Set Up: Stand with right foot in front and left in back, hip distance apart. Pelvis should be square to the front. Weight is primarily in the front foot while the back heel is lifted acting as a kickstand. Hinge forward from the hips slightly to maintain neutral pelvis.
Execution: Inhale to bend both knees as you angle the tailbone to the back wall sitting back into a squat-like position- keep lengthening through the spine. Exhale to stand following the same forward angle that keeps the crown of your head in line with the back heel, squeezing gently into your right glute. Repeat 10x and switch to left foot in front.
Focus: Primary focus is the right glute. Keep front knee stacked over ankle the entire time. Be sure to maintain length in lower back while keeping lower abs engaged. Taper ribs toward hip bones while keeping hips square/level.
Importance: Great exercise for glute strengthening, balance, and stability.
Modifications: To make it easier, use a chair, or wall to hold onto until balance improves. To make it harder, add free weights to incorporate some arms simultaneously, or simply transfer weight solely to front leg as you stand floating the back leg off the floor for a little extra balance challenge!
Wait! Marie Kondo has you throwing out your favorite jeans because the joyless saggy bottoms that your tushy cannot manage to fill out? We are seeing an epidemic flat butt among mamas, plumbers, barre fanatics, and office workers—all with strangely similar symptoms—pelvic floor dysfunction, low back and sacroiliac pain, and a tucked under pelvis. In this blog we will explore why the position of the pelvis, the maker of flat butts and the maker of less flat booties, is important and how to more easily move out of this position for benefit beyond your behind.
Besides needing a new wardrobe, why should I care about my flat bum?
The flat bum or preference towards posterior pelvic tilting shrinks the distance between the front and back of pelvic outlet which changes pelvic floor muscle tension. The body needs access to the full range of the pelvis and pelvic floor muscles. Over time, this position could cause excessive pelvic floor activity to compensate for the loss of resting tension. Think of the pelvic floor muscles simplified as a rubber band between two points, the pubic bone and tailbone. When the distance between the two points decreases, the rubber band loses its stability from resting tension. Changes in pelvic position alters stability from the pelvic floor muscles. This posterior pelvic tilt position also decreases the accessibility for hip extension and therefore the upper glute muscles get sleepy. As the top of the pelvis moves back, the sacroiliac joint in the low back opens and decreases its bony stability. Translated into everyday life, the flat butt position increases the potential for incontinence, pelvic floor muscle tension, sacroiliac pain, and decreased efficiency in movement.
The Flat Bottom. Only in the eye of the beholder?
The disagreement of the “neutral pelvis” or zero-point causes confusion when describing pelvic tilt—anterior pelvic tilt, posterior pelvic tilt, and neutral pelvis. Some argue that the neutral pelvis is when the ASIS’s (front hip bones) are level to the PSIS (back butt dimples). Others say that the pelvis is neutral when ASIS’s are in the same plane as the pubic bone. Or for those with X-ray vision, pelvic tilt is the vector of the sacral angle at S2 in relation to the vertical axis. But often, neutral pelvic position is subjective to the observer and relative to other parts of the body—namely the spine/rib cage and thigh bone. Clinically, this “neutral pelvis” is hard to find because 1) pelvis’ are shaped very differently, 2) left and right pelvis on the same person can also be quite different, 3) feeling these bony landmarks have been shown to be remarkably unreliable, 4) the neutral pelvis should be on top of vertical thigh bones. See how the eyes can be tricked confusing spinal curve focusing on pelvic tilt without also including rib position.
The inability to move in and out of posterior pelvic tilt and anterior pelvic tilt decreases efficiency and possibly results in pain and instability. Anterior pelvic tilt is when the front part of the pelvis moves forward/down. Posterior pelvic tilt is when the front part of the pelvis moves back/up. A neutral pelvis on top of vertical femurs and happy rib cage should correlate with better muscle performance.
Do I have a flat butt?
Aside from the saggy jeans, the flat butts of the world have a few other correlations.
1. The Tailfeather Test: Stand comfortably and squeeze the gluts.
a. Neutral pelvis: Thigh bones rotate.
b. Posterior tilt-ing pelvis: The butt will further tuck under and mainly access the lower glutes.
c. Anterior tilt-ing pelvis: The pelvic floor muscles will do most of the work.
