The signal of pain is a warning that all is not well. What has caused that body part to be stressed? One has to consider the contribution of intrinsic factors that may directly or indirectly lead to the overload on the injured area, such as altered posture, muscle imbalances, stiff spinal joints or poor pelvic control.

For example, if a tennis player has a stiff thorax and upper back, in order to generate sufficient power while serving he may overload the shoulder, thus potentially developing a tear in the rotator cuff muscles.

Altered muscle function can directly affect the health of our joints. In the torso, the muscle control of the spinal joints and the large ball and socket joints – the shoulder and hip are intimately related.

Addressing the root cause

The nerves which drive the muscles throughout our body exit the spine in close proximity to the spinal joint. Substandard muscle control in the trunk invariably causes some spinal joints to become either stiff and/or overworked. This is associated with local inflammation, which can irritate the adjacent nerve. Sciatica is one manifestation of this. As these nerves supply the joints, muscles and related soft tissues in the limbs, when irritated, they can also contribute to other aspects of altered function in these ‘target tissues’, helping to explain the development and persistence of many limb symptoms such as ‘tendinopathy’, heel pain, shin splints, tennis elbow etc.

While it may well be necessary to treat the ‘sports injury’ locally to reduce symptoms, without addressing the intrinsic and spinal factors (by mobilising stiff joints, correcting posture and spinal control), the adverse neural input to the affected area probably does not change, and is therefore likely to recur, if it settles at all.

The possible causes of running related injuries are manifold. Current evidence recognises the role of the pelvis in many back and lower limb injuries.

How might the pelvis develop problems that could influence running?

Long periods of sitting commonly lead to inefficient collapsed sitting or ‘slouching’ where there is poor muscular support in the pelvis and spine. This way of sitting usually becomes habitual and over time, may contribute to the development of joint asymmetries and inadequate flexibility as well as poor muscle control and strength in the spine, pelvis and hips, potentially hampering your ability to run efficiently.

The pelvis is an important crossroad of posture and movement in the body – supporting the trunk above and controlling the legs below.

When the pelvis and hips have adequate and symmetrical flexibility and control, the pelvis can act as a proper platform of support for the spine and the lower limbs allowing satisfactory transmission of forces and absorption of the load of the body during the ‘single leg phase’ of the run.

When stiffness or imbalanced muscle activity develop around the hips and pelvis, further compensations in other joints such as the knees or spine are required to occur. This could also interfere with efficient propulsion of the body during the run where the natural momentum and energetic efficiency is damped, necessitating more repeated force generation – you have to work harder!

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Any asymmetry or imbalanced control in the body may also tend to abnormally direct the incumbent load to travel more through the path of least resistance – or your weak link in the system. This could be the feet (eg plantar fasciitis), the shin (eg shin splints, stress fractures, compartment syndrome), the knees (eg patello-femoral pain syndrome, iliotibial band friction syndrome), hips and groin (bursitis, snapping hip syndrome) and the low back.

More and more, research is demonstrating the role of the pelvis and hip control in the prevention and management of running related spine and lower limb injuries, as well as their potential to influence running training and technique.

Adequate training and technique together with reducing the frequency, distance and duration of the run have also been shown to play an important role in minimizing the risk of lower limb injuries associated with running.

You may be surprised to learn however, that there is insufficient evidence to support the role of lower limb stretching exercises and/or the use of shock absorbing shoe wear in the prevention of lower limb injuries associated with running.

Your physiotherapist can assess your pelvic posture, muscle flexibility and control, and gait biomechanics to further advise you on how to excel in your running and sports as well as how to minimize your risk of injuries.

Picture 1

When we ask our clients what they think is an ‘ideal’ sitting posture, most of them either have no idea or a vague notion of throwing their chests and rib cage forward by using a lot of unnecessary muscle tension (see picture 2). 

Picture 2

The spine is a column, with 3 natural curves – curves forward in the neck and lower back and a reciprocal curve backwards in the mid-back. These curves should be fairly much preserved when we sit and stand and during most daily activities. 

All column structures depend upon good foundations to support them – yours is in your pelvis. 

So in order to sit properly, the starting point is in the pelvic girdle. To find your ‘sitting bones’, roll your pelvis forward and back until you are sitting on the top front part of your sitting bones and not on the cheeks of your bottom. Then try and bring them slightly apart so as to ‘fan your tail’. You should feel that your spine elongates up and away from the pelvis naturally – and that you breathe more easily! 

Now check your breast bone – imagine 2 elastics both stretching from the centre of your breast bone to the front of each shoulder. Stretch these elastics to widen your chest, without throwing your ribcage forwards or pulling your elbows back (as in Picture 2). 

Make sure you aren’t tense or rigid here – but see if you can get better at feeling the ’inner lift’ and doing little movements from your sit bones – where you are ‘up’ yet supple and it feels ‘easy’. 

It is most important is that you stop the bad habit of crossing your thighs when you sit as this makes it more difficult to ‘sit properly’ – the spine risks being more stressed and developing pain and stiffness. 

A good sitting posture not only makes you look better, it also makes you feel so much better because you are turning on your ‘core muscles’ naturally and using them as part of your everyday function (picture 3). 

Picture 3

Initially, because of longstanding joint stiffness and muscle weakness it may be difficult for you to ‘sit properly’. You may need support from cushions or a lumbar roll to help you maintain this more ideal alignment 

If you are still not sure what an ideal sitting posture is, make sure you check with your physiotherapist when you come into the clinic.

