Brace yourselves: protecting your pelvic floor during CrossFit and loaded exercise

If you are a male and either currently participate in CrossFit workouts or another form of Olympic weightlifting, and have developed one or more of these symptoms: perineum pain with sitting, lower abdominal pain with intense activity or ejaculation, testicular pain that radiates to the abdomen or the vice versa, and urinary hesitancy with urgency and frequency, this blog is exactly for you. If you’re a woman who participates in high intensity sports training or weightlifting or CrossFit, this is also for you. And if you are a postpartum mom, or really anyone who has been thinking about kicking up their fitness regime to add higher intensity, increased load bearing activities, this is also for you.

I want to discuss a clinical pattern I have observed of multiple male patients with pelvic pain and core instability issues who also participate in a CrossFit-type exercise. I’d also like to approach the topic from a vantage point that differs from the previous contention that has surrounded CrossFit Games and pelvic floor physical therapists regarding stress urine leakage during certain competitive exercises (see the video that stirred up debate here). I’m hoping that my interest in the proper mechanisms of breathing, bracing, and postural cueing during heavy lifting may create a resource for this population to create connections within and between the pelvic health community and the gym. Ultimately I want to create a link for patients who feel that he or she may be the only human out there suffering from pelvic floor dysfunction and performing a high intensity sport. Our training as doctors of physical therapy emphasizes how important it is for us as health care providers to help patients try to get back to their functional goals. For many women high intensity lifting can lead to stress incontinence, particularly if proper training is lacking. For many men I’m seeing a possible link between pelvic pain and improper form during lifting activities. How can physical therapists help patients with pelvic floor dysfunction get back to a high intensity sport such as weightlifting?

Let’s start with the core stability angle:

When I examine my patients I always check their abdominal wall. In my physical exam I tend to find many male patients with the above listed symptoms present with a physiologic phenomena called diastasis recti (DR),which is defined by a separation of the right and left rectus abdominis muscles–what we typically think of as the “6-pack”–along the midline.¹ The separation most commonly occurs in postpartum women at the linea alba, or vertical band of connective tissue connecting the two sides of the abdomen. DR occurs at the linea alba due to excessive pressure and stretch on the abdominal wall from the internal organs. Often, this separation can extend beyond two fingers width, which creates a deep cavern between the two sides of the abdominals. What lies beneath your rectus abdominis muscle is the peritoneal cavity, or the sheath of fascia containing your digestive organs.² Research suggests that DR be linked to impairments of core stabilization support mechanisms that may contribute to the development, or recurrence of, pelvic floor muscle dysfunction.³

The medical and fitness communities mostly talk about diastasis recti in terms of postpartum women, but what we don’t discuss is that the separation of the rectus abdominis muscle can affect men as well. To familiarize yourself with the anatomy and rehabilitation of a diastasis recti (DR), check out Malinda’s blog here. To read about the most recent research on rehabilitation of the abdominal split check out Jandra’s blog here. The truth is there’s not a lot of research on the prevalence of male diastasis recti, or much research on the causation of DR on the non-childbearing population. A study done in 2007 examined the prevalence of DR in a population of patients with urogynecological impairments (meaning pelvic organ prolapse, urinary symptoms, or pelvic pain). Of the 541 female patients in the study, 81 (52%) presented with DR, and 15% of these women were nulliparous (non-childbearing). Of the nulliparous women, 28 (35%) had DR.⁴ The literature suggests that in both nulliparous women and in men DR may be related to activities that create repetitive mechanical stress on the linea alba, such as sit ups, prolonged increases in abdominal pressure, or obesity.⁵