2. You bear weight more in the heels
3. Back of your rib cage is behind your pelvis
4. Your Thigh bones are angled so that your pelvis is front of your knees
5. Your lower belly pooch
6. You Sit with pressure more on the sacrum/tailbone vs. sit bone
7. You have Overactive and possibly overworking pelvic floor muscles—the front to back pelvic distance decreases with your posterior tilted pelvis and loses the resting tension from length. As described earlier, this is similar to tensile strength of a slightly stretched rubber band vs. rubber band without pull/tension. Therefore, your pelvic floor muscles have to work harder to keep some type of tension for purposes like continence, stability, etc. The inability for the pelvic floor muscles to work optimally can lead to incontinence, pain, and constipation.
9. You have Breathing and abdominal pressure problems
10. You have Sacroiliac joint pain. As the pelvis tips back, the sacrum moves away from the ilium decreasing the bony stability. The hip muscles have to work harder, but as felt in the Tailfeather Test, the glut muscles aren’t in a good place to work.
Is there a better fix than butt implants?
Bodies have and love variability for posterior, anterior and “neutral” pelvic positioning. The brain likes positions where muscles and nerves work with ease and stability—life shouldn’t be so difficult—but it needs the chance to choose and learn it. Folks working with bodies have traditionally “corrected” spinal curves by changing pelvic position. From what has already been discussed, spinal and pelvic position can be altered many different ways—from the changing weight-bearing area in the feet, to position of ribs and range of breath, and even head angles with visual and vestibular input. Consider these hacks into pelvic stability until the brain learns how to access this stability in many situations and positions.
1. Standing. Bring your chin down to your neck and keep looking down until you see the front of your ankles. You’ve just untucked your pelvis and brought your ribs over your pelvis. This one is courtesy of my colleague, Stephanie Stamas. Or check in to feel where the weight is going through your feet. The front to middle of the foot is a good place to start and then do the Tailfeather Test. You might have to toggle other parts of the body because of how the body will compensate in the chain.
2. Sitting. Get your hips as far back as possible. Or put a pillow in the back of the chair so that your hips can find the pillow and you are sitting on top of your sit bones. Then, relax the trunk into the seat back/pillow. Again, you’ve untucked your pelvis and brought your ribs over the pelvis.
3. Better squats/lunges/burpees/stairs/ab work. You can do 5 sets of 20 squats, but still no junk? Take care to see if your pelvis is tucking under in the movement. If so, use an inhale to keep the pelvic floor lengthening as your hips bend in movement. Later, the movement should be dissociated with breath pattern (as long as you are breathing.)
4. See a physical therapist. Often times, the habits of pelvic tucking are a little more complicated because it is a protective and compensatory mechanism for stability. A physical therapist can help with seeing the bigger picture and how different parts of the body relate to each other. They can also help facilitate better movement through manual therapy and specialized movement.
We are reposting an old post broadly discussing the LGBTQ+ community, with special focus on transgender individuals. Please keep checking back as we continue to discuss specific issues relating to the care of the LGBTQ+ community.
Amy Stein PT, DPT and Fiona McMahon PT, DPT
Who are LGBTQ+ individuals?
At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc. They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.
Never Assume. Listen, Ask.
We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community. First rule of thumb: with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.
As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us. Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.
We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in trans care. Hormones, either testosterone, estrogen, lupron, puberty blocking, testosterone suppressing can be used in many patients, but are also used specifically to aid in transition in transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options. There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration. Hormones can be administered via injection, pellets, patches, creams, gels, and pill form. It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc. Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals. Progression of hormones can be monitored for each patient and according to patients wants and needs.
For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs. Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.
How is care for the LGBTQ+ community funded and regulated?
Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.
How can physical therapy help?
At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction. We also specialize in orthopedics and functional manual therapy. We treat the LGBTQ+ community and we welcome any questions at email@example.com or call 212-354-2622. We are happy to help and look forward to hearing from you! Resources: Center of excellence for transgender health.
Almost all postpartum women experience some degree of diastasis recti, or separation of the rectus abdominis or 6 pack muscles. Think about it, your abdomen is stretching continuously for a solid nine months! Something’s got to give. The linea alba (line of connective tissue that splits your rectus abdominus right down the middle) separates as a result of a growing baby. On some women, this separation naturally heals itself within the first year postpartum. In other women, the separation is so severe that they need a little extra attention and care to fuse their rectus abdominis back together again.
Once you’ve given yourself enough time to heal the inflamed tissues from giving birth, usually about 6-8 weeks, then you can start implementing some basic Pilates principles into your routine. Drawing attention to the breath, the transversus abdominus (TA), and the pelvic floor without creating excess pressure throughout your system, will be essential while moving towards healing your diastasis.