There is mounting evidence that altered control of posturo-movement is associated with most musculoskeletal pain disorders. The basic problem is how the brain directs the muscles to work. Movement patterns begin to change with less options and variety in the performance of simple physical tasks, such as getting out of bed in the morning or bending to pick something off the floor, as well as more complex tasks such as running and sport. Much like worn out tyres on a car with bad wheel alignment, this can contribute to the development of various symptoms – strains, pains, sprains, aches, stiffness, ‘aging pains’, balance problems and so on. In a sense, our once good movement habits are unlearned by the brain.

Importantly, over time, the repetitive nature of these entrenched, less ideal movement habits mean that certain muscles in the body become overused and tight (hence the feeling of needing to stretch), while other muscles are hardly used and become weakened (hence the perceived need to strengthen).

Mind over matter

However, stretching and strengthening these muscles in isolation does not necessarily mean our brain relearns healthy movement habits, or that we are able to move with more ease and less discomfort. You cannot strengthen a muscle that the brain is not using! In the act of stretching and strengthening single muscles, poor patterns of motor control are often reinforced and we learn even more substitution habits to compensate – a short term solution.

Stretching and strengthening is mind over matter. Recognition and correction of these inefficient movement habits, with new awareness and correct guidance, is often the key to managing those aches and pains long term – much like saying what the mind perceives the body achieves.

The Key Moves™ Programme of Therapeutic Exercise and Movement Classes provides the opportunity to relearn effective control of ‘key movements’ while also incorporating elements of healthy ‘stretching’ and ‘strengthening’.

Instead, in many cases, it is linked to an inability to relax the pelvic floor muscle. Overactivity of this muscle has led to it becoming fatigued, irritable and tight, with a resulting loss of control over bladder function.

It is a common problem, affecting both men and women, and can take different forms (footnote 1).

So what can be done? Physiotherapy for urinary incontinence should work not only on improved control of the pelvic floor muscle, but also needs to focus on other movements linked to the pelvis – the way we sit and stand.

Most people don’t appreciate the fact that the pelvic floor also plays an important role in contributing to proper control of posture and movements of the pelvis – it is a primary muscle group contributing to our ‘core control’.

Research has shown that sitting and standing with a normal lumbar curve with the pelvis upright encourages automatic contraction of all the deep core muscles, including the pelvic floor muscle.  Sitting slumped or standing with a sway back reduces activity in the pelvic floor. (See articles on Core stability and Sitting properly).

It is important to work on this. Incontinence develops when the pelvic floor muscle (footnote 2) becomes inefficient, overactive or weak due to excessive downward pressure on the muscle as a result of a sustained increase in intra abdominal pressure.

This can occur for a range of reasons: pregnancy, vaginal birth, chronic cough, chronic constipation and straining, high impact sports, repeated heavy lifting, upper chest breathing, abdominal crunches, excessive abdominal bracing and poor posture.

Doing it the right way

When contracting their pelvic floor, many people do it incorrectly by flattening then tightening their abdominal muscles. They need to learn to relax the pelvic floor muscle as well as contract it while breathing properly without tightening and contracting the upper abdomen.

Your therapist can show you the right way and prescribe the best exercises for you.

To help with urinary incontinence there are also many things you can do as part of your daily activities.

To keep the pelvic floor muscle in good shape

• Sit upright with a lumbar curve. Don’t cross your legs. (see article on Sitting properly)
• Stand with your weight on both feet, only slightly apart and your pelvis aligned over your ankles. Stop the habit of clenching your buttocks
• Drink 2000ml of fluid daily, preferably water. Drink more if it is hot or you are exercising. Eat plenty of fibre
• Only urinate when you need to; break the habit of urinating ‘just in case’. Urinate 4-6 times a day only (300-350mls each time). Encourage the kids to urinate when they need to, not when it suits you!
• Contract and lift your pelvic floor muscle prior to lifting. Do not lift more than your pelvic floor muscle can handle

Using the toilet

• Sit; don’t hover over the toilet as the pelvic floor muscle can’t fully relax in this position
• Keep your lumbar curve in neutral, by sitting upright and lean slightly forward at your hips to allow the pelvic floor muscle to relax
• While urinating or defecating do not brace or bear down on the pelvic floor muscle. Relax your abdominal muscles while breathing into your abdomen
• After passing urine or faeces, contract and lift the pelvic floor muscle, then fully relax it.

When exercising:

• Aim to maintain the natural lumbar curve
• Ensure you breathe into your abdomen and avoid bracing with the upper abdominals, as this will increase the intra abdominal pressure. Always relax the pelvic floor muscle fully after actively contracting it
• Avoid high impact and explosive exercise (running, jumping) until your pelvic floor muscle is working effectively. For some this may mean avoiding this type of exercise all together. Abdominal crunches and ‘sit ups’ are not recommended
• Walking, swimming and supervised appropriate floor exercises such as our Key Moves™ exercise classes are recommended. Don’t avoid all exercise. Laugh lots and have great sex! 

Footnote 1

There are 2 types of urinary incontinence which may be present, in isolation or in combination:

Stress incontinence occurs where there is leakage of urine with a sudden increase in intra abdominal pressure e.g. when you cough, laugh, jump, sneeze, lift run or perform a sudden exertion.

Urge incontinence occurs when one feels the urge to urinate, even when there is only a few mls. of urine in the bladder. Thus, one releases small amounts of urine regularly.

The first type is a matter of physical control, the second is more mental, linked to habits and responses to cues.

Footnote 2

The pelvic floor muscle is a multi layered muscle that sits like a hammock at the base of the pelvis. It is slung between the sit bones (ischial tuberosities), the tail bone (coccyx) and the pubic bone in front. It specifically supports the bladder, the uterus and the bowel. It contains the muscle sphincters around the openings for the urethra (tube from the bladder), vagina and the anus and is therefore largely responsible for maintaining continence.