Given the apparent link for DR and increased stress/pressure on the connective tissue of the abdominal wall, PTs and movement specialists usually advise against exercises like sit-ups, Pilates roll-ups, plank-type exercises, quadruped or downward dog-type positions, and motions like double leg-lowers other exercises in Pilates-type work where you support the weight of legs with abdominal wall should be avoided during recovery, as these exercises can increase pressure on the weakened abdominal wall and push the organ contents toward the stressed opening. Again, there is a gap in the literature on this topic in men, but I did locate a systematic review that looked at the effects of exercise of DR in antenatal and postnatal periods. Benjamin et al. 2014 states: “The abdominal wall has important functions in posture, trunk and pelvic stability, respiration, trunk movement and support of the abdominal viscera. An increase in the inter-recti distance puts these functions in jeopardy, and can weaken abdominal muscles and influence their functions. This may result in altered trunk mechanics, impaired pelvic stability and changed posture, which leave the lumbar spine and pelvis more vulnerable to injury.” Given the extra vulnerability DR presents to lumbar spine stability as well as pelvic floor function, rehabilitating the core stability of patients with this impairment seemed all the more vital to eliminating pelvic dysfunction and low back pain.

My fitness and training background is in Pilates, not weightlifting, so despite my basic knowledge of what a proper squat technique should include, I decided to call an expert strength and conditioning coach and a fellow doctor of physical therapy, Sean McBride,DPT, OCS, who also happens to train at SF CrossFit. When I told him about my patients he didn’t seem at all surprised; he said that breathing and bracing problems are common within the sport and need to retrained just like any other postural issue impeding progress and risking injury. He noted that in his practice he often finds a lack of coordination in fundamental diaphragmatic breathing, which is one cause of DR. If you lift weights, the term “core bracing” or just “brace” the spine is probably somewhat familiar–many of my patients say that their trainers tell them to “arch their backs” when performing deadlifts or squats, to help keep their form, but also report “holding their breath” during a lift or not being aware of their breath at all during the exercise. As I spoke with Dr. McBride about the various improper breathing techniques that can lead to core and pelvic dysfunction in lifting, it became clear that a trained eye is necessary when you’re just getting started in the sport of weightlifting. One similarity between weight training and Pilates is the importance of a good breathing technique. I can attest to the fact that teaching correct breathing is the most difficult aspect of teaching any movement process.

Breathing is automatic, but that doesn’t mean that the breath doesn’t often require rehabilitation in and of itself. The lungs fill and deflate based on intricate intra-pulmonary pressure ratios that are far too complex for this blog. Inhale and exhale are ruled by the diaphragm, our primary respiratory muscle, and by the intercostal muscles (between your ribs); accessory muscles that help with breath are the anterior neck muscles, the abdominals, and even the pectorals, the lats, and the quadratus lumborum. The diaphragm is integral to the core musculature and function: it forms a dome-like structure like an expanding umbrella under our rib cage and is the top of the “core canister” that is completed by the pelvic floor “bowl” at the bottom of the canister. As we inhale the diaphragm contracts and descends downward toward the pelvic floor, and our lungs expand. As we exhale the diaphragm releases and pushes the air out of the lungs. One main school of thought around diaphragmatic breathing and proper intra-abdominal pressure is from the Postural Restoration Institute (PRI), which focuses on on “balloon breathing” and retraining what they call the “Zone of Apposition,” or ZOA. The ZOA is essentially the upper dome-shaped part of the diaphragm and the expansion and contraction space it claims underneath our lower rib cage. PRI utilizes a breathing rehabilitation technique called “balloon breathing” to retrain a functional ZOA… if that just sounds like a lot of acronyms, read Rayner and Smale’s blog post on the topic and watch the instructional video she includes to get an idea of how this technique works.

As the thoracic cavity is continuously altered with the breath, so is the abdominal and pelvic cavity, in somewhat of the same way that a piston-like pump would contract and retract, therefore affecting the pelvic floor muscles in kind. The pelvic floor responds to the inbreath by slightly eccentrically lengthening, and reflexively relaxes to normal resting position with exhale. We can alter this natural rhythm with added thoracic pressure, for example during bowel movements: When pooping one often braces the abdominal cavity on an inhale (the diaphragm is contracted) and accentuates the eccentric contraction of the pelvic floor thereby promoting the rectal contents to be pushed out. In extreme cases this would equal straining. When maintaining continence during a higher intensity exercise like landing during a jump, one may contract the pelvic floor as the core braces the spine for impact. As you can imagine, there are more than several ways that the neuromuscular function of the breath can be the opposite of the above.

