Clinical gains like heavier loads lifted and race PRs crushed while simultaneously resolving pelvic health issues shows value. However, demonstrating an association between performance and pelvic health via peer reviewed research holds added weight. We need both.

Quantifying the Impact

Efforts to quantify the impact of pelvic health issues on performance have been made. Data indicates that fit and athletic folks leave or modify their participation in physical activity due to pelvic health symptoms.

• 41% percent stop and 38% modify physical activity due to urinary incontinence (UI). (Cook et al. 2021)

• 75% of those with pelvic organ prolapse (POP) and 60% of those that report anal incontinence (AI) stop or modify exercise. (Cook et al. 2021)

• Urinary Incontinence was the most frequently named barrier to exercise in 18-55 year olds (reported over lack of time and musculoskeletal injury) (Dakic et al. 2022)

• Approximately 2/3 of those that reported POP or UI as an exercise barrier stopped exercising entirely. (Dakic et al. 2022)

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Qualitatively Defining the Impact

While this suggests an impact on how intensely one might play or run, choosing an alternative activity, or that someone may stop participating entirely, it doesn’t get at the direct effect of pelvic health on how folks perform. To do that we had to look beyond quantifiable outcomes typically tied to performance like speed, load, PR, etc. Instead, we needed to get at it by looking at indirect variables such as the mental load of symptoms, the ongoing awareness of pelvic health symptoms or the evidence of something like a visible leak has on an athlete’s performance. How heavy was that extra load that athletes carried?

Turns out it’s a lot.

• Dancers reported loss of concentration, worries about visible leaks or odors, reduced training, and fear of re-occurance (Winder et al. 2025)

• Rugby players reported changing body positions during contact, changing techniques or speed in non-contact activities, and reducing weight training (McCarthy-Ryan et al. 2024)

• Rugby players also reported reducing training intensity, activity avoidance

  and loss of concentration during sport (Dakic et al. 2025)

• World Athletics U20 track and field athletes (multiple sports) reported loss of concentration, mistakes in performance, and adjusted movements to avoid discomfort (Giagio et al. 2025)

• Elite female athletes (multiple sports) reported embarrassment, fear, concern/worry, annoyance, and frustration (Culleton-Quinn et al. 2022; Giagio et al. 2025)

• Of the 41.7% of elite female power lifters and olympic weight lifting athletes that reported stress urinary incontinence, 87.8% reported that symptoms had a negative influence on performance. They cited similar concerns as reported above-loss of concentration, avoiding symptom triggering training activities, and visible leakage, etc. (Skaug et al. 2022)

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Nevertheless, She Persisted

Cited studies quantifying fitness modifications and attrition have primarily been performed with recreational athletes. It is notable that in the elite athlete qualitative studies above, the tendency was for the athletes to carry-on and utilize coping strategies such as dehydration, use of pads, increased frequency urination during or pre-voids prior to training or competition (Culleton-Quinn et al. 2022; Skaug et al. 2022). Often, athletes assume pelvic health issues are to be expected in athleticism, are unaware of solutions, or haven’t had any practitioners inquire about symptoms (Dakic et al. 2023; Bosch-Donate. et al 2024)

While these strategies may somewhat address the invisible weight of some symptoms (visible leaks for example), they do not address how altering movement, avoiding training, or loss of concentration may impact competition preparation or game-day performance. In addition, it may be worth considering the injury vulnerability that may result from reduced training, on-field movement pattern changes, and reduced concentration.

We Are IN

While the current data suggests more of an indirect effect of pelvic health on performance, it is reasonable to suggest that this is our IN to start conversations (or bolster existing ones). Female athlete pelvic health is starting to gain a lot of attention, and now we have more information to help coaches, trainers, strength pros, and the sports med community understand the value of addressing pelvic health as a building block toward whole athlete health, performance, therapeutic alliance, and sport longevity.

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References

1. Cook J, Frawley H, Dakic J, Hay-Smith J, Lin KY. Pelvic floor disorders in exercising women: impact on participation, symptom disclosure and screening. J Sci Med Sport. 2021;24(Suppl 1):S56. doi:10.1016/j.jsams.2021.09.142

2. Dakic JG, Cook J, Hay-Smith J, Lin KY, Ekegren C, Frawley HC. Pelvic Floor Symptoms Are an Overlooked Barrier to Exercise Participation: A Cross-Sectional Online Survey of 4556 Women Who Are Symptomatic. Phys Ther. 2022;102(3):pzab284. doi:10.1093/ptj/pzab284

3. Winder BR, Heineman H, Scherb E. Prevalence and Impact of Urinary Incontinence and Other Pelvic Floor Symptoms in Female Aerialists. Journal of Women’s and Pelvic Health Physical Therapy. 49(1): 2-25; 35-44.

4. McCarthy-Ryan M, Perkins J, Donnelly GM, et al. Stress urinary incontinence prevalence and risk factors in female rugby players: a common health problem across four nations. BMJ Open Sport Exerc Med. 2024;10(1):e001832. Published 2024 Feb 6. doi:10.1136/bmjsem-2023-001832

5. Dakic J, Perraton L, Lindstrom J, Hain E, Chuah S, Stay S. The Hidden Challenge: Pelvic Floor Symptoms and Their Impact on Performance and Well-Being in Elite Female Rugby Players. Eur J Sport Sci. 2025;25(8):e70013. doi:10.1002/ejsc.70013

6. Giagio S, Adami PE, Bermon S, et al. Nearly half of 325 athletes reported pelvic floor symptoms: a cross-sectional study at the Lima 2024 World Athletics U20 Championships. BMJ Open Sport Exerc Med. 2025;11(3):e002564. Published 2025 Jul 25. doi:10.1136/bmjsem-2025-002564

7. Culleton-Quinn E, Bø K, Fleming N, Mockler D, Cusack C, Daly D. Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review. Int Urogynecol J. 2022;33(10):2681-2711. doi:10.1007/s00192-022-05302-6

8. Skaug KL, Engh ME, Frawley H, Bø K. Prevalence of Pelvic Floor Dysfunction, Bother, and Risk Factors and Knowledge of the Pelvic Floor Muscles in Norwegian Male and Female Powerlifters and Olympic Weightlifters. J Strength Cond Res. 2022;36(10):2800-2807. doi:10.1519/JSC.0000000000003919

9. Dakic JD, Hay-Smith J, Cook J, Lin K, Frawley HC. Screening for pelvic floor symptoms in exercising women: a survey of 636 health and exercise professionals. J Sci Med Sport. 2023;26(2):80-86. doi:10.1016/j.jsams.2023.01.008

10. Bosch-Donate E, Vico-Moreno E, Fernández-Domínguez JC, et al. Symptomatology and knowledge regarding pelvic floor dysfunctions and influence of gender stereotypes in female athletes. Sci Rep. 2024;14:11052. doi:10.1038/s41598-024-61464-x

2027 Course dates are here for High Performance Pelvic Health: From Screening to Sport! Designed to equip both sports medicine and pelvic health providers with a dual skill set to support female athlete return to fitness and sport keeping pelvic, pregnancy, and postpartum health in mind. Get your seat- 2026 courses filled fast!

Belfast, UK ( 30 20 seats remaining)
January 30-31, 2027

Sligo, IE ( 30 19 seats remaining)
February 6-7, 2027

Vancouver, BC ( 30 24 seats remaining)
February 27-28, 2027

Brisbane, AU (30 seats remaining)
July 17-18, 2027

Sydney, AU (30 seats remaining)
July 24-25, 2027

Check out course description HERE!

