Why Kegels are Bad for your Tight Pelvic Floor
| August 29, 2012 | Posted by Elizabeth Rummer under Pelvic Pain |
Note to Readers: Yesterday we posted a blog summarizing an article titled “Stop Doing Kegels: Real Pelvic Floor Advice for Women (and Men)” written by Nicole Crawford and published on BreakingMuscle.com. There was some confusion that resulted from the post about when kegels are and are not appropriate. The article advises that women (and men) should never do kegels. I do not completely agree with the article. While women and men with tight pelvic floors should never do kegels, they are appropriate for a certain patient population, patients that have weak pelvic floors.
But what about patients who have weak and tight pelvic floors?
This updated edition of the post, will fully explain when kegels are and are not appropriate, including what is appropriate in situations when the pelvic floor muscles are both weak and tight. I apologize for any confusion, but am thankful for the opportunity to add clarity to this issue that I know is super-confusing to so many!
Kegels are no good for a hypertonic or “tight” pelvic floor.
For decades doctors, PTs, trainers, therapists, you name it, have been hammering away at women—and men too—that if they want to strengthen their pelvic floors, they must do their kegels.
Getting folks to stop doing kegels is a bit of an uphill battle because it’s advice that’s seeped into the mainstream consciousness. On an episode of “Sex in the City” Samantha jokes about doing her kegels; Oprah Winfrey had experts on her show dispensing the advice to her zillions of viewers, and if you google “kegels” you’ll come up with about 1.3 million hits.
So you can imagine my delight when I came across an article that went against the party line, and actually delved into the potential harm kegels can do to the pelvic floor. An issue that PTs who treat the pelvic floor are all too familiar with.
The article is titled “Stop Doing Kegels: Real Pelvic Floor Advice for Women (and Men)” is written by Nicole Crawford and published on BreakingMuscle.com.
Ms. Crawford’s article is a Q&A with Katy Bowman—a master’s level Biomechanist whose focus is the mechanical causes of disease. In the past, Ms. Bowman has made waves advising folks against doing kegels.
Ms. Bowman says that at the heart of the problem with doing kegels to strengthen the pelvic floor is a theory in biomechanics called: “Overgeneralized Theory of Strength.” When you do a kegel, she explains, you are doing a muscular contraction, and if you already have a tight pelvic floor, contracting these muscles will only make it tighter, making your pelvic floor problems worse.
Here I agree with Ms. Bowman 100%. If you have a tight pelvic floor, or even a pelvic floor with active trigger points, you should not do kegels. Doing kegels under these circumstances will compound your pelvic floor problems.
Ms. Bowman goes on to say that kegels are never appropriate. In her prior writing on the topic, she’s held that doing kegels can actually cause weakness. As an alternative to kegels for pelvic floor strengthening, Ms. Bowman recommends deep squats. Her reasoning is that deep squats strengthen the glutes, which in turn “pull the sacrum back, stretching the pelvic floor from a hammock to a trampoline” and thus providing for a stronger or more stable pelvic floor.
Here is where I am forced to disagree with Ms. Bowman both on her assertion that kegels are never appropriate and her advice that deep squats are a better way to combat a situation where the pelvic floor is weak.
If you’re not someone who has dealt with the symptoms of a tight pelvic floor, you might wonder why a tight muscle is a bad thing. Often folks equate tight muscle with “toned” muscle. In fact, here’s a comment from a reader on this very point:
“Why is a tight pelvic floor a bad thing? Isn’t it the same as a toned pelvic floor? And a toned muscle is not a bad thing. I understand that if you over-do it, your pelvic floor muscles can become too tight, but isn’t that the same as with any other muscle fatigue in the body when you over do it? The muscle rests and relaxes a bit then it’s fine.
A toned muscle is not a bad thing, the reader is correct. Unfortunately, however, if you “over do it” with your pelvic floor muscles, they do not just rest and relax. Your pelvic floor muscles are the only group of muscles in the body that never get to rest, ever. If they completely relaxed we would be incontinent. So, they are working all the time to maintain continence, to support our pelvic organs, and to contribute to our posture and stability.
Therefore, these muscles are “working out” all the time, and don’t follow the same rules as the other muscle groups in our body. If you do get carried away with kegels and over-strengthen your pelvic floor muscles, they can become too tight, which in turn can cause dysfunction and symptoms, such as pain, urinary urgency and frequency, among others.