This breath holding, or Valsalva maneuver, is described as taking a breath and forcefully exhaling against a closed mouth, glottis (throat), and nose–and is often utilized when performing a task where we need abdominal and spine stiffness to help create more force. Baessler K. et al, 2017 examined the effects of the Valsalva maneuver versus straining on the bladder neck and the pubrorectalis pelvic floor muscle on continent and incontinent women. They concluded that valsalva and straining are two different tasks, and that the pelvic floor is stiffer  when utilizing valsalva techniques, leading to increased bladder neck support. Straining appeared to  increased stress on the bladder neck and pelvic floor muscles.  In the case of a female athlete with stress incontinence issues, a stiff pelvic floor may indicate a tight but weak set of muscles that are unable to hold urine in under great stress. In the case of a male who has difficulty urinating and presents with a weak stream, this can indicate similar conditions; a tight, hypertrophied pelvic floor that is paradoxically contracting when it should be relaxing. This may be explained by overcompensation during bracing techniques. I came upon a blog by elitefts regarding proper weightlifting that highlighted the difference between “just breathing” and “bracing,” which illustrated why “Valsalva,” “straining,” and “bracing” are all terms we should be able to define when watching our patients perform movements. I also appreciated their graphics which highlighted the Dynamic Neuromuscular Stabilization (DNS) teachings on development and rehab, and how inaccuracy or interchanging the terms could create problems based on poor technique and posture during increased intensity.

Sean McBride, DPT, agreed; He discussed a very common error in form is where the lifter can’t maintain adequate spinal extension while simultaneously maintaining deep hip flexion, i.e. the squat, and states that he uses DNS-based breath retraining for correction of faulty breathing patterns under load. He emphasized that a common squatting compensation is to “flare” the front of the ribs forward and stick your pelvis behind you to arch the lumbar spine. If one braces here, the forces of the breath will push outward and downward to the weakest links: the rectus abdominis linea alba and the pelvic floor. Hence, re-learning to breathe properly in a supine position (on your back) is the first step towards regaining the neurological connection to our core stability that we once had as babies. Once supine breathing feels natural and the core muscles are able to stabilize the spine while moving the limbs as challenging levers, the progression is to breath and stabilize in sitting, then standing, then isometric exercise, then light loading, and finally testing body limits by loading or challenging stability, tempo, or both.

This was really my central reason in calling Sean and discussing this topic with other sport rehab specialists; I had a hunch that what was happening with these patients during lifting began with faulty posture and was leading to pelvic floor compensation. To be fair, I think 99.9% of us all struggle with deep, coordinated breathing–don’t be ashamed–it’s a national crisis that diaphragmatic breathing is more challenging for most of us then double-unders! But the importance of breath can’t be underestimated, regardless of your sport or activity. Diaphragmatic breathing has not only been found to help increase our parasympathetic nervous system (rest and digest), but to help us access a deeper connection to our core musculature, and is the central stimulator for our neuromuscular connection to healthy posture, stability, and even digestion related actions.^6,7,

To close this chapter of an increasingly complex conversation, Dr. McBride left me with a reminder that in efforts to return to our previous activity intensity we must also adhere to the basic principles of tissue healing. Injury recovery takes a strategic process based on specific tissue healing phases: 

1. Acute phase ( one to seven days post injury): Goal is to control inflammation and pain, Rest-Ice-Compression-Elevate (RICE)
2. Subacute phase (day five up to two to three weeks): Goal is to begin therapeutic movement–typically the best time for physical therapy. Isometric exercise and form are paramount.
3. Remodeling phase ( one to six weeks): Goal is to encourage normal ranges of flexibility and motion; begin to challenge the tissue by gradually loading.
4. Functional phase (six weeks to six months): Goal is returning to sport without re-injury; here we would begin to challenge load and speed.