Sports medicine and orthopedic providers aren’t offered training to include pelvic health, pregnancy, or postpartum variables in their differential diagnoses or return to play programming. Instead they are only empowered to screen and refer.

Similarly, pelvic health providers may have limited exposure to the strategies required to progress fit and athletic folks back to fitness, training, or sport.

The result is a siloed, less effective model of care: pelvic, pregnancy, and postpartum health needs are untreated, screened and referred (often in pelvic practitioner deserts), or isolated from movement and training programs. Fit and athletic folks are left without resolution, support, or guidance back to play or optimal performance.

More Course Details:

• Practitioners will gain a structured thought process to interpret biopsychosocial histories, pelvic health screens, in-sport symptom behavior, and movement analysis to build well-reasoned programs for recreational to elite athletes across the lifespan.

• Participants are introduced to a contemporary pelvic health model that integrates pelvic floor strength, power, coordination, and endurance into fitness and sport preparation rather than treating them in isolation.

• Drawing on familiar movement and conditioning principles such as graded exposure, progressive overload, impact and pressure management, and exercise scaling, this course provides a practical, coachable framework for pelvic health.

• Providers will learn to apply a systems-based thought processes to develop individualized, sport-specific progressions grounded in the whole-athlete presentation.

• This course offers externally focused, indirect, movement based, and integrative assessment and intervention strategies only. This course does not provide direct, internal assessment or intervention tools.

See Objectives and a Topical Outline HERE

This is a live, in-person, 2-day course with practical application opportunities via labs and case studies. Course material is intended for PhysicalTherapists/Physiotherapists, credentialed Athletic Trainers/Therapists, Exercise Therapists, Kinesiologists, medical providers in all areas of adult care (urology, orthopedics, sports medicine, pain, women’s health, etc.), and strength and conditioning specialists (CSCS).

(This course offers externally focused, indirect, and integrative assessment and intervention strategies only. This course does not provide direct, internal assessment or intervention tools.)

Thanks again for being here, Squad- and I hope to see you there!

PS-Don’t see a course near you? Check out online course options with supportive strategies and content on similar topics. ON SALE starting May 31 (35% off for Substack subscribers)!

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Content Without Context

Social media is full of content without context. It’s difficult to navigate. We strive to keep up with the latest-emerging evidence, clinical insights, and new ideas. Algorithms also dictate what we see, and provides it on repeat. So the same ideas seem to float our way from different accounts. At some point the pure volume of folks that are lauding a new technique, course, or thought process gives it weight in our minds. Doubt creeps in…am I behind, am I not providing best practices? Something that sounded fringe, now sounds sorta reasonable.

How do we innovate clinically in a way that optimizes the patient experience and avoids stagnation, but steers clear of what are at best ineffective treatment strategies or at their worst dangerous to patients? Social media is the third wheel in the relationship between research and clinical innovation that can hype a good idea, or propel a bad one (see video).

How do we pursue evidence informed care and sift through social media sourced ideas?

How do we innovate clinically to bring change and avoid harm to thought or body?

Folks often say “research always catches up with clinical” so how can we actually be evidenced-based clinicians? On the contrary, if research leads the way, how do we create research questions that have clinical relevance and utility?

Since the answer is likely somewhere in-between…. what does the ideal inter-relationship between emerging research, clinical insights, and social media hype look like? (PLEASE check out a companion recorded Q and A that discussed exactly this complexity in a respectful, collegial context- a clip and more details below!)

Check out the Recorded Q and A

How we can hold the middle ground?

Here are some ideas on how to navigate the Wild West of low quality evidence and high volume social media advice at the edges of clinical care.

• Clinical Reasoning is Queen- Dichotomous extremes (always/never, either/or), formulas, factoids, and social media sound bites run out of utility fast in real life client situations. But solid clinical reasoning applies to every patient.

• Filter new ideas through what is known- Is it logical? Does it make sense? Is it presented with context to allow you to connect dots between known and new? What questions does it bring up for you to help you test the waters?

• Extrapolate research from other areas of practice- Sports medicine can inform pelvic health; pelvic health can inform sports medicine (How can we apply what we understand over there, here?)

• Reflect and re-assess regularly- Reflect, reflect and reflect some more. Take a step forward, monitor, modify, consider different responses…adapt. Rinse, repeat.

• Patient context-Consider what worked, what didn’t through the lens of the context of the patient in front of us - their history, their story, their needs, their environment, their goals. Tailor what we do know in the evidence within their context.

• Learn from different responses to care-Why did Patient A respond and Patient B didn’t? What was unique or were there other variables to consider for each patient?

• Ask a lot of questions- Ask questions, then refine your questions, and ask more questions. Develop a clinical question then hit up Pub Med, and answer it yourself with existing evidence (social media is not the only place to stimulate your thinking!).

Look Before You Leap

Before you jump on a social media trend or band wagon - please ask questions, consider the context, seek out the evidence to support it. There may not be a randomized control trial, but what’s the thought process behind the idea? How’d they get there- can you retrace their logic and reasoning? And certainly work with the concept clinically with an appropriate patient, troubleshoot the idea, learn, modify, consider…..before you share it back out into the socials.

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IMPORTANT EPILOGUE

I knew this post could cause a stir. My hope is to call out concepts, not people. But I didn’t realize how rampant this had become. When I typed into google- does the ilium internally rotate….the AI slop said ‘yes’, and used video and blogs of folks with these springy pelvises as support for the answer. Red alert. Mixed in were skeletal anatomy textbook chapters and research that acknowledged only small amounts of movement occur at pelvic joints (both the SI and PS-millimeters and a few degrees of motion in different planes) which was good to see.

So I cut the video above into something social media length and waiting for the right time to post when I could weather the storm.

Q and A Convo

to the Rescue (Here’s a Clip)

Check out the Recorded Q and A

But then we actually had an incredible conversation on my April Quarterly Q and A discussing how to evolve practice with well reasoned interventions in the absence of evidence . How do we innovate in a grounded way in the era of social media? That led us to a respectful, in-depth, collegial conversation thinking through the birth position/hip internal rotation mechanism. With permission from the two PT pros that were there (Micaela Zettel and Haley Mitchell) that conversation is now a public post, not a paywalled post. It honestly highlights and models how we should be navigating complexity in this era of social media hot takes. Interacting in a safe space around the real issues we have on the ground trying to be evidence informed clinicians. This conversation is exactly why I created this Substack- in-person, respectful, nuanced conversation.

If this brings up questions, challenges your thinking, or raises concerns-please watch the Q and A before responding. Hoping to continue having thoughtful discussions that support being evidence informed and well reasoned in the gaps.

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Lewis CL, Laudicina NM, Khuu A, Loverro KL. The Human Pelvis: Variation in Structure and Function During Gait. Anat Rec (Hoboken). 2017;300(4):633-642. doi:10.1002/ar.23552

Sako N, Kaku N, Kitahara Y, Kubota Y, Tagomori H, Tsumura H. Three-Dimensional Evaluation of Innominate Bone Rotation in Female Patients with Developmental Dysplasia of the Hip. Clin Orthop Surg. 2022;14(2):196-204. doi:10.4055/cios21032

• We discussed how to evolve practice with well-reasoned interventions in the absence of evidence.

• We had some conversation around the extent to which we can use EMG internally, and how to be well reasoned in evidence interpretations.

