Fit to Run:
Tips from a Pelvic Health Physiotherapist to Prevent Leaking

Running is one of Canadians favorite fitness choices, for good reason, as it brings many benefits to our health, including increased energy, improved mood, better sleep, lower incidence of depression, promoting cardiovascular health and healthy body weight.   This is why physiotherapists are dedicated to help people run without problems.  Recent research highlights the role Pelvic Health Physiotherapists add to a runner’s success with training and performance. 

How Running Impacts your Pelvic Floor

Running is a high impact exercise, with measured forces of 2-6 times bodyweight each time the foot contacts the ground. The pelvic muscles play a large role in supporting the body’s ability to absorb these impact forces. When the pelvic muscles cannot keep up with these impact loads it can result in unwanted bladder leaks, known as Urinary Stress Incontinence, the most common pelvic muscle dysfunction. 

Like other muscle systems the Pelvic floor muscles can have dysfunction identified with weakness, poor endurance, tension, stiffness or over activity of the muscles in the pelvic /lumbar girdle. This dysfunction ultimately limits the pelvic muscle’s ability to function their best under impact loads like running.

Suffering in Silence?  You are not alone.

Typically, most people are not comfortable talking about what happens behind bathroom doors, so discussing their experience of leaking urine while exercising can be very embarrassing.  Furthermore, leaking urine is often mistakenly viewed as a problem only for older women or women who have had babies. So, when individuals who have never had babies experience bladder leaking, they may feel alone and often suffer in silence.

Bladder leaking with exercise is more common than most people realize.  In fact, it is so common that researchers use the term Athletic Incontinence to define unwanted bladder leaks which occur ONLY during exercise and not in everyday life or with coughing or sneezing (Sorrigueta-Hernández · 2020).  Research further suggests that athletic incontinence is NOT gender or age specific, and is also present amongst varsity athletes who have never had children. 

 ATHLETIC INCONTINENCE FACTS :

• Study of young healthy varsity athletes found 33% reported leaking during their sport
• Research found 45.1% of female and 14.7% of male varsity athletes surveyed reported leaking
• 5% athletes had never discussed their incontinence with a health professional
• Pelvic Health Physiotherapy is considered the first line of treatment for Athletic incontinence according to research studies (Pieres, T.F., 2020).

What causes bladder leaks in strong, fit athletes?

Research continues to look into possible reasons people experience athletic incontinence, and it seems that there may be a variety of explanations including:

• Insufficient pelvic floor muscle strength to hold in the urine with increased pressure from impact, is considered a possible cause. Research has found that 30% of women are unable to contract their pelvic floor muscles correctly (Bo K, Sherburn M, 2005). 

• Overactive poor relaxing pelvic floor muscles may contribute to leaking in some athletes. Ongoing tightness of pelvic floor muscles results in fatigue, reduced flexible and ultimately inability to produce enough force to sufficiently to hold in urine during impact forces. 

• Some athletes are assessed to have strong pelvic floor muscles with poor coordinated use of these muscles during the complex movements of their sport, leading to urine leaks. 

• Researchers hypothesize that in some athletes prolonged intense physical activity “may overload, stretch and weaken the pelvic floor” (Bo K 2004), resulting in urine leaks during impact exercise.

What can I do to stop bladder leaks when I run or exercise?

Although athletic incontinence is common, it is a sign that the pelvic muscles are not working their best and athletes do not need to live with it.   Pelvic Health Physiotherapists are specially trained to assess and treat pelvic muscle dysfunction so the muscles can work their best during impact exercise.  

Pelvic health physiotherapy should always be tailored to each individual athlete according to their assessment findings and goals.  However, there are some general “tips” that can safely help reduce loads on the pelvic floor, and help reduce the risk of leaking during running.

Tips from a Pelvic Health Physiotherapist to reduce Pelvic floor impact when running. 

I. Remember to Breath!

The pelvic floor muscles work together with the diaphragm (breathing muscle), transverse abdominus (deep abdominal muscles) and multifidi (deep lumbar spine muscles) to provide core stabilization as we move.  All these muscles work their best as a co-ordinated team.  When we hold our breath, (sometimes without realizing during lifting/exercise), we compromise the efficiency of this core system and place increased pressure downward onto the pelvic floor.  This constant downward pressure can overload the pelvic muscles and leaking urine may result. 

Remembering to breath (i.e. not holding breath) helps improve the entire core systems ability to absorb impact loads, support the bladder and enhance performance when running.  Furthermore, breathing out with forceful tasks (eg. Lifting) improves the co-ordinated recruitment of the core system (pelvic muscles, diaphragm, Transverse abdominus and Multifidi) to better support the spine/ pelvis during heavy loads.  Blow As You Go – is a helpful cue to facilitate core engagement when needed.