Physical therapists are movement specialists, but there are a lot of people in the fitness and training industry who are excellent resources in rehabilitation, just make sure you vet your trainers, as you would any other product you would invest in. CrossFit and bootcamp type workouts are popular because we value community–it helps hold us accountable, shares with us our accomplishments, and lifts us up when we are low. But community can also present peer pressure or Fear Of Missing Out, and despite pain, people push themselves beyond their own tissue’s capability. I think this speaks to the complexity (and visibility) of the injury–a tear of the ACL ligament and surgical repair is a thoroughly researched and well documented injury recovery, however, injuries of the pelvic floor are not only minimally researched, they aren’t even spoken of! Many men (and women) spend months, even years, on multiple rounds of antibiotics, undergo injections for pain and neural blocks, take numerous medications, and even have surgeries that didn’t address their pain. By the time they find a pelvic floor physical therapist, often frustration, depression, and lack of hope are among the impairments that a patient is dealing with. It’s fairly easy to find a PT to help you reload your knee post surgery, but it isn’t quite as common to ask your weightlifting coach for pelvic floor guidance.The first step is being able to demystify the condition, ask for guidance and a referral, and get to a pelvic health PT, and then begin the steady (albeit often slow) climb back to full function. If you are a reader who finds yourself in the category where your trainer jams his knee into your back to emphasize “proper” spine form during a squat, and there’s no emphasis on the abdominal canister stabilization, you may be in the market for a PT or a sports conditioning coach who has a background in DNS or PRI. If you are someone who finds themselves straining to urinate, experiencing pain in the perineum while sitting, or feel sharp pains in your testicles after workouts or ejaculation, this may also be a sign that you are due for a breathing tune-up and a pelvic floor physical therapist.

Special thanks Dr. Sean McBride, DPT, OCS, for his interview and helping to create an awareness around complex topics in training. You can find him here.

References:

1. Turnage RH, Badgwell B. Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperitoneum. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 45
2. Spitznagle T, Leong F, Van Dillen L. Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J (2007) 18:321-328.
3. Sapsford RR, Clarke B, Hodges PW. The effect of abdominal and pelvic floor muscle activation on urethral pressure. World J Urol. Jun;31(3):639-44.
4. Urquhart DM, Hodges PW, Allen TJ, Story IH. Abdominal muscle recruitment during a range of voluntary exercises. Man Ther. 2005 May;10(2):144-53.
5. Baessler K, Metz M, Junginger B. Valsalva versus straining: There is a distinct difference in resulting bladder neck and puborectalis muscle position. Neurourol Urodyn. 2017 Jan 31.
6. Stafford RE, Coughlin G, Lutton NJ, Hodges PW. Validity of Estimation of Pelvic Floor Muscle Activity from Transperineal Ultrasound Imaging in Men. PLoS One. 2015 Dec 7:10(12)
7. Egger MJ, Hamad NM, Hitchcock RW, Coleman TJ, Shaw, JM, Hsu Y, Nygaard IE. Reproducibility of intra-abdominal pressure measured during physical activities via a wireless vaginal transducer. Female Pelvic Med Reconstr Surg. 2015 May-Jun;21(3):164-9
8. Dynamic Neuromuscular Stabilization Program, Prague School of Rehabilitation (DNS).
9. Janssens L, et al. Inspiratory muscle training affects proprioceptive use and low back pain. Med Sci Sports Exerc. 2015 Jan; 47(1):12-9.
10. Perciavalle V, et al. The role of deep breathing on stress. Neurol Sci. 2017 Mar, 38(3):451-458.
11. Rayner & Smale: Physiotherapy Blog. Sharing Knowledge and Encouraging Growth.  http://www.raynersmale.com/about/
12. Elitefts blog