When this happens, it often takes the expertise of a pelvic floor PT to return the pelvic floor muscles to a normal tone to eliminate the symptoms.
So, the pelvic floor muscles do not need extra strengthening from doing kegels, unless something has happened that has overstretched them or injured them in some way that has made them truly weak (not weak AND TIGHT, more on that in a bit). Your pelvic floor muscles can become overstretched and weak after childbirth, around menopause, and after some gynecological surgeries. And this overstretching and weakening can lead to organ prolapse.
So kegels are appropriate when the pelvic floor is truly weak and/or overstretched. I prescribe them all the time for this patient demographic. And there are many experts in the field of pelvic floor rehabilitation that will strongly agree that doing kegels are appropriate when pelvic floor muscles are overstretched and/or weak. And in fact, there are many articles in medical journals that support this.
It’s important to note though that many postpartum women can actually have tight pelvic floor muscles so any woman who thinks she needs to do kegels after pregnancy should absolutely get an evaluation by a trained PT to make sure that is indeed what she needs to do. Because if you start a pelvic floor strengthening program when you actually have a tight pelvic floor, you will create problems, I promise you. So, unless you’ve been evaluated by a pelvic PT, and told you have a weak, not tight, pelvic floor, do not continue to do kegels.
So tight muscles = kegels bad. Weak and/or overstretched muscles = kegels okay. Oh, if only we could end things here. But as anyone who has researched the pelvic floor knows, there is no black and white when it comes to this part of our anatomy–only lots of shades of gray, and more than 50, I can tell you that much!
Here’s the clincher: it is possible for a weak pelvic floor to also be tight and/or to contain active trigger points. In this situation, it is NOT okay to do kegels.
So what does someone who has both a tight and a weak pelvic floor do, especially if he or she has a prolapse or other symptoms caused by the weakness. Well, the appropriate course of action in this situation would be to first work to clear up the tightness and trigger points with PT and whatever other treatments are appropriate. And then once the pelvic floor muscles are at a healthy tone–no longer too tight, and all active trigger points gone–do kegel exercises recommended by a trained PT to strengthen your pelvic floor without fear of causing further problems.
So, to summarize: kegels are not appropriate for folks with a tight pelvic floor or active trigger points or folks with a weak AND TIGHT pelvic floor. But, it’s okay to do kegels to strengthen a weak pelvic floor.
I hope this updated post has cleared up all confusion. But, if you still have questions or concerns, please don’t hesitate to send them my way.
All my best,
Liz
So, what is the right thing to do to strengthen weak muscles (that aren’t tight)if contractions isn’t the answer?
As I mentioned in another response to a comment, I have to disagree with Katy that Kegels are never appropriate. I think they are a useful treatment strategy for a pelvic floor that is overstretched/not tight and weak. Sorry for the confusion!
I’ve revised the blog to reflect this, please give it a read if you have time.
All my best,
Liz
Thanks for your response Liz. I appreciate it. I read the other comment and your response regarding tightness and weakness, which I do get.
Unfortunately, I’m more confused than ever. I am seeing a quality women’s health PT that wasn’t easy to find. I’ve actually been reading Katy Bowman’s blog for months. I really like what she’s saying about the PF as well as whole body alignment. Based on her blog, it seems she really isn’t recommending the kegal for anyone, including those of us with prolapse. She has responded that too many kegals might actually result in prolapse for some, so I don’t understand why I would then use them to correct prolapse. I’m finding it impossible to get a straight answer that women’s health professionals agree on. I have read that she warns not to go to a deep squat right away with prolapse as it could increase intra-abdominal pressure, but I haven’t found anywhere that she recommends kegals for prolapse. Speaking of elephants in the room, I think those of us who have prolapse are a giant one. There’s a lot of current information about treating pelvic floor tightness or avoiding prolapse, but not much new on the treating prolapse front. I know I and others with prolapse are unsure on how to proceed. Thanks for your time!
Hi Dee,
It is confusing, no doubt about it. In fact, I’ve done a complete re-write of my blog post in the hopes of completely clearing up the confusion once and for all–if you have a sec, please give it a read!
In answer to your above question, and as reflected in the updated version of my post, I have to disagree with Katy that Kegels are never appropriate. I think there is a time and place for them. Therefore, if you are seeing a good pelvic floor physical therapist and she is prescribing Kegels for you, that may be the correct treatment for your pelvic floor.
