor, which over time causes strain and weakness,” explains Calko. It’s only after a full assessment is done that the proper therapy can be prescribed, which is likely to include a lengthening and strengthening exercise regime.
Calko also emphasizes that it’s important to pay attention to your intra-abdominal pressure throughout the day. “Things like holding one’s breath, engaging in high-impact activities with regard to posture or force or impact, or chronically clenching one’s abs can lead to pelvic floor dysfunction. My number one recommendation for clients is to work on a good 360-degree breathing pattern to avoid holding their breath throughout the day,” says Calko. And she, like the other experts, emphasizes that most importantly of all, you should reach out to a pelvic floor therapist in person to receive “a thorough and individualized assessment and treatment.”