The Ankle Bone is Connected to the Pelvic Floor Muscle Function

By: Shannon Pacella, DPT, PHRC Lexington

With Halloween just occuring, I had been seeing skeleton decorations everywhere and it got me thinking about anatomy. Cue the ‘Dem Bones’ song we sang as kids – “the knee bones connected to the thigh bone, the thigh bones connected to the hip bone,” the ankle bones connected to the pelvic floor…wait, I didn’t think that’s how the song went!

So the ‘ankle bone’ (the ankle is a joint) does not directly connect to the pelvic floor, but it may have some influence on pelvic floor muscle function. I wanted to explore this further and found a few research articles that looked at just that – how ankle position affects pelvic floor muscle (PFM) contraction. Most of the research I found looked specifically at how this may affect people with stress urinary incontinence (SUI).

Here’s a quick overview of ankle positions I will be mentioning:

Ankle neutral/horizontal is when the feet are flat on the ground.
Ankle dorsiflexion is when the heels are down and toes are lifted upwards; this can be done passively (with a wedge under the toes or actively by using your muscles to lift the toes up).
Ankle plantar flexion is when the toes are down and the heels are lifted upwards (position of feet in high heels); this can be done passively with a wedge under the heels, or actively by using your muscles to lift the heels up).

Photo by Connexions

The first research article Relationship between ankle position and pelvic floor muscle activity in female stress urinary incontinence by Chen et al., looked to determine whether pelvic tilt, as changed by various ankle positions, influences PFM activity in women with SUI.¹ 39 women who had been diagnosed with SUI were instructed to perform three maximal PFM contractions, with a ten second rest between each contraction; PFM activity was measured by electromyographic (EMG) biofeedback via intravaginal probe and surface electrodes.¹

The three different positions being tested were:

Horizontal standing – neutral pelvic tilt posture.
Standing with the ankles dorsiflexed (passively on a board inclined 15 degrees) – this results in anterior pelvic tilt posture (butt/tailbone sticking out).
Standing with the ankles plantar flexed (passively on a board declined 15 degrees) – this results in posterior pelvic tilt posture (butt/tailbone tucked underneath).

Maximal PFM contraction was highest in standing with ankles dorsiflexed, second best maximal PFM contraction was in the horizontal standing position, and the weakest maximal PFM contraction was in the standing with ankles plantar flexed position. The anterior pelvic tilt provided increased PFM activity during ankle dorsiflexion. This movement (anterior pelvic tilt) results in the closure of the urethra, bladder neck, and suburethral vaginal wall, and urethral support is elevated.¹ These findings may be helpful when treating those with SUI, to train PFM contractions in a standing position with toes lifted by a wedge/towel roll and in an anteriorly tilted pelvic posture.

A second research article by Chen HL et al. entitled, The effect of ankle position on pelvic floor muscle contraction activity in women, looked at the effects of passive and active ankle flexion positions on PFM activity.² When this study was done, there were no other known studies that had looked at active ankle positions and PFM activity. The researchers hypothesized that active ankle positions would result in greater PFM activity.² 31 women comprised of a mix of those with and without SUI, were instructed to perform the same amount and timing of PFM contractions (three maximal PFM contractions, with a ten second rest between each contraction) that were measured with the same equipment (EMG biofeedback via intravaginal probe and surface electrodes) as the previous study.

The nine different positions being tested were:

Horizontal standing (HS)
Standing passive dorsiflexion with 2.5cm block under toes (2.5 DF)
Standing passive dorsiflexion with 4.5cm block under toes (4.5 DF)
Standing active dorsiflexion (DF)
Standing active dorsiflexion with arms raised up (DFAU)
Standing passive plantar flexion with 2.5cm block under heels (2.5 PF)
Standing passive plantar flexion with 4.5cm block under heels (4.5 PF)
Standing active plantar flexion (PF)
Standing active plantar flexion with arms raised up (PFAU)

The image below was included in the research article² to give you a better idea of each position.

Chen HL, et al. The effect of ankle position on pelvic floor muscle contraction activity in women. Urology. 2009 March; 181:1217-1223

The greatest PFM contraction was seen in the active plantar flexion with arms up position (PFAU); the second best position for PFM contraction strength was in passive dorsiflexion on a 4.5cm block (4.5 DF).² The researchers suggested that the PFAU position resulted in simultaneous abdominal, back, thigh, and leg muscle contractions in order to maintain posture.² This co-activation of surrounding muscles enhanced the PFM contraction force.

So what do these findings mean for clinical practice? This research has shown that different ankle positions can influence PFM contraction by changes made in pelvic positioning and surrounding muscle co-activation, which means the ankle bone is indirectly connected to the pelvic floor!

The first study found that passive ankle dorsiflexion resulted in an anterior tilt of the pelvis which enabled a stronger PFM contraction than posterior pelvic tilt (found during passive ankle plantar flexion). So even if you take the ankle movement out of the equation and just focus on pelvic position, it seems from this study that a more anteriorly tilted pelvic position may result in a stronger PFM contraction. To achieve this ideal anterior pelvic tilt position, I would recommend not going into the end range, but finding the position about halfway between a neutral pelvic position and the end range of anterior tilt. I explain this to patients by saying, “place your hands on your hips and gently rotate your hips forward so your fingers move downward and your thumbs move upward, and allow your buttocks to stick out slightly; make sure your hips are not rotated so far forward that they cannot go any further, you want to be about halfway between your starting point in a neutral position and the furthest forward you can rotate your hips.” This can be a helpful cue for patients during various PFM strengthening exercises in sitting, standing, and supine/hook lying positions. The second study found that active plantar flexion with arms raised up allowed for the strongest PFM contraction, which could have been secondary to other muscle group co-activation. That being said, when treating people with PFM weakness, I believe it is important to incorporate various challenging positions while performing the PFM strengthening exercises, when appropriate. This may include the PFAU position which I would have my patients get into by saying “stand on your tiptoes and raise your arms up to the ceiling.” But there are many other options that can facilitate muscle co-activation and potentially enhanced PFM contractions, such as standing on one leg, wall sit position, and side plank position to name a few.

If you are experiencing stress urinary incontinence or other symptoms that may be related to PFM weakness, the first step is to find a pelvic floor physical therapist, here at the Pelvic Health and Rehabilitation Center, we are happy to help! Each physical therapist will be equipped in giving you an individualized treatment and exercise plan to help achieve your goals. To learn more about pelvic floor physical therapy evaluation and treatment, click here. To find a pelvic floor physical therapist near you, click here.

Resources:

Chen CH, et al. Relationship between ankle position and pelvic floor muscle activity in female stress urinary incontinence. Urology. 2005 Aug;66(2):288-92.
Chen HL, et al. The effect of ankle position on pelvic floor muscle contraction activity in women. Urology. 2009 March; 181:1217-1223.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.