Thank you for reading and taking the time to write in!
All my best,
Liz
This is a suprise to me. How can you tell women to STOP doing Kegels? What do you tell women with prolaps? And women past menopause, which have had surgery, or even hysterectomy? If women dont have any options at that age or with that kind of problems, they will live in pain, and discomfort.
As I mentioned in the above comment response, I have to disagree with Katy that kegels are never appropriate. I think they are a useful treatment strategy for a pelvic floor that is overstretched/not tight and weak. Sorry for the confusion!
I have re-written the blog to reflect this, please give the updated version a read if you have a sec.
All my best,
Liz
Most women which have a pelvice prolaps problems have weak pelvice. My concern is, what kind of excersise should they do? I was told by my pelvice therapist that I should never do a wide squat at my gym class. And after my prolaps surgery, I did not know this, and did squats, and I have had discomfort since! My therapist told me NOT to do squats, since it presses down on the pelvice mussles. This is totally different from what is said here. Now if this article is meant for young women which have not had any children, I can see that. This needs to be clear, for all women with prolaps or pain in the pelvice.
Gunna.
In the article, Liz says that she disagrees with Katy Bowman about doing squats to strengthen the pelvic floor! So she is NOT advocating doing squats for people with weak pelvic floor muscles!
It seems to me that the general problem is that the “experts” are telling EVERYONE to do kegels across the board. I think this speaks to the general lack of knowledge about the pelvic floor in the healthcare community and beyond. Telling everyone to do kegels is akin to telling everyone to take blood pressure medication–not everyone needs it, and for some it would be harmful!
Can you have photos or a video showing how to do the deep squats? There is so many variations.
Thank you!
Hi Michele,
We recommend either “squat drops” or “flat back drops.” You can see photos of each as well as a video of the “flat back drop” towards the end of this blog post: http://www.pelvicpainrehab.com/blog/2012/08/pelvic-floor-drops-weak-and-tight-muscles-tilted-pelvis-and-more.
We aren’t proponents of the “deep squat,” which Katy Bowman describes. You might be able to find more info on that version on her website: http://www.alignedandwell.com/katysays/
Please let me know if you have any more questions.
All the best,
Liz
Hi Liz,
I am a man and Im curious to what extent your advice applies to the male gender? Many suggested kegeling to retain harder and longer lasting erections, or suggested it as cure to erectile dysfunction. What are you thoughts?
Cheers
Thank you for your question. It is fairly uncommon for men to need to do Kegels because there aren’t too many reasons for a man’s pelvic floor muscles to become weak. Weak pelvic floor muscles are the only reason one would need to do Kegels. One situation a man would likely need to engage in a pelvic floor strengthening program (do Kegels), is after a prostatectomy. There is no research to support Kegels for better erections or orgasms. In fact, if you do too many Kegels when you don’t need to, you’ll make your pelvic floor muscles too tight which will negatively effect the muscles ability to contract optimally.
All my best,
Liz
I’m 23 weeks pregnant and have been told that kegels are absolutely beneficial. Now I’m doubting this advice. But how do I know whether my pelvic floor is weak or hypertonic, or just normal? Would doing kegels be helpful for birth if my pelvic floor is normal to begin with?
Dear Lisa,
There’s so much information out there, it is difficult to know which is the best for you. Being pregnant puts extra demand on the pelvic floor, simply because there is more weight that needs to be supported, among other things. During labor and birth, the muscles relax and stretch to accommodate the baby. Kegels are a “shortening” exercise, so when you voluntarily recruit them and do a Kegel, the muscles contract and therefore build strength (similar to a bicep curl). The tricky thing about the pelvic floor is that it is on all the time to support us, maintain continence, and aid in sexual function. It’s working now to hold in urine and stool, and support your uterus and growing baby. As the demand increases on the muscles, they must be strong enough to continue to work properly and accommodate the new demands. Kegels will help strengthen the pelvic floor, not necessarily “relax” it, if you will. And, yes, it can be helpful in pregnancy if the muscles are beginning to tire out and become weak. Usually signs of weakness include stress incontinence, for example. But, it’s hard to tease that out in late pregnancy because the baby is also tap dancing on your bladder! To really tell what state your pelvic floor is in, it is best to have an evaluation by a qualified physical therapist. She can evaluate your muscles and assess whether they are weak, short, or strong, and if you should be doing Kegels or not. To answer specifically if they would be helpful in birth, my personal opinion is that they are more helpful in the recovery of birth (if you are on the weaker side going into delivery).
