Neurokinetic Therapy® Blog

The Pelvic Floor-Overactive or Underactive?

Weakness of the pelvic floor muscles is associated with lower back pain, incontinence, constipation, and sexual dysfunction. The use of Kegel exercises to correct this is commonplace and widely utilized by physical therapists and Pilates instructors. When employed correctly these exercises can strengthen the core, the lower back, and the pelvic organs. Problems occur when these muscles are overactive and are inhibiting associated core and lower back muscles. Asking overactive pelvic floor muscles to perform Kegel exercises can lead to pelvic floor pain and irritation of the pudendal nerve. The question is then how do we determine if the pelvic floor muscles are overactive or underactive?

A simple way to determine this is to use manual muscle testing. For example, if the pelvic floor muscles are weak, other associated muscles will have to compensate and thus become tight and painful. Let’s say the obturator internus remains tight and painful despite your best efforts to release it. Have your client do some Kegels and then reevaluate the obturator internus. If the OI has become more pliable you know you’re on the right track. This technique can be applied to the psoas, quadratus lumborum, gluteus maximus, sacroiliac area, and the hip joints.

But what to do if the pelvic floor is overactive? Start by evaluating the core and lower back muscles for weakness. For example, if the psoas tests weak have the client tighten the pelvic floor and retest. If the psoas now tests strong you know it is being inhibited by the pelvic floor muscles. This process can be applied to all associated muscles. If you are familiar with manual release of the pelvic floor it would be appropriate to do that. If you’re not there is a simple way to release the pelvic floor muscles. With the client supine, have them bend their knees and turn them out at a 45° angle so that the soles of their feet are touching. Then have them place their hands on their knees. Release of the pelvic floor muscles occurs when the hands resist a superior/diagonal movement of the knees. It is important that only light resistance is applied. This technique works very well as a home exercise program which would include this movement first followed by strengthening of the inhibited muscle.

Determining if the pelvic floor muscles are overactive or underactive is crucial in their treatment. Exercising an overactive pelvic floor can lead to serious pain and nerve irritation. Exercising an underactive pelvic floor can lead to vast improvements in core strength and lower back, sacroiliac, and hip joint function. It is truly a double-edged sword.

12 Responses

  1. Alfiya

    Great article
    Worked really well with a patient of mine. She is now relieved of hrt chronic pain.
    Thank u

  2. Karla

    I have a very over active pelvic floor due to very weak glute muscles but I am working on it. How am I supposed to reach / touch / gently press on my knees when laying down as I can only reach half way up my leg unless I am sitting upright (engaging my core) or I could place an exercise ball between my knees and gently squeeze (as that seems to work). Can you provide / send me a picture? Thanks and much appreciated.

    • neurokinetictherapy

      Bend your knees to 90 degrees

  3. Nice article on the pelvic floor and I enjoyed the discussion on the relationships between other structures. I do have one question. I followed the idea of retesting muscles that are overactive after Kegels to see if activating the pelvic floor allowed them to soften. What I was confused about was the tightening of the overactive pelvic floor to see if it turned inhibited muscles back on (the psoas in the example above). Is this because, even though the pelvic floor is short and tight, it is unable to effectively engage?

    • neurokinetictherapy

      No, the psoas wasn’t engaging and the pelvic floor was helping

      • Ok, I understood that. But if the pelvic floor is OA and is inhibiting the psoas or if the psoas is inhibited causing the pelvic floor to have to work harder, why would further engaging the pelvic floor turn the psoas back on?

        • neurokinetictherapy

          Release the pelvic floor, don’t engage it further.

          • Jeremy

            I had the same question as Brian.

            “if the psoas tests weak have the client tighten the pelvic floor and retest. If the psoas now tests strong you know it is being inhibited by the pelvic floor muscles.”

            If it’s overactive, why would activating it further cause the hip flexor to test strong?

          • neurokinetictherapy


  4. Great article.

    • neurokinetictherapy

      take an NKT seminar

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