Do you know how the hip is connected to the pelvic floor?
Likely no, but that's where we come in.
Short version of below: Everything is connected
Hip and low back pain are some of the most common types of pain that people experience and seek out treatment from physical therapists. Yet, many forget to evaluate and consider the larger role that the pelvic floor plays in hip stability and core bracing. Weakness or tightness in the base of the pelvic floor can lead to referring hip or low back pain, with or without the traditional symptoms of pelvic floor dysfunction.
The body works as a closed system, not different parts in isolation. If one group of muscles is working harder than another due to a compensatory mechanism, the opposing group or adjacent group likely is as well. Clinicians and patients themselves should consider a differential diagnosis and assessment of these pelvic floor muscles when addressing hip or low back pain, male or female! Doing so can reap significant rewards, especially in those who have plateaued under other therapies or are finding no real results with typical interventions.
Hip Pain
Hip pain and tightness can be due to more than just the hip muscles. Pelvic floor muscles tightness can limit hip extension. Tightness can restrict range of motion around the hip complex or create weakness and imbalances in stability which can be part of the root cause for hip and low back pain, or even exacerbate the pain.
Research shows that in 85.9% of women with hip, low back, or pelvic girdle pain and without internal vaginal pain, were found to have bilateral internal vaginal myofascial pain with an internal exam.1 This means that, 85.9% of women assessed in this study had underlying pelvic floor dysfunction and pain on top of the existing hip, low back, or pelvic girdle pain.
There are many overlapping muscles of the hip and pelvic floor that work synergistically together. The hip muscles and pelvic floor muscles sit very closely to one another and the obturator internus and piriformis are two of your deep hip rotator muscles. Although not technically pelvic floor muscles, because of their proximity to the hip, sometimes the treatment of releasing tension in these muscles—much like the pelvic floor muscles—can sometimes help to relieve hip and low back pain. And the best way to access and release the obturator internus (one of the deep hip rotator muscles) is through an internal access point through the pelvic floor.
If you've been experiencing pain that is persistent and non-responsive to other therapies, you should consider a pelvic floor evaluation, especially if you have hip and lower back pain. The number of muscles that cross through through the hip, pelvic floor and lumbar spine may all play a role in dysfunction and pain, no matter which specific area is feels like it starts at.
Pelvic Floor Pain
We just mentioned hip and lower back, but what about when it starts with pelvic floor symptoms? When issues like incontinence and prolapse arise, patients and clinicians should consider assessing hip strength and hip mobility as a contributor.
In a recent study of people with experiencing urinary urgency and frequency, those who had urgency + frequency had pelvic floor muscle strength that was the comparable to healthy controls, but demonstrated weaker hip internal rotators (like the piriformis and obturator internus) and abductors.2 Another study showed that those people with symptoms of stress incontinence (typically leaking due to weakness) also have better results when hip strengthening was coupled with pelvic floor muscle strengthening in treatment plans compared to pelvic floor strengthening alone.3
Prolapse is something common but often under-diagnosed and treated. Similar studies regarding pelvic floor symptoms and hip/lower back strength have been done in women with pelvic organ prolapse. One study showed that physically active women lifting weights <15kg were more likely to report symptoms of pelvic organ prolapse than women lifting greater than 50kg.4 This means that women who lift more weight and are typically stronger are less likely to have symptoms of pelvic organ prolapse.
As a patient you should advocate for an assessment of hip, lower back and the pelvic floor if you feel you have any of these overlying symptoms. Finding a clinician who understands that treatment for the pelvic floor, hip and lower back pain should be comprehensive to yield best results.
Conclusion
All of this is great news. There is something that can be done about all of these issues. You don’t need to live with them. And the answer: Physical Therapy.
So, when is it time to consider your pelvic floor involvement when you’ve been having hip pain? If you have been struggling with hip or low back pain that has been resistant to other therapies or if it’s gotten somewhat better but you haven’t been able to get back to 100%, it might be time to consider seeking out a pelvic physical therapist for an internal assessment. If you’re struggling with incontinence or prolapse, hip strengthening and mobility should be part of the treatment plan.
Everything is connected!