If you are strong going into labor, and you are able to relax your pelvic floor and bear down appropriately, you may have a little easier recovery. Again, this is all woman-specific, and there are a lot of variables to take into consideration. So…should you do Kegels while pregnant? It depends on where you are now, and what state your pelvic floor is in. Remember, your pelvic floor muscles are working all the time, so your pelvic floor may be perfectly strong and may be accommodating the pregnancy and added demand on them just fine, so you may not need to take any action, it really just depends on the woman. So touching on the WebMD comment, it’s not completely bunk, because yes those muscles help support all those structures mentioned, but like I mentioned above, Kegels don’t help relax or lengthen the muscles, and that’s what you really need for birth. It’s all about balance. You want the muscles to be strong to continue to support you and the baby, and also decrease the risk of urinary incontinence after birth, but at the same time, you need to be able to relax them and control them appropriately. The best way to learn how to do all those things is to have an evaluation by a qualified pelvic floor physical therapist. I believe the overall message here is that this is an issue that’s complicated with many variables. So an across the board edict to either “do Kegels” or “don’t do Kegels” is just not appropriate.
All my best,
Marcy
Sorry, as a follow up to the comment above, WebMD says this:
“Kegel exercises help strengthen the muscles that support the bladder, uterus, and bowels. By strengthening these muscles during your pregnancy, you can develop the ability to relax and control the muscles in preparation for labor and birth.”
Is this bunk?
Dear Lisa,
There’s so much information out there, it is difficult to know which is the best for you. Being pregnant puts extra demand on the pelvic floor, simply because there is more weight that needs to be supported, among other things. During labor and birth, the muscles relax and stretch to accommodate the baby. Kegels are a “shortening” exercise, so when you voluntarily recruit them and do a Kegel, the muscles contract and therefore build strength (similar to a bicep curl). The tricky thing about the pelvic floor is that it is on all the time to support us, maintain continence, and aid in sexual function. It’s working now to hold in urine and stool, and support your uterus and growing baby. As the demand increases on the muscles, they must be strong enough to continue to work properly and accommodate the new demands. Kegels will help strengthen the pelvic floor, not necessarily “relax” it, if you will. And, yes, it can be helpful in pregnancy if the muscles are beginning to tire out and become weak. Usually signs of weakness include stress incontinence, for example. But, it’s hard to tease that out in late pregnancy because the baby is also tap dancing on your bladder! To really tell what state your pelvic floor is in, it is best to have an evaluation by a qualified physical therapist. She can evaluate your muscles and assess whether they are weak, short, or strong, and if you should be doing Kegels or not. To answer specifically if they would be helpful in birth, my personal opinion is that they are more helpful in the recovery of birth (if you are on the weaker side going into delivery).
If you are strong going into labor, and you are able to relax your pelvic floor and bear down appropriately, you may have a little easier recovery. Again, this is all woman-specific, and there are a lot of variables to take into consideration. So…should you do Kegels while pregnant? It depends on where you are now, and what state your pelvic floor is in. Remember, your pelvic floor muscles are working all the time, so your pelvic floor may be perfectly strong and may be accommodating the pregnancy and added demand on them just fine, so you may not need to take any action, it really just depends on the woman. So touching on the WebMD comment, it’s not completely bunk, because yes those muscles help support all those structures mentioned, but like I mentioned above, Kegels don’t help relax or lengthen the muscles, and that’s what you really need for birth. It’s all about balance. You want the muscles to be strong to continue to support you and the baby, and also decrease the risk of urinary incontinence after birth, but at the same time, you need to be able to relax them and control them appropriately. The best way to learn how to do all those things is to have an evaluation by a qualified pelvic floor physical therapist. I believe the overall message here is that this is an issue that’s complicated with many variables. So an across the board edict to either “do Kegels” or “don’t do Kegels” is just not appropriate.