Connecting to your breath and your TA should be the first step. Deep three-dimensional inhalation to the back of the ribs and mindful exhalation, tapping into the TA will be crucial. During the exhale you should feel as if your abdomen is hugging or wrapping around your waist like a belt. This is TA activation. Once you’ve established the TA activation, focus on drawing your bottom ribs towards your naval and narrowing your ASIS (hip bones) towards each other. Imagine a drawstring; when you pull the drawstring, the opening of whatever object you’re trying to close, draws together from all sides evenly. That is the effect we are trying to create with the abdomen. Visualize your naval as the center of the opening and your exhalation pulling the drawstring closed.
Once you’ve mastered connecting breath to the TA, shift your focus to the pelvic floor. The easiest way to achieve this is by lying on your back with a neutral pelvis with knees bent and feet flat on the floor. Visualize the tailbone unfurling and your sits bones widening as you inhale allowing the pelvic floor to gently stretch and relax. On the exhale, as you engage the TA and obliques, feel the pelvic floor tighten slightly and if appropriate (after a pelvic floor check from your PT) find a kegel. The ultimate goal is to be able to contract and release your pelvic floor without any problems. After practicing this breathing exercise every day for about 8-10 reps, you should start to feel stronger throughout your core and find some closure or firmness in the linea alba.
This first step is HUGE. After 2-3 weeks of consistent breath work and core activation, layering more extensive exercises will become safe and accessible. Keep in mind that it is not wise to go from zero to one hundred, but rather continue to build and progress slowly. It may feel tedious, but I can’t stress enough how imperative it is to lay this foundation and rebuild your core after birth. Once you feel you’ve made considerable progress with breath work, add in marches (leg lifts) targeting lower abdominal stabilizers and add in a side lying series to challenge pelvic and core stability while also strengthening glutes. Try a side plank starting on knees and then progressing to feet. Any exercise in quadruped is a safe bet that targets shoulder stability, core, glutes, and hamstrings!
One thing to note is that women with more severe cases of diastasis should avoid abdominal curls, rollups, or flexion of the rectus abdominis until there’s been a considerable amount of progress with the deeper core muscles. If you fall under this category and constantly wonder if you’ll ever close your diastasis, yes! You can! And you will if you dedicate the attention and mindfulness to connecting to your body. Think you’re doing everything right, but still feel like no progress is being made? Feel free to book a session with me at Beyond Basics Physical Therapy! I’d be more than happy to help you out on closing your diastasis and transitioning you back into the wonderful world of pilates 🙂
If you follow anything in the physical therapy world, you probably have heard about myofascial release, or MFR if your hip to our abbreviations. It has been a darling of the manual therapist’s tool kit for some time. But did you know their many different camps of physical therapy and these different camps prefer different tools? I love coming from a field that can produce multiple solutions to any given problem. I feel it maximizes every unique individuals’ chances of finding meaningful relief through treatment, but it’s definitely fair to say that MFR does have some detractors in the physical therapy field. In this blog, I will be discussing why MFR is a wonderful tool for treatment of pain conditions and functional issues. MFR doesn’t always get the love it deserves and it is my hope, that by the end of this blog you will understand how MFR is thought to work and why it can be so helpful.
What the heck is the myofascial system?
As the name would imply, the myofascial system is the combination of the muscular system (myo) and the fascial system (fascial). Most of us have a pretty good concept of the muscular system but the concept of fascia is slightly more elusive. Fascia is the covering and connection of just about everything in the body. It wraps around organs, nerves, and muscles and allows these parts to retain their shape and function well. The composition of fascia is fascinating, even if you aren’t a total nerd, like me. We may encounter fascia when removing that filmy substance from a chicken breast while preparing it. When you see that film it looks pretty simple, but on a microscopic level that “stuff” is actually teaming with diverse and different cells all doing different things. Within fascia we have adipocytes, (fat cell makers), fibroblasts, which make collagen and elastin…. AND ARE CONTRACTILE! Yes I put this in all caps because it is amazing and it can be easy to overlook when you are thinking about fascia. Fascia also has mast cells (which make histamine) and histocytes (are part of the immune system). It’s honestly a cell party inside that stuff. Keeping with the metaphor of cell party, the house those cells are chilling in is made up of collagen (which provides support), elastin (which provides strength and flexibility), and ground substance (which is the cushioning).