• We discussed how to innovate clinically in a grounded way in the era of social media or be discerning when we hear something in a continuing education course.

Then at around 36 min into the convo we shifted gears to discuss a recent trend that we are seeing around call to train pelvic internal rotation, demonstrated by pelvises with springs that show large, independent movements of the ilium/innominate (one side of the pelvis). The pelvis doesn’t do that. (clip below)

(See the companion Substack here: Content without Context)

That led us to a respectful, in-depth, (very collegial) conversation thinking through the birth position/hip internal rotation mechanism. With permission from the two pros that were there (I wanted their sign-off), I have made this a public post (no paywall), it was too good not to share broadly. It is a beautiful representation and model of how we should be discussing these issues and considering new information when it challenges our thinking. We need safe spaces like this for interacting around the real issues we are navigating on the ground as we strive to be evidence informed clinicians.

This conversation is exactly why I created this Substack: in-person, respectful, nuanced conversation. We need more in-depth understanding, not social media superficial hot takes and battles.

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I sat on the companion Substack post for months, knowing it might create a social media storm. But this conversation offered a broad, nuanced, deep dive to provide A LOT of context for the post and the topic. My hope is that folks will engage in all of this content, and really consider what comes up for them (questions, concerns, challenges) before responding.

Check it all out:

• 🎥 Full video: Social media often makes us doubt ourselves- something that sounded fringe, starts sounding reasonable when so many are sharing it.

• 📝 Blog post (Substack): How can we navigate the inter-relationship between emerging research, clinical insights, and social media hype?

• 🎙️ Substack Q&A conversation: Colleagues respectfully thinking through the pelvic internal rotation and birth position / hip internal rotation mechanism together, in real time.

Hoping to continue having thoughtful discussions that support us all being evidence informed and well reasoned in the gaps.

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(Huge shout out to Micaela Zettel and Haley Mitchell for digging deep with me in real time!)

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Show Notes/Resources:

Article about creating CONTEXT for our patients around what they are experiencing.

Bialosky JE, Beneciuk JM, Bishop MD, et al. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018;48(1):8-18. doi:10.2519/jospt.2018.7476

Links provided to research in coursework that supports birth position changes to open the pelvic outlet- (but they don’t discuss hip rotation).

1. https://www.sciencedirect.com/science/article/abs/pii/S0002937814005985

2. https://pubmed.ncbi.nlm.nih.gov/33422852/

3. https://pubmed.ncbi.nlm.nih.gov/41572012/

Recently I had the opportunity to be a part of granted project aimed at reaching more individuals with accessible information and tools to support their pelvic health via The Pelvic Floor Power Podcast Series-developed through a collaboration of the Urology Care Foundation, The National Association For Continence (NAFC) and Virginia Mason Franciscan Health.

LISTEN IN HERE!

From the show notes: “So you’ve done your Kegels and you’ve finally worked on getting your pelvic floor strong again. But for some reason, you’re still leaking urine when you workout and now you feel stuck. You may be wondering if you’re destined to leak during your workouts, or maybe you’re just not able to workout like you used to. The good news is that there is hope and this episode is a great place to start.

Sharing a partial clip here of the conversation with host, Dr. Una Lee discussing how to apply pelvic floor strength to your workout or run (full clip here).

Access the entire conversation (25 min) for more ways you can work to support your pelvic floor and return to movement you love, no matter your fitness goals.

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Hey Julie-Quick question. How should someone breathe during squats to support their pelvic floor? TIA

This question is born from the now more mainstream understanding that breath strategies can influence squat mechanics, central control systems (aka-core), pelvic/abdominal health, intra-abdominal pressure management, pregnancy recovery, and postpartum return to fitness. It is now understood that the pelvic floor is part of multiple systems, and we can use breath as an entry point to support an athlete’s pelvic health while preserving their access to fitness movements like a squat. We’ve come a long way!

However, this type of inquiry is also born out of the click bait, social media tips and tricks-type culture that drove this updated mainstream awareness AND propelled limited, formulaic ways of applying it.Social media regularly offers content without context, but context is where the magic happens.

Formula seekers, beware, this post isn’t for you (or is it?)

In addition to how should I breathe during squats, some pretty common questions I receive are.…

• What are your breathing suggestions for a maximally loaded squat?

• Do I inhale down and exhale up for a squat?

• Should I always “Blow Before I Go” during a squat?

• If I have a pelvic health issue, can I still hold my breath during squats?

The answer to all of them is the same. We can go with the classic- it depends. Or how about we adopt an update- Help me understand the patient context.

There is no prescriptive, everyone-should- breathe-like-this strategy for lifting. You have to know why you are changing breath mechanics for this athlete in order to choose a pattern to facilitate their goals. You need to understand their context.

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Help me understand the patient (client) context

Hoping for quick answers won’t move us toward the in-depth clinical reasoning. There are no short cuts. My goal is to keep point folks toward deeper reasoning by answering “quick” clinical questions with, well, more questions. Here are some food (or questions) for thought:

•Why are you changing their breath mechanics?

•What is happening in their lifting that is prompting you to make a change (symptoms while lifting? pregnancy? prevention? trying to help them reach a new goal?)

•Are they pregnant? Yes? How far along in pregnancy are they?

•Are they post-partum? Yes? How far our from delivery are they?

•Did they deliver vaginally or by C-section (planned or emergency)?

•Are they experiencing pelvic health symptoms during or after a lift?

•Do you, as a practitioner, know how to screen and ask questions to help you discern if they are having pelvic health symptoms?

• Do they have a diastasis? If yes, how is that impacting their capacity to control their center, and retain pressure to support lifts?

•Are they demonstrating good mechanics unloaded or under submax loads? Maximal loads? When they fatigue?

•What is their current strategy to meet that demand? Is it working for them?

•What should you be monitoring for to determine if the pattern you have selected is appropriate to meet their goals and your therapeutic goals?

•How can you modify the activity to keep progressing it without symptoms?

•How will you decide the client is ready to move on to a new pattern, load, challenge?

Heads-up…anticipate this as my new auto-reply for all clinical questions! How should I breathe when I squat? Help me understand the patient context. What should I do with my pelvic floor during a squat? Help me understand the patient context. Can I squat with a diastasis? Help me understand the patient context.

Here’s to more content with context.

Wanna ask deeper questions?

If you want to better understand the questions above: how are breath and pelvic health linked in the first place? Why or how does pregnancy change my recommendations? Why does it matter how far post-partum a client is? What is a diastasis? How do I screen for pelvic health issues? How are pelvic health and fitness intertwined? Check out one of my foundational courses intended for pros online or live courses (Currently running waitlists for upcoming 2026 High Performance Pelvic Health courses in NY and Cork- jump on the lists for updates). AND subscribe below for more content like this to help you dig deep!

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What…

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If you’re interested in learning to develop a blended dual sports medicine and pelvic health skill set - this case report offers some fuel for new thought processes and strategies. It includes details on the comprehensive biopsychosocial intervention pathway, differential diagnoses based on objective data interpretation, and gradual progression based on response to care

I also discussed the case recently on the Celebrate Muliebrity Podcast with Michelle Lyons, PT.

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Abstract is below!