II. LESS IS MORE!

Sometimes, the with the intention to become stronger (or perhaps in an attempt to “look stronger”), we might continuously grip our abdominals (sucking in our stomach) or constantly hold our pelvic floor muscles tight (sustained Kegels) during exercise or daily activities.  Unfortunately, this constant state of muscle tension can lead to poor core and pelvic muscle function.

Muscles held in sustained contraction (tension) cannot work efficiently and in the pelvic muscles over tension may lead to urine leaks with running or impact loads.   In fact, muscles work best when they fully relax between each effort.

Furthermore, constantly tightened abdominal and pelvic muscles make it more difficult for the diaphragm (the breathing muscle) to work it’s best, leading to reduced breathing efficiency, earlier fatigue, possible tissue overload and increased risk of injury and leaking when running.   So, remembering “less is more” refers to being mindful to balance muscle work (contraction) with important rest (relaxation cycles) during exercise.

III. GOOD Posture!

Time and time again, we are reminded how poor posture can place undue strain our bodies during our day, and running posture is no exception. 

When maintaining good posture during running (i.e. keeping our ribs over top of our pelvis and our landing foot close to our center) our core system is set up for success to reduce loads on the pelvis and joints.   Good running posture allows the diaphragm (breathing muscle) to work more efficiently, improving oxygen to the body and improves endurance capacity.  Running with good posture allows the core system (including the pelvic muscles) to work best as a team to better absorb high impact loads, steady the trunk, maximize circulation and support the pelvic organs during running.   These benefits lead to improved muscle and heart function to enhance running performance, reduce injuries and prevent bladder leaking. 

Helpful cues to maintain good posture when running include:

• “Run Softly”: This cue encourages a closer forefoot landing when running. Research demonstrates that a forefoot landing in running significantly reduced impact loads on the body compared to an over striding heel contact running style.  

• “Look forward (Not up or down)”: This cue encourages good head alignment over the ribs and pelvis, maximizing the pelvic muscles ability to work their best during loads. 

• “Swing your Arms”: Efficient running requires good trunk rotation to successfully transfer the impact loads through our pelvis as we run. Using a proper equal arm swing encourages this important trunk rotation movement and helps reduce loads on the pelvic muscles during running. 

IV. Strength Train:

Research supports the importance of strength training to enhance the bodies resilience to impact loads in runners.  Strength training improves the bodies’ ability to absorb impact, reducing runners’ risk of bladder leaks and injuries.   Strength training should focus on running specific movements, including single leg strength, agility and balance of the lower limb muscles and core.

V. Progress Slowly:

Too often running injuries occur from progressing distance and intensity of training by too much too fast. The body needs time to adapt to new training loads, and without proper progression or proper time for recovery tissues in the body are a risk of injuries and in the pelvic muscles this may lead to leaking urine.

Running progression should be individualized and based on each runner’s response to training changes, however some general progression guidelines can be considered, including:

• Start with walk / run intervals to allow appropriate balance for muscle loading and recovery during training.
• Follow the “10% Rule”, suggesting the weekly training mileage increase by a maximum of 10%.
• Schedule Recover days (including yoga / meditation) and Cross training (bike or swim) between running days to allow the body to adapt to training demands and be ready to function at its full potential when running.

VI. Listen to your Body

Our body gives us signals that it is not managing well with increased loads or stresses.   Technology can help us monitor these signs.  Noticing a trend of increased Resting Heart Rate (HR) in the morning or decreased Heart Rate Variability (HRV) scores suggests that our body is not managing increased loads/demands on the body and could be at risk of injury or bladder leaks with running. 

Monitor for new any pain, or chronic pains that are over 4/10 on a pain rating scale, that is not resolving with 24 hours of training.  Monitor for any bladder leaks or pelvic pain/pressure with or after exercise.   These symptoms suggest the muscles are not keeping up with the load demands and should be further investigated to avoid long standing problems.  Discussing these concerns with your health care provider is important to get the care you need to address the problems.

BREAK the Silence…

Experiencing urine leaking, pelvic, hip or low back pain with running is more common than most think, and are all signs that the body is not keeping up with the load demands of running.   Pelvic Health physiotherapists are trained to help listen to your concerns and provide safe gentle care to help you body and pelvic muscles function their best and keep you running without symptoms.   Let’s work together to break the silence about Athletic Incontinence and help athletes feel comfortable reaching out for pelvic health physiotherapy to address their individual needs and goals.  

Written by: Natalie Lehto, Registered Physiotherapist

Reference List:

• Sorrigueta-Hernández · 2020 , Clin. Med.2020, 9(10), 3240
• Pieres, T.F. et al Int J Sports Med 2020; 41(04): 264-270)
• Bo K, Sherburn M, Therapy 2005 Mar;85(3):269-82.
• Bo K, Int Urogynecol J Pelvic Floor Dysfunct. 2004 Mar-Apr;15(2):76-84.