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Feet and the Pelvic Floor

I just finished another foot workshop. I love doing them because they are literally your foundation and also the foundation of all the work that follows, typically the pelvic floor. So yes, next up is a pelvic floor workshop (my second!). I thought I’d write a post about how feet and the pelvic floor are related, and why you can’t really address one without the other.

Let’s establish some very basic anatomical details:
1. Your hip joint is made up of the ball and socket of the femur and the acetabulum. The femur is your thigh bone. It ends in a “ball” which sits in a rather deep socket made up of your pelvic bones.

2. Your knee is in the middle of your leg and this joint is formed by the bottom of the femur (thigh bone, see #1) and the top of the lower leg bones, specifically the tibia. The top of the tibia is like a plateau. In fact, it’s called the Tibial Plateau. Poetic eh? The back of the knee is what we’ll be looking at today.

Here's what the back of the knee of the average person looks like. The red dots are indicating the hamstring tendons. With the feet in turn out, the hamstrings almost face straight back (this person probably walks with more turn out than she is showing here).
Here’s what the back of the knee of the average person looks like. The red dots indicate the hamstring tendons. With the feet in turn out, the hamstrings almost face straight back (this person probably walks with more turn out than she is showing here).

3. Your ankle is at the bottom of the leg, between the lower leg and the foot, and it is made by the two lower leg bones (tibia, fibula) and the top bone in the foot called the talus. The talus is a magical wonderful bone. It has no muscular attachments (the only bone in the body with this distinction!). It supports your whole body like a keystone in architecture. The talus in turn sits on the heel bone (calcaneous).

4. Of course your foot is at the bottom of the leg and is comprised of 26 bones, 33 joints, and basically three arches; one arch on the inside of the foot (often collapsed or “pronated”), one on the outside and another one across the ball of the foot called the transverse arch. (This last one is often also collapsed.) The foot is considerably more complex than the hip or knee.

Let’s get personal. I’m going to introduce you to my pelvic floor. My pelvic floor has done a great job for me over the last 5+ decades. It has birthed two children and held in my internal organs pretty effectively. I’ve not had any really serious issues with my pelvic floor (no prolapses). I’ve had some incontinence following the birth of my kids, but only when I jump around on trampolines (not that often) or laugh really hard (unfortunately not that often) or sneeze really hard (about 100 times a day). I’m willing to bet that most of my female clients have some degree of the same issues and haven’t even mentioned it because “it’s normal.” Most people wouldn’t consider what I’ve just described as a Pelvic Floor Disorder. That has to be more complicated/severe/advanced/painful right? Well, that is incorrect. Peeing when you sneeze or laugh is not normal. It’s common, but not normal. So what if you have the same problems, or perhaps something more problematic, such as a prolapse (unfortunately very common as well) or pain in your pelvic floor? What has that got to do with your feet?

The soles are your connection to the earth, and that fact has many ramifications. For one, there is traction between your foot skin and the ground, unless you are in the nasty habit of wearing those contraptions otherwise known as “shoes.” Then your foot skin is in traction with a sock within a shoe. But whatever. How your foot meets the surface of what you are walking on will affect the joints listed above (ankle, knee, hip). The best biomechanical situation for your feet is with the feet facing straight forward in the direction you are going. This enables the ankle to articulate on it’s correct axis, or plane (which is forward and back, not side to side). But if you walk with your feet pointing out (even a few degrees) the movement that should occur at the ankle occurs below the ankle where the talus articulates with the foot bones, creating an overuse situation that may result in lax ligaments (ankle sprains anyone?).

The foot is made to articulate in all manners of ways with those 33 joints, to accommodate all manner of surface variants, so all these movements aren’t damage making in themselves, but in their frequency of use. Because we walk on flat surfaces pretty much 100% of the time, this turned out position will end up creating the shapes of the bones of the legs, and changing the orientation of the joints of the knee and hip as well as the ankle! Pretty radical eh?