A 40-year-old professional female Iron-distance triathlete presented with an 11-month history of left hip, iliotibial band and pelvic pain. She had fallen from her bicycle onto a railway track, and injured the soft tissue of her left buttock. The patient reported persistent hip pain. Furthermore, her attempts to return to training had led to pelvic pain symptoms that were made acute by walking, rolling over in bed and activities of daily living. Her continuing pain resulted in a fear of movement. A lack of progress with a sports medicine physiotherapist and five pelvic health physiotherapists led the patient to seek a more comprehensive approach to care. She was provided with a biopsychosocial programme that drew from the fields of pelvic, musculoskeletal and sports performance physiotherapy. The intervention strategy reduced her fears about movement, and altered her gluteal–pelvic floor muscle synergy by linking the dynamic interrelationship of the diaphragm, abdomen and pelvic floor to sport-specific movements that were meaningful to the

patient. This increased her tolerance for challenges over time. Collaboration with the patient’s strength, running and swimming coaches led to her return to training and short-distance racing within 2 and 6 months, respectively. Integrated pelvic health, musculoskeletal and sports performance concepts led to the resolution of the patient’s symptoms, and her subsequent return to competition. Full Text Here.

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Hosted By:

Physiotherapy Department Cork University Hospital
VFJQ+W5 Cork University Hospital
Wilton, Cork, Ireland

October 3-4, 2026

REGISTER HERE Total Enrollment: 30 ( 24 seats remaining. Offered internally first.)

Early Bird- €385 (Prior to May 31, 2026)

Regular Pricing- €425 (Registration Closes Sep 18)

Fit and athletic females* experience pelvic health symptoms at high rates with negative impacts on their performance, training longevity, physical and mental health, and quality of life. Yet many rehabilitation professionals lack the confidence to assess or address them within their clinical settings. Sports medicine and orthopedic providers are rarely trained to include pelvic health, pregnancy, or postpartum variables in their differential diagnoses or return to play programming. Often, they are only empowered to screen and refer. At the same time, pelvic health providers may have limited exposure to the strategies required to progress fit and athletic folks back to fitness, training, or sport. The result is a siloed, less effective model of care: pelvic, pregnancy, and postpartum health needs are untreated, screened and referred (often in pelvic practitioner deserts), or isolated from movement and training programs. Fit and athletic folks are left without resolution, support, or guidance back to play or optimal performance. Our practice patterns must evolve.

Designed to equip sports medicine and pelvic health providers with a dual skill set, this course offers an un-siloed, middle ground.

• Practitioners will gain a structured thought process to interpret biopsychosocial histories, pelvic health screens, in-sport symptom behavior, and movement analysis to build well-reasoned programs for recreational to elite athletes across the lifespan.

• Participants are introduced to a contemporary pelvic health model that integrates pelvic floor strength, power, coordination, and endurance into fitness and sport preparation rather than treating them in isolation.

• Drawing on familiar movement and conditioning principles such as graded exposure, progressive overload, impact and pressure management, and exercise scaling, this course provides a practical, coachable framework for pelvic health.

• Providers will learn to apply a systems-based thought processes to develop individualized, sport-specific progressions grounded in the whole-athlete presentation.

(This course offers externally focused, indirect, movement-base, and integrative assessment and intervention strategies only. This course does not provide direct, internal assessment or intervention tools.)

*Identified biological female at birth

Course Instructor: Dr. Julie Wiebe, PT, DPT

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Upon completion of this course, participants will be able to:

1. Describe the anatomical, and neurophysiological inter-relationships that provide interventional bridges between pelvic, musculoskeletal, and performance health.

2. Gain an understanding of the etiology and symptomatology associated with a broad range of pelvic health conditions across the lifespan commonly experienced by female-bodied athletes beyond urinary incontinence (painful sex, pelvic pain, pelvic organ prolapse, diastasis recti, gut issues).

3. Develop an individualized whole-athlete pelvic health risk profile based on biopsychosocial variables – age-specific co-factors, physical and pregnancy history, genetics, fueling, sleep, stress, fitness/training history, and kinesiophobia.

4. Interpret pelvic health screen findings and in-sport symptom patterns to develop a clinical hypothesis that supports exercise selection, loading strategies, and return-to-play progressions.

5. Analyze movement, fitness, and sport demands to identify symptom triggers and patterns to identify clinical and conditioning opportunities to coordinate the pelvic floor into fitness and athletic movements.

6. Create setting-specific interventions that integrate the pelvic floor into three different types of sport-specific movement patterns appropriate for early rehab.

7. Apply concepts of graded exposure, progressive overload, impact and pressure management, and/or exercise scaling to progress pelvic floor tissue adaption, load or impact tolerance, and coordination in three different sport-specific demands.

8. Build communication tools to bridge collaboration gaps and re-imagine referral patterns with pelvic health, orthopedic, sports medicine, strength and conditioning, and sports dietician disciplines to support un-siloed, athlete-centered care across the lifespan.

9. Value abdomino-pelvic health as an essential component of comprehensive, whole athlete care.

This is a live, in-person, 2-day course with practical application opportunities via labs and case studies. All participants will be required to complete an online module with conceptual introductory material prior to attending the in-person professional course. This will allow in-person time together to be well-spent on deeper concepts. In addition, participants are expected to bring a client case to review and potentially share with the group, with written patient consent.

Audience: Course material is intended for Physical Therapists/Physiotherapists, credentialed Athletic Trainers/Therapists, Exercise Therapists, Kinesiologists, medical providers in all areas of adult care (urology, orthopedics, sports medicine, pain, women’s health, etc.), and strength and conditioning specialists (CSCS).

Topics will include:

Day One: Conceptual Context and Strategies that Support any type of Athleticism across the Lifespan (with Synthesis through Labs and Case Studies)

• Pelvic Health is a Team Sport- Anatomical, Neurophysiologic Systems Thinking

• Contemporary Pelvic Health-Research and Practice Pattern Updates

• Pelvic Health as a Performance Variable: Symptoms are Signals.

• Biopsychosocial Framework Across the Lifespan: Symptom Context, Physical and Pregnancy History, Fitness and Recovery Strategies, Fueling Habits, and Kinesiophobia.

• From Screening to Strategy: Interpretation and Clinical Decision-Making (beyond urinary incontinence)

• Coaching Pelvic Health: Movement Analysis Through a Pelvic Health Lens

• Creating Adaption: Modification of Load, Impact, and Pressure Across Training

• Integrative Programming: Pelvic Health Within Return to Sport Plan of Care

Day Two: Practical Application

• Young Adult Athlete Pelvic Health (no pregnancy history): Clinical Reasoning and Special Considerations

  • REDs, Beyond menstrual tracking, Low Energy Availability, Incontinence, Bone Stress Injury, Hypermobility, and more

• Athleticism in Pregnancy: Clinical Reasoning and Special Considerations

  • Pregnancy preparation, Monitoring and tailored modifications in various fitness/sport, Diastasis screening and more.

• Athleticism in Postpartum: Clinical Reasoning and Special Considerations

  • Role of genetics, Return to activity reasoning, Kinesiophobia, Individualizing Care, Progression Strategies, and more.

• Athleticism in (Peri)Menopause: Clinical Reasoning and Special Considerations

  • Hormonal transitions, Systemic changes, Muscular composition and training, Connective tissue considerations, and more

• Case Presentations:

  • Concept synthesis via individual and group processing opportunities.

  • Plan of care and program development

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Hosted By: Prescribed Motion Physical Therapy & Exercise, 5501 Main Street (Rear) Williamsville, NY 14221

September 12-13, 2026

REGISTER HERE (Only US date in 2026)

Max Enrollment: 30 ( 27 seats remaining. Offered internally first.)