All this stuff together helps fascia to accomplish some pretty cool tasks. Like I said before, fascia covers everything in the body and helps it keep its form. It also allows organs and muscles to slide and glide over each other, which is obviously very important when we are thinking of muscles. But what’s most interesting, in my opinion, is that fascia acts as a sense organ. It is innervated with type III and IV sense receptors and responds to light touch. It can contract and when fascia is stimulated it has an effect on the autonomic nervous system (think flight or fight). You probably could guess that issues within the myofascial system could wreak havoc on the rest of the body.
What goes wrong with the myofascial system and why does it get messed up?
The concept of fascia and its dysfunction contributing to pain is not necessarily a new one. People were thinking about myofascial pain although they had different words for it as early as the late 1600’s with the first description of trigger points in 1816. Trigger points have been called many different things from “nodular tumors” in the 1800’s to “muskelshweile” meaning muscle calluses, which is my personal favorite.
So where do these “muscle calluses” and trigger points come from? The reasons are myriad. Fascia can become restricted with discrete injuries (what I term, “the Oh Poo moment”, where you know you have injured yourself) or they may build quietly over time due to poor posture and other types of repetitive strain or chronic muscle holding.
Fascial restrictions and trigger points can cause a whole host of symptoms. It should seem obvious that restrictions in the fascia of a certain area of the body will restrict the movement in in that area. But fascial restrictions can present in less obvious ways.
Fascial restrictions can affect organs and dysfunction in the organs can affect fascia. This is because of the somatovisceral reflex and viscerosomatic reflex respectively. We see a lot of organ and myofascial interplay at Beyond Basics Physical Therapy. We commonly see increased trigger points in parts of the body that are innervated by similar nerve root fibers off of the spinal cord. Specifically, we may see someone who has endometriosis adhesions on their rectum experience pain and trigger points in their pelvic floor. Additionally trigger points in the pelvic floor can refer to other parts of the body and present as pain in the bladder or rectum, and other places.
Restrictions and trigger points in the fascia are linked to a whole host of symptoms. Treating the body at the level of the fascia is often very helpful at easing or resolving these symptoms. Below is a non exhaustive list of symptoms and conditions related to myofascial trigger points and dysfunction:
Fibromyalgia pain syndrome
Myofascial pain syndrome
Complex regional pain syndrome
Urinary and fecal incontinence
Sports and orthopedic injuries
How do we treat it?
Here is where it gets “controversial” in the health community. Fascia is strong. Really, really strong. Some would say as strong as steel. There are many in the community that claim myofascial release is impossible because there’s no clinician who is strong enough and applying enough force to break through and make a difference in the knots… I mean, I have a pretty solid deadlift but you won’t be finding me bending metal beams anytime soon. This argument misses the point and fails to recognize how complex fascia is. Think back to our cell party. We are not simply trying to break through fascia; we are providing a sensory stimulus and allowing the fascia to adapt or change in response. When true myofascial release is formed correctly, very little force is being used and it is usually an extremely gentle technique that can be tolerated by many patients who may not have been able to tolerate more aggressive techniques. When performing myofascial release, the clinician engages the barrier, meaning they apply enough force to feel the first inklings of resistance, and they hold their pressure there and slowly take up slack as the barrier melts underneath them. There is nothing forceful about it. In fact, when I first learned this technique from a mentor trained in Barnes myofascial release technique, she would always say, “If you think you are working too hard, you probably are”. There’s nothing steel beam bendy about MFR at all. Myofascial release allows the tissue to respond to the input the clinician is providing, rather than aggressively stretching, mashing, or pulling it. Although the exact mechanism of how MFR works is elusive, many theories recognize the individual players and cell types within the fascia, (remember our cell party), whether that be down regulation of the autonomic nervous system, (reduced fight or flight), activation of the central nervous system, and release of chemicals from the cells within the fascia.
The fact is with physical therapy, there are so many different tools that one can use. Usually clinicians tend to gravitate towards what they are good at and what tends to help the maximum number of their patients. At BBPT we value MFR as a helpful tool in our repertoire.
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By: Fiona McMahon, DPT
Hey Ladies!!! In the next installment of our Pelvic Health 101 course, we are hosting a women’s only session to allow for a safe and non-threatening place to discuss many issues that can affect the health of your pelvic floor. This class one of Stephanie Stamas’s (the founder of PH101’s ) favorites and is definitely not to be missed. Hear more about it in her video below! Join us at 7pm on April 23. Please register at pelvichealth101.eventbrite.com
No one told you that the pain of childbirth doesn’t end with that final push and it doesn’t matter if you had a vaginal or belly birth. If you are the roughly 10% of demigoddesses who delivered without a tear, bless you and your fairy child.* If you are a mere mortal, here are some secrets for post-partum “battle wound” care.
