Should My Pelvic Floor Physical Therapist Be Checking My Hip?

Jackie is a 31-year-old mom of one who has been experiencing some urinary incontinence, specifically with sneezing and jumping exercises during her workout classes. She has been doing kegels diligently, which has helped, but has not completely resolved her leakage. She will notice an occasional twinge in her right hip but nothing that lingers longer than a few hours here and there. Jackie finally made an appointment with a pelvic floor physical therapist (PT) and was surprised that the PT began assessing her hip range of motion and strength instead of going straight to the pelvic floor.

While it is very important for your physical therapist to assess your pelvic floor, especially if you are experiencing symptoms in that area, it is also important for your PT to examine surrounding areas like the hip. There is a significant amount of cross over between the muscles, fascia, and nerves between the hip and the pelvic floor. In fact, they work together for optimal function. For example, it has been found that urethral wall and pelvic floor muscles contract together during hip adductor (squeezing the legs together) and gluteal muscle contraction.¹

Piriformis muscle thickness has been found to increase the most during a simultaneous contraction with the pelvic floor. Thickness can be thought of as a contraction or pulling together of the muscle when it is being used. In other words, the piriformis muscle is most effective while being used with the pelvic floor.²

Another study looked at resisted hip rotation versus pelvic floor strengthening exercises over 6 weeks to determine its effect on stress urinary incontinence (SUI). Interestingly, both groups demonstrated improvement in their symptoms, which indicates that hip strengthening can be a helpful, important component when addressing SUI.³

This is not to say that your pelvic floor physical therapist should not be assessing the pelvic floor muscles for strength, coordination, endurance, and lengthening abilities as this could still play a role in an individual’s symptoms. However, it is important that assessment outside of the pelvis is taking place to create a balanced system for optimal function. The opposite can also be true when you are dealing with a persistent orthopedic concern outside of the pelvic floor.

A good example is the case report of a 45-year-old female distance runner with proximal hamstring pain that was present for four months and referred to physical therapy. Her initial visits focused on education, pain management, trunk stabilization, and gluteus maximus strengthening. While she experienced a reduction in symptoms, they did not fully resolve. Upon pelvic floor examination, she was found to have pelvic floor hypertonic dysfunction meaning that there was too much tension in the muscles. After addressing her pelvic floor by lengthening it through manual techniques, down-training with biofeedback, and stretches, the patient’s symptoms reduced and eventually eliminated altogether.⁴

Even if you do not experience hip pain, it is important to keep in mind the role that the hip plays in both pelvic floor and low back pain. A study found that those who experience non-specific low back pain experience tenderness over the glutes, greater trochanter (hip bone) and lumbar paraspinals (muscles along the side of the spine) more commonly on the affected side (side with symptoms) as compared to the unaffected side (side without symptoms). Additionally, it was found that gluteus medius (the middle glute between the gluteus maximus and gluteus minimus) had a significant decrease in strength on the affected side as compared to those without low back pain. While testing the gluteus medius strength in standing, it was found that those with low back pain had difficulty maintaining pelvic alignment during a single leg test on the affected side as compared to the unaffected side.⁵  This means that even if your back is the more bothersome area, your PT may very well incorporate hip strengthening for improved functioning on each side.

It is also thought that some who experience urinary urgency and frequency have increased muscle tone, or tension, in their pelvic floor muscles and are overused in an attempt to remain continent. While more research is needed, a study found that 21 women with urinary urgency and frequency have significantly less hip external rotation and hip abduction strength than those without symptoms. Interestingly, there was no difference between the two groups in regards to pelvic floor muscle strength or endurance. The study indicated that “assessing hip muscle performance may be important for those with” urinary frequency and “a more thorough musculoskeletal assessment may be warranted, including assessment of hip muscle strength”. This means that hip strengthening can be important for both stress urinary incontinence and urinary urgency and frequency.⁶

Overall, whether you are experiencing urinary urgency, urinary frequency, incontinence, pelvic pain, or back pain, your physical therapist should be examining the pelvis, spine, AND hips to ensure that a well-rounded approach to your concerns is implemented. Even if you do not have symptoms in a given area, that area may still need to be addressed in order to make improvements toward your primary concern. Your physical therapist should be able to explain why they are having you perform certain exercises or activities and how it relates to your body. So, if you are experiencing pelvic symptoms or pesky back and/or hip symptoms that just don’t go away, reach out to your local pelvic floor physical therapist for an evaluation and get those symptoms taken care of properly!

Written by Jordan Schmidt, PT, DPT

References

1. Bø, K., & Stien, R. (1994). Needle EMG registration of striated urethral wall and pelvic floor muscle activity patterns during cough, Valsalva, abdominal, hip adductor, and gluteal muscle contractions in nulliparous healthy females. Neurourology and urodynamics, 13(1), 35–41. https://doi.org/10.1002/nau.1930130106
2. Wang, Z., Zhu, Y., Han, D., Huang, Q., Maruyama, H., & Onoda, K. (2021). Effect of hip external rotator muscle contraction on pelvic floor muscle function and the piriformis. International Urogynecology Journal, OnlineFirst, 1-7.
3. Schweinle, W. (2014). Comparing Resisted Hip Rotation With Pelvic Floor Muscle Training in Women With Stress Urinary Incontinence A Pilot Study. Journal of Women's Health Physical Therapy, 38(2), 81–89-81&ndash-ndash;89-81–89.
4. Podschun, L., Hanney, W. J., Kolber, M. J., Garcia, A., & Rothschild, C. E. (2013). Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report. International journal of sports physical therapy, 8(4), 462–471.
5. Cooper, N., Scavo, K., Strickland, K., Tipayamongkol, N., Nicholson, J., Bewyer, D., & Sluka, K. (2016). Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. European Spine Journal, 25(4), 1258-1265.
6. Foster, S., Spitznagle, T., Tuttle, L., Sutcliffe, S., Steger-May, K., Lowder, J., Meister, M., Ghetti, C., Wang, J., Mueller, M., & Harris-Hayes, M. (2021). 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", 45(3), 126-134.