Early Bird- $495 USD (Prior to May 31, 2026)

Regular Pricing-$550 USD (Closes Sep 1)

Fit and athletic females* experience pelvic health symptoms at high rates with negative impacts on their performance, training longevity, physical and mental health, and quality of life. Yet many rehabilitation professionals lack the confidence to assess or address them within their clinical settings. Sports medicine and orthopedic providers are rarely trained to include pelvic health, pregnancy, or postpartum variables in their differential diagnoses or return to play programming. Often, they are only empowered to screen and refer. At the same time, pelvic health providers may have limited exposure to the strategies required to progress fit and athletic folks back to fitness, training, or sport. The result is a siloed, less effective model of care: pelvic, pregnancy, and postpartum health needs are untreated, screened and referred (often in pelvic practitioner deserts), or isolated from movement and training programs. Fit and athletic folks are left without resolution, support, or guidance back to play or optimal performance. Our practice patterns must evolve.

Designed to equip sports medicine and pelvic health providers with a dual skill set, this course offers an un-siloed, middle ground.

• Practitioners will gain a structured thought process to interpret biopsychosocial histories, pelvic health screens, in-sport symptom behavior, and movement analysis to build well-reasoned programs for recreational to elite athletes across the lifespan.

• Participants are introduced to a contemporary pelvic health model that integrates pelvic floor strength, power, coordination, and endurance into fitness and sport preparation rather than treating them in isolation.

• Drawing on familiar movement and conditioning principles such as graded exposure, progressive overload, impact and pressure management, and exercise scaling, this course provides a practical, coachable framework for pelvic health.

• Providers will learn to apply a systems-based thought processes to develop individualized, sport-specific progressions grounded in the whole-athlete presentation.

(This course offers externally focused, indirect, movement-base, and integrative assessment and intervention strategies only. This course does not provide direct, internal assessment or intervention tools.)

*Identified biological female at birth

Course Instructor: Dr. Julie Wiebe, PT, DPT

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Upon completion of this course, participants will be able to:

1. Describe the anatomical, and neurophysiological inter-relationships that provide interventional bridges between pelvic, musculoskeletal, and performance health.

2. Gain an understanding of the etiology and symptomatology associated with a broad range of pelvic health conditions across the lifespan commonly experienced by female-bodied athletes beyond urinary incontinence (painful sex, pelvic pain, pelvic organ prolapse, diastasis recti, gut issues).

3. Develop an individualized whole-athlete pelvic health risk profile based on biopsychosocial variables – age-specific co-factors, physical and pregnancy history, genetics, fueling, sleep, stress, fitness/training history, and kinesiophobia.

4. Interpret pelvic health screen findings and in-sport symptom patterns to develop a clinical hypothesis that supports exercise selection, loading strategies, and return-to-play progressions.

5. Analyze movement, fitness, and sport demands to identify symptom triggers and patterns to identify clinical and conditioning opportunities to coordinate the pelvic floor into fitness and athletic movements.

6. Create setting-specific interventions that integrate the pelvic floor into three different types of sport-specific movement patterns appropriate for early rehab.

7. Apply concepts of graded exposure, progressive overload, impact and pressure management, and/or exercise scaling to progress pelvic floor tissue adaption, load or impact tolerance, and coordination in three different sport-specific demands.

8. Build communication tools to bridge collaboration gaps and re-imagine referral patterns with pelvic health, orthopedic, sports medicine, strength and conditioning, and sports dietician disciplines to support un-siloed, athlete-centered care across the lifespan.

9. Value abdomino-pelvic health as an essential component of comprehensive, whole athlete care.

This is a live, in-person, 2-day course with practical application opportunities via labs and case studies. All participants will be required to complete an online module with conceptual introductory material prior to attending the in-person professional course. This will allow in-person time together to be well-spent on deeper concepts. In addition, participants are expected to bring a client case to review and potentially share with the group, with written patient consent.

Audience: Course material is intended for Physical Therapists/Physiotherapists, credentialed Athletic Trainers/Therapists, Exercise Therapists, Kinesiologists, medical providers in all areas of adult care (urology, orthopedics, sports medicine, pain, women’s health, etc.), and strength and conditioning specialists (CSCS).

Topics will include:

Day One: Conceptual Context and Strategies that Support any type of Athleticism across the Lifespan (with Synthesis through Labs and Case Studies)

• Pelvic Health is a Team Sport- Anatomical, Neurophysiologic Systems Thinking

• Contemporary Pelvic Health-Research and Practice Pattern Updates

• Pelvic Health as a Performance Variable: Symptoms are Signals.

• Biopsychosocial Framework Across the Lifespan: Symptom Context, Physical and Pregnancy History, Fitness and Recovery Strategies, Fueling Habits, and Kinesiophobia.

• From Screening to Strategy: Interpretation and Clinical Decision-Making (beyond urinary incontinence)

• Coaching Pelvic Health: Movement Analysis Through a Pelvic Health Lens

• Creating Adaption: Modification of Load, Impact, and Pressure Across Training

• Integrative Programming: Pelvic Health Within Return to Sport Plan of Care

Day Two: Practical Application

• Young Adult Athlete Pelvic Health (no pregnancy history): Clinical Reasoning and Special Considerations

  • REDs, Beyond menstrual tracking, Low Energy Availability, Incontinence, Bone Stress Injury, Hypermobility, and more

• Athleticism in Pregnancy: Clinical Reasoning and Special Considerations

  • Pregnancy preparation, Monitoring and tailored modifications in various fitness/sport, Diastasis screening and more.

• Athleticism in Postpartum: Clinical Reasoning and Special Considerations

  • Role of genetics, Return to activity reasoning, Kinesiophobia, Individualizing Care, Progression Strategies, and more.

• Athleticism in (Peri)Menopause: Clinical Reasoning and Special Considerations

  • Hormonal transitions, Systemic changes, Muscular composition and training, Connective tissue considerations, and more

• Case Presentations:

  • Concept synthesis via individual and group processing opportunities.

  • Plan of care and program development

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Y’all are some of the first to know- I’m rolling out a brand new course this year: High Performance Pelvic Health: From Screening to Sport! Designed to equip both sports medicine and pelvic health providers with a dual skill set to support female athlete return to fitness and sport keeping pelvic, pregnancy, and postpartum health in mind.

There’s only one domestic and one international opportunity this year:

September 12-13 Williamsville, NY (Early Bird rates available)*

October 3-4 Cork, Ireland (Early Bird rates available) *

*(as a perk both hosts had a head start to fill the course internally)

Sports medicine and orthopedic providers aren’t offered training to include pelvic health, pregnancy, or postpartum variables in their differential diagnoses or return to play programming. Instead they are only empowered to screen and refer.

Similarly, pelvic health providers may have limited exposure to the strategies required to progress fit and athletic folks back to fitness, training, or sport.

The result is a siloed, less effective model of care: pelvic, pregnancy, and postpartum health needs are untreated, screened and referred (often in pelvic practitioner deserts), or isolated from movement and training programs. Fit and athletic folks are left without resolution, support, or guidance back to play or optimal performance.

More Course Details:

• Practitioners will gain a structured thought process to interpret biopsychosocial histories, pelvic health screens, in-sport symptom behavior, and movement analysis to build well-reasoned programs for recreational to elite athletes across the lifespan.

• Participants are introduced to a contemporary pelvic health model that integrates pelvic floor strength, power, coordination, and endurance into fitness and sport preparation rather than treating them in isolation.

