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.