For many mamas, the scars from delivery heal without any intervention. However, in our clinic, we often see hypersensitive or immobile perineal and cesarean scars that affect other parts of the body and can be a reason for the loss of core stability mechanisms, pain with intercourse, and urinary and fecal incontinence.
Scars are the body’s glue and use a complex set of proteins. While scars are never as strong as the original (70% of the original strength), it usually doesn’t cause a problem. The healing process after cutting your finger on that dull knife is the same for a cesarean incision and perineal tear/cut. Immediately after the injury, lots of good inflammation comes into the area to clot and start a loose frame for new tissue to develop. In the first days, collagen and other healing buddies come in to pull the wound together. It’s not particularly organized, but that’s okay because really, priorities are to keep things from getting in. In the next weeks, the collagen fibers will start organizing according to the demands of that particular tissue resulting in a pinkish or red color to the scar. It’s about this time that you can tell if things aren’t going well, namely, the scar shouldn’t be painful. We don’t know for sure why some scars cause problems and others don’t. The best guesses have to do with genetics, tissue tension, hormonal glands, and blood supply. Within 7-12 weeks, not only should the scar not be painful, but it also should move as freely as the tissue around it—without tugging at other places. The scar should be flat and slightly lighter than skin color.
MOVEMENT AND ICE
In the first days, keep good blood flow to the area while managing the pain. For perineal scars, you can work by breathing gently into your pelvic floor and changing your position regularly so that blood doesn’t stagnate in the area. For cesarean scars, working on deep breathing is a safe way to gently move the area without disrupting the healing. You want to keep big movements limited (but really, you’re a mom and movements are a part of life). Use the pain meds as needed so that your muscles continue to function normally. Things like vagsicles (frozen maxi-pads) and support belts can also help with the pain. A regular ice pack for the c-section scar is also a good option. Make sure to place a thin towel between the ice or vagiscles and the skin.
At the postpartum six-week appointment, have your physician or midwife check the mobility of the scar. If it is painful or stuck, ask if the scar healed enough to start gentle scar massage. The idea of the scar massage is to give a non-threatening stimulus for desensitizing the area and re-orienting fibers so that the tissue moves freely.
For both the perineal and cesarean scar, if the movement of the scar exceeds pain 2-3/10, start with just desensitization. This can be as simple as tapping the scar or rubbing the scar gently with a towel for 3-5 minutes/day.
For a perineal scar, use a clean finger to slightly push the scar along perineal body up towards the body to create some slack. Then, move the scar away from the center in all directions (north, south, east, west, and in between) to find out which direction is the least mobile. Hold the scar in the restricted direction for 30 seconds. The pain should not exceed more than 2-3/10. Repeat 3-5 more times. You should be able to steadily tolerate more movement within a month.
For a cesarean section scar before 3 months, lift the tissue around the scar in a generous pinch and move the scar up and down, then side to side. Continue along the length of the scar until you find an area of pain or restriction. At this point, spend a little more time and move that area of the scar 10-30 times and keep moving. Again, the pain should not exceed 2-3/10. For a cesarean section scar older than 3 months, you can mobilize the scar in the same movements by direct pressure or skin rolling—up and down, side to side, clockwise and counterclockwise and lifting with skin rolling.
For the new mama, this is easy to incorporate in the precious quiet moments in the shower.
The gold standard of stubborn scars is silicone with or without compression. For hypertrophic scars and keloids in other parts of the body, silicone sheets and gels are the primary non-invasive prevention and treatment. Silicone strips and gels are easily used over a cesarean scar. Silicone is used daily for 12-24 hours for 2-4 months to soften and decreases the height of the scar. The sheets and compression can also help with the hypersensitivity. Because of the proximity to the body cavities, silicone is not advised for perineal scars.
*If you want to try to avoid perineal tearing altogether, ask your birth team to help birth baby’s head slowly and use warm compresses during pushing, stay active during labor, deliver in a side-lying or upright position, and perineal massage in late pregnancy can all help reduce the risk of perineal tearing.
If you have tried these simple interventions and still find your scar problematic or think your scar is related to pain in neighboring areas, find a women’s health physical therapist to help manage your care. Recent studies show that in 4-8 sessions, skilled physical therapy changes the mobility and thickness of old scars to decrease pain and improve function.
Scar management is widely promoted in post-operative care in orthopedics, plastics, and dermatology—we hope that scar care will soon be standard of care in post-partum care.
Joanna practices at our Downtown location
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