• Drawing on familiar movement and conditioning principles such as graded exposure, progressive overload, impact and pressure management, and exercise scaling, this course provides a practical, coachable framework for pelvic health.

• Providers will learn to apply a systems-based thought processes to develop individualized, sport-specific progressions grounded in the whole-athlete presentation.

• This course offers externally focused, indirect, movement based, and integrative assessment and intervention strategies only. This course does not provide direct, internal assessment or intervention tools.

See Objectives and a Topical Outline HERE (NY) and HERE (IRELAND)

This is a live, in-person, 2-day course with practical application opportunities via labs and case studies. Course material is intended for PhysicalTherapists/Physiotherapists, credentialed Athletic Trainers/Therapists, Exercise Therapists, Kinesiologists, medical providers in all areas of adult care (urology, orthopedics, sports medicine, pain, women’s health, etc.), and strength and conditioning specialists (CSCS).

Thanks again for being here, Squad- and I hope to see you there! Grab your spot in New York or Ireland in the Fall!

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Better questions are:

• Does this exercise support you right now, at this stage in your recovery?

• Can we modify the exercise to make it supportive and less symptomatic?

• Or do we just need to wait and try again in a week or two or more?

  

So rather than have a naughty or nice list of exercises (unsafe or safe for prolapse), let’s generate some ideas to help you understand your symptoms as a guide. They can help you determine how to modify activities for you, individually- based on your tissues, your delivery, your recovery timeline, the type of activities you are pursuing, and what modifications are available to you for the exercises you are interested in.

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How long since delivery?

Early postpartum tissues will be more sensitive and more easily irritated by movements and loads (this is normal, and not necessarily associated with a prolapse). Think of those sensations as signals that healing is in process, and they are alerting you to be gentle with yourself, take heed, slow down, or change something. Learning to listen and modify what you are doing when they occur can look like taking a break, but it can also be sitting down instead of standing for a diaper change, interacting with the baby in the swing for a bit instead of holding them, or walking around the block (prolonged positions are sometimes irritating and movement can be the salve).

Learning to do this early on, can help you reduce fears and develop some control over the symptoms and sensations. You can support your recovery by finding ways to adapt movement to stay active and not irritate symptoms. It also creates some personalized tools to ease the symptoms if you pushed a little too hard one day (Ex: when I feel X, it feels better when I do Y). You have already left yourself breadcrumbs for the path back to reducing the symptoms.

If you have learned to hear increased symptoms as a signal to change something or cool it, it can ease fears of a flare-up and keep you in control.

As you ramp your activities up and start reintroducing fitness movements, load, impact, etc.-symptoms are your guide again. They can alert you that you are hitting your limit for that activity, that workout, or that day. A lack of symptoms during an activity that was previously provocative can be your signal that it’s time to take it up a notch. Be aware that this process won’t necessarily follow a prescriptive timeline, everyones path and pace is different.

Sometimes symptoms get grouchy when you introduce a new activity, this may be a signal to you that the tissues aren’t ready-right now. Consider how to practice a lower level of that goal activity (less weight, less range of motion, see more ideas below), and then try again in a few weeks.

My clinical experience is that as you move from more acute stages of healing to further out from your delivery- the symptoms get more predictable. You know what your triggers are, and can build in some strategies to manage them and/or avoid them.

So what becomes ‘safe’ for you is different than what might feel ‘safe’ for others, the goal is putting those pieces together in an individualized way.

Some Ideas for Exercise Adaption

1. How are you moving (not what kind of movement)?

A study by O’Dell (2007) compared the intra-abdominal pressure generated in crunches (often considered ‘unsafe’ for prolapse) vs downward dogs (usually considered ‘safe’ for prolapse). Participants generated a range of pressures that were similar for both activities. Some did a low pressure crunch, while others did a high pressure downward dog. Therefore, the activity wasn’t the bad guy, how they did it made the activity potentially symptom free or symptom full. Adapting how you are doing the activity can help you keep any activity in the lower pressure range and likely more tolerable to your tissues.

Start by not holding your breath during an activity that irritates your prolapse or focus on exhaling prior to and during the exertion. (Check out more on that here)

More recently Campos (2025) found that runners with stress urinary incontinence demonstrated running patterns that resulted in absorbing impact forces at the hip and pelvis, while runners that stayed dry absorbed impact at lower leg and ankle. Changing running patterns and form can alter how and where your body is absorbing impact. Extrapolating this to prolapse symptoms, keeping the forces further away from the prolapse near the lower leg and ankle may help reduce symptoms as you gradually build back running resilience.

A place I like to start is to encourage folks to lean into the run. (Check out more about that here), and to rotate the torso while running (Check out more about that here)

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2. How much? How often?

If an activity is bugging your prolapse (or any other pelvic health issue) consider how much you are doing. The volume of abdominal exercises in postpartum programs is often out of balance with the amount of exercise devoted to other muscle groups. Heavy emphasis on abdominal work may generate increased forces and pressures from above that may overwhelm the pelvic musculature and organ supportive tissues below. Those tissues are regaining strength, coordination, timing, and resilience. They may not be able to match those forces and pressures from above yet!. Please remember your whole body went through the pregnancy, not just your abs.

Look at your workout plan, and balance out the program. 30 ab-targeted reps may be enough to restore some strength and keep you symptom free…..whereas 150 reps may ramp-up your prolapse symptoms.

As you restore your tissues, they may require more recovery than you are accustom to- less sets, less reps, fewer sessions a week, slower progressions. YOU as a whole may require more recovery than you realize, as sleep and fueling opportunities become less consistent when you have a new baby and stress increases when you add in work, other kids, life.

Recognize that when your physical and emotional tank is low, it might be a good day for less intensity and lower volumes….or a walk….or a break….or a cookie.

3. How fast?

Speed is a big consideration when tissues are healing and regaining resilience. Slow it down! When re-building the timing and coordination of pelvic tissue, you need to give it some mental focus. This is actually the first part of any strengthening program-your neurology has to set up the pattern for your biology. The brain and pelvic organ support system may need time and practice to be able to catch-up and re-learn movement patterns at the gym.

Learning to use the abdominal-diaphragm-pelvic floor system together within movements and fitness will help build that timing and patterning back. That system may need to start slow, then you can gradually pick up speed overtime.

4. How about try something new?

Vary your training! Many activities have repetitive movements like running, or consider if you are moving only in one plane (everything is flexion and extension such as crunches, bicep curls, squats). Shake things up! Consider other movement and fitness patterns to give the tissues a break from the same types of forces over and over again. For example, the abdominals are active when you do a push-up and a squat, but the forces and pressures generated in the activity are distributed more globally, not directly at the pelvic floor and organs. Switching things up can also be a part of your recovery strategy for the tissues when you are starting back to more challenging activities.

Find new ways to move, it will offer your tissues more opportunities to recover, build resilience, practice new patterns, and adapt.

To summarize the long answer- tailor your program to YOU and your symptoms! By applying some new ideas, you can help make any exercise ‘safe’ (or ‘nice’) for prolapse. And please, stay hopeful!