All my best,
Marcy
I have a question. I have been dealing with pelvic floor and SI joint issues since my pregnancy 2 years ago. I saw a great PT in my area for over a year. First, I stretched the pelvic floor, then we moved on to Kegel’s after all my pelvic floor pain was gone. I had little increase in strength with kegel’s so after several months we started using a vaginal stimulator. This did increase muscle strength, and after 45 days I stopped using it. My pelvic floor soon started loosing strength again and I noticed that the stimulator increased my SI joint and groin pain. She suggested using the stimulator 1-2 times a week then using the dilator after to stretch, but it causes more groin and SI jt pain. I think the stimulator is also contracting my psoas. I have tried different positioning with the stimulator with no relief. She says there is not much else we can do. Are there any other ways to strengthen the pelvic floor when Kegel’s are not enough? could other postural changes like Kati suggests help in this situation? What are my other options? I have seen other PT’s who also specialize in pelvic floor who have been little help.
Dear Shannon,
I am assuming you are referring to a home “e-stim” machine, or NMES unit to help assist with pelvic floor muscle contractions. I’m glad your PT had you balance out strengthening with stretching, I think that is a smart way to go. As with any muscle group, if you don’t maintain your exercises, strength will decline. My question is, how did you know you were losing strength? Did you start to experience leaking or other symptoms? Personally, I prefer not to use e-stim machines, so I have my patients do a combination of isolated pelvic floor strengthening (if appropriate) in conjunction with deep abdominal work and functional exercises. We need our pelvic floors to be strong during daily activities, not just when we are laying down. Posture will also play a role in your SIJ, PFM, and groin pain, and should be addressed, as well as looking at the function of your abdominal and multifidi muscles (core). I would suggest being evaluated by a PT who specializes in post-partum PT and pelvic floor dysfunction, to see if she can link orthopedic issues with your pelvic floor issues. I hope this helps. Good luck!
Marcy
Hi Liz
Your post is very informative and highlights the importance of truly understanding pelvic floor’s responsibility and function. It is a myth that a tight pelvic floor cannot be dysfunctional and that all pelvic floor exercise is created equal for all people.
Any muscle that has become tight has been shortened by default and the opposing muscles become long and weak. It is hard to distinguish within the pelvic floor exactly which muscle is short and tight, but it is important for women who want to consider deep squats as a way of effectively working their pelvic floor to note the role and responsibility of the muscles within the butt (as well as their own postural limitations) to ensure they are ‘doing their job’ of extending the hip, or rotating the hips and knees outward, instead of primarily stabilising the pelvis because of instability within the pelvis, which can cause dysfunction within the pelvic floor when the buttocks act as a stabiliser for the pelvis as their primary role when this should not be the case.
This faulty recruitment alone can cause the piriformis to become overactive along with the ischiococcygeus and together they can cause the pubococcygeus to become underactive. Since this part of the pelvic floor is crucial to ensuring continence during intra abdominal pressure, deep squatting without ensuring the effectiveness of this muscle and the whole pelvic platform alongside the transverse abdominals, can actually be detrimental. The important thing for the practitioner and the patient is to understand muscle and movement in relation to the individuals history and lifestyle.
My book Pelvic Floor Secrets, gives the reader a user friendly guide to understanding their pelvic floor and be able to seek the appropriate assistance for their individual desired outcome.
We are all individuals and we all function uniquely, so we should not look for shop shelf exercise programmes if we want optimal health.
Stay blessed
Jenni Russell
I think what is not being recognized, and is most important, is diet. If you do kegels or any exercise, you want to eat the proper foods. In this case you want foods rich in fat and protein, such nuts, seeds fatty meats like beef or chicken with the skin. Organ meats are good also. You want to eat these foods within an 1.5 after doing the exercises. The reason is because, the pelvic floor is made up of mostly slow twitch fibers that deal with mostly fat. This makes sense since the muscles have to work all day, so they need a constant source of energy, which fat provides. The protein helps with small repairs that may need to be done. The rest of the muscle fibers are fast twitch which deal with sugars. This helps deal with quick reactions like sneezing or physical labor.
People tend to think exercise is the main thing that changes their body, but it’s just a piece of the puzzle. Without the proper foods, exercise won’t do much, but with the right foods, and eaten at the proper time, exercise will make your muscle STRONG, yet relaxed when it needs to be.
I know these things because I work out, and made no changes until I did things different with my diet, and timing of eating the foods according to my exercise routine.
Hope this helps someone.