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1. Cobb WS, Burns JM, Kercher KW, Matthews BD, Norton HJ, Heniford BT. Normal intra-abdominal pressure in healthy adults. J Surg Res. 2005;129(2):231-235. doi:10.1016/j.jss.2005.06.015

2. Campos NC, Fonseca ST, Nunes LJ, et al. Inefficient impact absorption and reduced shock attenuation in female runners with stress urinary incontinence. J Biomech. 2025;187:112753. doi:10.1016/j.jbiomech.2025.112753

Read more

Pelvic health symptoms can be a significant barrier that keeps (peri) menopausal runners from running. Historically, pelvic health symptoms experienced in menopause have been seen through the lens of an expected and/or ‘normal’ change- for example aging is an accepted a risk factor for stress urinary incontinence. Previous solutions, like Kegels (pelvic floor muscle training) have been offered as support, but they lack specificity to address the complex demands of running. So are pelvic health issues inevitable….or have we simply not had the right tools to address them? New ideas and strategies exist to shake up what we can expect from our menopause transition.

Listen in to an event for a global running community (organized by CoachPerry.com in South Africa, and SheRunsStrong on You Tube) for (peri) menopausal runners. It addresses pelvic health considerations keeping the complexity of running in mind via education, guidance for self-assessment and symptom pattern tracking, modifications and training options to build pelvic health resilience.

Time to rewrite what aging athleticism can look like.

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Wait, what?

Most pros and individuals are more familiar with pelvic health needs like urine leaks and readily associate them with underactive pelvic floor muscles (overwelmed, weak, or damaged tissues), but many are less familiar with the idea that an athlete can have an overactive pelvic floor that may contribute to leaking during sport too…wait what? How are we going to sort that out in real time at our clinics or training rooms as non-pelvic health providers? Screen. Screening athletes for a range of pelvic health symptoms, including gastrointestinal issues, pelvic organ prolapse, sexual health, and other types of urinary symptoms- can help you recognize symptom patterns that are more common with pelvic floor overactivity or underactivity, informing next steps

Pelvic Floor Overactivity?

First, to help discern between the two, let’s get more familiar with pelvic floor overactivity. Pelvic floor overactivity is a clinical term, describing a non-neurogenic increase in pelvic floor muscle (PFM) resting tension (tone), sustained PFM activity, or inability to relax the PFM^1,2. This can be voluntary - performing Kegels during running to stop leaks- may lead to sustained activity. Or involuntary- regular co-contraction of the PFM during “core” conditioning- contributing to higher resting tone or difficulty relaxing³. It can also be a protective mechanism in response to somatic pain (Urinary Track Infections, Endometriosis, etc), or an anticipatory protective mechanism (anxiety, painful sex, etc)². Frawley et al¹ suggested persistent increased tone (‘spasm’) may result in ‘stiffness’ (p 1228) in active and passive pelvic floor structures. This stiffer, less absorptive tissue state may help us understand why overactivity in the pelvic floor can result in urine leaks - it’s less responsive and adaptable to absorb running related impact forces for example.

There are specific urinary, gastrointestinal, sexual health, and musculoskeletal symptoms that are commonly associated with an overactive pelvic floor². Clusters of these symptoms can help paint a picture of what is going on with your athlete’s pelvic floor.

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Time to Sort it Out

So let’s start to tease this out. Symptoms and issues often associated with pelvic floor underactivity (and reduced passive tissue restraints) include:

• Stress Urinary Incontinence- loss of urine when you don’t want to

• Fecal or Anal Incontinence-loss of stool (fecal) or gas (anal) when you don’t want to

• Pelvic Organ Prolapse-a sense of vaginal pressure, heaviness, dragging, or tissue protrusion, lump or bulging in vagina

Common issues associated with pelvic floor overactivity (and increased passive tissue tone) include:

• Urgency- Feeling like you need to pee NOW, often it is for a small volume not long after you just peed

• Frequency-Needing to pee lots (8-10x/day and more)

• Weak urine stream- Slow or not robust

• Defecation Straining-Straining to poop; can be related to constipation, and/or challenges relaxing PFM to release the poo

• Dyspareunia-Painful penetrative sexual intimacy, or it may manifest as pain with tampon insertion if folks are not sexually active

• Persistent Pelvic Pain- Pain experienced internally, deep in the pelvis (different from external pelvic girdle, musculoskeletal symptoms).

• Low back, pelvic girdle, and hip pain- Particularly if it is not resolving with more traditional care (more info on musculoskeletal clues below)

There’s rarely a single culprit for any of one of these issues, but pelvic floor overactivity is particularly worthy of consideration when you see a lot of these symptoms in the same patient. Overactivity symptom clusters should give you pause to provide Kegels as a first line intervention. This includes looking at their musculoskeletal presentation.

Musculoskeletal Links

If you are a clinician in orthopedics, or sports medicine, it is likely that folks have come to you for pain, musculoskeletal (MSK) or performance needs, not pelvic health. However, low back, pelvic girdle, and hip pain and tightness in particular should flag you to consider the pelvic floor in your thought process.

• Dufour et al⁴ found that 95.3% of patients referred to an orthopedic physio group for lumbopelvic pain had an underlying pelvic health need. Of those 70.6% experienced pelvic floor tenderness to palpation which is often associated with pelvic floor overactivity.

• Neville et al⁵ noted that participants with persistent pelvic pain (deep, internal pain) were more likely to experience musculoskeletal findings. Also, a positive Forced-FABER test accurately predicted persistent pelvic pain in 89.5% of participants with symptoms.

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Anatomical, neuromuscular, and fascial relationships of the pelvic floor to the low back, pelvis, and hip help to bridge our understanding of why an overactive pelvic floor might have some influence on adjacent areas of the body.

• Pelvic floor muscles are a component of the deep core: part of trunk and pelvic control mechanism^6,7

• Pelvic floor and gluteal muscles have neuromuscular and fascial interconnections

  • Glute strengthening has been shown to increase vaginal squeeze pressures⁸

  • Urinary Urgency and Frequency associated with Hip ER/ABD weakness⁹

  • Glute Max have fascial interrelationships with the pelvic floor complex, Obturator Internus, external anal sphincter, and urogenital diaphragm¹⁰

  • Glute Max and the pelvic floor have a phase matched co-activation of glute during the gait cycle (synching 44-69% of the time)¹¹

(We are still working to understand the mechanisms of some of these associations)¹²

Suggested Screening Tool

In conjunction with your traditional musculoskeletal assessment, screening for a range of pelvic health needs to identify symptom clusters, will enhance your MSK differentials and optimize your approach. The Queensland Pelvic Floor Questionnaire (link to downloadable pdf) asks questions in four domains- urinary, gastrointestinal, prolapse, and sexual function- supporting investigation of a range of pelvic health symptoms as you seek to identify clusters. It is also the recommended outcome measure by the International Olympic Committee¹³, because it covers a variety of symptoms in one screening tool.

Adding pelvic health-focused questions to intake assessments can help identify underlying issues, and improve differentials. Of course screening is just the beginning- taking stock of the context and sport specific triggers for your athletes symptoms are great next steps to guide interventions. Check out ‘An Athlete Tells You They Leak with Running- Now What?’ for some ideas to consider as you tailor a well reasoned plan to support your athlete.

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Self-Guided Resources

References

1. Frawley H, Shelly B, Morin M, et al. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodyn. 2021;40(5):1217-1260. doi:10.1002/nau.24658

2. Padoa A, McLean L, Morin M, Vandyken C. The overactive pelvic floor (OPF) and sexual dysfunction. Part 1: Pathophysiology of OPF and its impact on the sexual response. Sex Med Rev. 2021;9(1):64-75. doi:10.1016/j.sxmr.2020.02.002

3. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev. 2022;10(2):209-230. doi:10.1016/j.sxmr.2021.03.002

4. Dufour, S., Vandyken, B., Forget, M.-J., & Vandyken, C. (2018). Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskeletal Science and Practice 34, 47–53. doi:10.1016/j.msksp.2017.12.001

5. Neville CE, Fitzgerald CM, Mallinson T, Badillo S, Hynes C, Tu F. A preliminary report of musculoskeletal dysfunction in female chronic pelvic pain: a blinded study of examination findings. J Bodyw Mov Ther. 2012;16(1):50-56. doi:10.1016/j.jbmt.2011.06.002

6. Hodges PW, Sapsford R, Pengel LHM. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-371. doi:10.1002/nau.20232

7. Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A.Phase-locked parallel movement of diaphragm and pelvic floor during breathing and coughing: a dynamic MRI investigation in healthy females. Int Urogynecol J. 2011;22(1):61-68. doi:10.1007/s00192-010-1240-z

8. Tuttle LJ, Autry T, Kemp C, Lassaga-Bishop M, Mettenleiter M, Shetter H, Zukowski J. Hip exercises improve intravaginal squeeze pressure in older women. Physiother Theory Pract. 2020;36(9):1007-1014. doi:10.1080/09593985.2019.1571142

9. Foster SN, Spitznagle TM, Tuttle LJ, et al. Hip and pelvic floor muscle strength in women with and without urgency and frequency-predominant lower urinary tract symptoms. Journal of Women’s Health Physical Therapy. 2021;45(3):126-134. doi:10.1097/jwh.0000000000000209

10. Siess M, Steinke H, Zwirner J, Hammer N. On a potential morpho-mechanical link between the gluteus maximus muscle and pelvic floor tissues. Sci Rep. 2023;13(1):22901. doi:10.1038/s41598-023-50058-8

11. Williams AMM, Sato-Klemm M, Deegan EG, Eginyan G, Lam T. Characterizing pelvic floor muscle activity during walking and jogging in continent adults: a cross-sectional study. Front Hum Neurosci. 2022;16:912839. Published 2022 Jun 30. doi:10.3389/fnhum.2022.912839

12. Proulx L, LaCross J, Lewis Cl. Exploring the connection between the hip and pelvic floor in women with exercise-induced urinary incontinence: integrating clinical hypotheses with current evidence. Journal of Pelvic, Obstetric and Gynaecological Physiotherapy. 2025;137 (Autumn), 38–53. doi:10.62399/QFKG9942

13. Moore IS, Crossley KM, Bø K, et al. Female athlete health domains: a supplement to the International Olympic Committee consensus statement on methods for recording and reporting epidemiological data on injury and illness in sport. Br J Sports Med. 2023;57(18):1164-1174. doi:10.1136/bjsports-2022-06620

Age? Pregnancy history?

Is this a young athlete (<12- prepuberty? Teen-post puberty? 18+ ? Never had a baby?)

• If they are young, or never had a baby- pelvic floor ‘weakness’ or ‘damage’ doesn’t really fit as the only source of leaks, so Kegels may not either.

• Instead, think about it like an overuse injury— you would identify triggers, look for patterns, and symptom behavior. When do the leaks while running occur and what factors contribute to them is crucial.

If they have a pregnancy or delivery in their history, we need to consider other variables.

• Vaginal or C-section? Number of pregnancies? Time between pregnancies?

• Were the symptoms present prior to pregnancy (see previous paragraph)? Started during pregnancy? Or new postpartum?

• Think about this as someone with an acute “injury or multiple injuries to the same area” who never rehabilitated and went straight back to their previous fitness or sport (over and over again). We need to promote resilience in those tissues, and positive adaptive strategies to rebuild and prepare them to take on the forces and demands of the activity.

• They need a graduated progressive overload plan.

Timing of Leaks During Sport?

We learn a lot about running related pain symptoms based on when in the activity they occur- we need to ask that same questions about leaks while running.

• Leaks occur immediately or early run/game? Think poor impact absorption, pelvic floor overwhelm (may not be weakness-check out this blog for more depth on this concept) and/or trunk stiffness could be factors.

• Mid-to-late run/game leaks? Think fatigue- not just pelvic floor fatigue- think whole body fatigue and fatigue related form changes (poor proximal hip control, respiratory endurance, heavier foot contact).

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Leak Pattern?

Again, we can take the same clinical reasoning approach we do for pain during running or any physical activity, and look for patterns. Are the leaks while running more common on…

• Certain surfaces (trail, track, or concrete)?

• With specific inclines (downhill or uphill)?

• Do speed changes make a difference-sustained speed changes or quick accelerations?

Identifying these triggers helps you plan a graded exposure program to address those specific challenges.

Co-morbidities?

Think whole person, whole presentation – what else is going on for that patient?

• Do hip or knee pain and leaks occur at the same time? Solve that trigger- Ex: poor proximal hip control and impact absorption may be build a plan that addresses those variables and you will have a win-win. Hint: There is a strong neuromuscular/fascial link between the glutes and pelvic floor!

• Are there sleep deficits? Do symptoms follow a hormonal pattern-worse certain times of the month? This may suggest modifications to training volume or intensity when sleep is less optimal or the part of the cycle that is more symptomatic to see if it would change symptom behavior.

There’s No Place Like Home

Click those ruby red heels together sports med pros- you’ve had the tools to understand and interpret an athlete’s leaks with sport all along! Use your reasoning skills to dig deeper and address leaks as a part of the your care plan. Don’t get results? Refer, co-treat, learn more (see below)!

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Wanna learn more? Check out our sports medicine/pelvic health online courses:

Treating and Training the Female Runner (or Any Female Athlete

Sports Medicine Bundle

Persistent Pelvic Pain in Athletes: A Biopsychosocial Approach.

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* High intensity cardio and resistance training is well tolera…

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Check out this silo smudging conversation with Michelle Lyons on her Celebrate Muliebrity Podcast. We chatted about bridging sports medicine and pelvic health covering:

• The importance of early detection and prevention of pelvic health issues in athletes

• The need to move beyond the current screening and referral paradigm. Time to empower the sports medicine community with tools to treat, not just screen.

• Incontinence screening as a tool for flagging low energy availability and REDS (Relative Energy Deficiency in Sport), as traditional menstrual cycle screening may not be reliable (more details on that topic here )

• Got to share more from results from my research with stats on pelvic floor overactivity in recreational runners, and some big reveals from my findings!

• The need for a more nuanced, multidisciplinary approach to treating pelvic health issues- building individualized athlete risk profiles inclusive of biopsychosocial variables

• Resources for athletes, coaches, and clinicians coming soon from the FIFA women’s health research team coming soon to help meet these need (Michelle is on that team)

Tune in to this great convo with Michelle ( her podcast is one of my faves! Honored to be a guest!)

PS: Don’t Miss Out!!

Join us for Journal Club this Wednesday, Sep 17 to hear directly from Dr. Margie Davenport, PhD and Amy Moolyk, MSc, CSCS, CEP as they discuss maternal and fetal cardiovascular responses to high intensity cardio and resistance training! Dr. Davenport’s lab at the University of Alberta is on fire right now-supporting all of us in practice trying to bridge sports medicine and pelvic health! Don’t miss this opportunity to engage with them live! Upgrade to paid to join in below! Already a paid subscriber? Event registration details hit inboxes last week, and a follow-up email to repeat registration details will go out late Tuesday!

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