Now the muscles of the pelvic floor are connected to the hip joint (both literally and figuratively) in that the position of the femur in the acetabulum (thigh bone in the hip socket) will change the resting tension of the pelvic floor. Add to that a chronic tail tucking position (which does NOT allow normal hip extension, which would engage the posterior butt muscles and create normal tensile loads on the sacrum – which is a heavy duty pelvic floor attachment site) and we’ve got some major mechanical flaws that will inevitably end up affecting the function of the pelvic floor.

Starting with the foot position, let’s get those feet facing straight ahead. And then have a gander at the back of the knees. You will notice that the grooves which are your hamstring tendon attachments are not facing straight back the way they should. They face more toward the sides, away from the midline, or laterally. So to get them facing back again, so the knee is also articulating on its correct axis, we need to externally rotate the femurs. This will end up affecting the foot position again – the medial (inside) border will lift off the ground. Only with diligent practice at mobility drills and walking on a variety of unlevel, uneven surfaces will the foot gain back the mobility it needs to evert the forefoot back to the ground – and VIOLA – ARCHES!

With the feet aligned you can see the hamstrings are pointing out to the sides. You can't even see the outside one on the L leg.
With the feet aligned you can see the hamstrings (black lines) are pointing out to the sides. You can’t even see the outside one on the L leg. The feet are flat but pointing straight ahead.

So there you have it, to get the arches back, and the resting tone in the pelvic floor, you need to start with the feet and work your way up to the hips. My foot workshops end with this external rotation, but it’s a concept that is very challenging to do without some guidance – the health of the knee can be compromised if done incorrectly. So please see a certified Restorative Exercise Specialist before you try it. There are also more detailed instructions in Katy Bowman’s books (links in sidebar).

Now the femurs are externally rotated. The feet lift up on the medial side. Eventually, when the feet are more mobile, they will come back down with this hip/knee arrangement: alignment complete!
Now the femurs are externally rotated (the right one needs more!). The feet lift up on the medial side. Eventually, when the feet are more mobile, they will come back down with this hip/knee arrangement: alignment complete!

By the way, it’s been 3 years since I corrected my foot orientation and began walking with correct hip extension. My pelvic floor is a lot stronger. I can sneeze 100+ times now and no leakage. Cool right? And that was accomplished without one kegel. Not one.


13 thoughts on “Feet and the Pelvic Floor

  • Please help! I live in VA in USA. Had bunion surgery
    Last year am STILL in pain ,mostly hips now. Am RN& walked/stood/ran on concrete floors only one year after retiring. I really don’t trust doctors much anymore. Plus I notice my second& third toes are separating now.
    Any suggestions will give me hope which I really need now. Thank you, Sarah

  • Sarah, I recommend you find a Restorative Exercise Specialist™ in your area. The Restorative Exercise Institute website lists all the practitioners. Or you could start by buying Katy Bowman’s book “Every Woman’s Guide to Foot Pain Relief.” Good luck!

  • Amazing post!! This is such an important issue, and I’m so thankful for your expert insight. As my yoga teacher always said – the perineum is third foot 😉 Great work!

  • My son is 22yo. He was diagnosed at 12yo with bilateral vertical talus foot deformity. He has had constipation since 3 mo.’s old. As he got older he ended up with a mega colon and fecal incontinence. He went through many tests to determine the cause. Within his colon anatomy was normal, nerves all intact, except internal sphincter muscles would not relax in order to have a bm. He has a cecostomy and we do flushes to try and relieve the constipation. He just recently saw a PT that specializes in pelvic floor dysfunction. She determined that he has very tight achilles tendons, hamstrings, and hip flexors. This is due to the vertical talus foot deformity. It’s highly unlikely that he will ever have full control, even with exercises to relax his muscles because the vertical talus cannot be corrected. If it had been corrected at birth he would not have all of these colon problems. Why is there no literature on this anywhere? Why didn’t the GI’s ever check his feet and muscles?

  • I’m sorry to hear this, it must be very hard for all involved to experience this suffering. I expect the doctors are trained to treat in isolation so they probably did their best. Sounds like you have a good PT now and I wish you both well! You might find Katy Bowman’s book Diastasis Recti and her foot book Simple Steps to Foot Pain Relief helpful.

  • I’ve been experiencing pelvic pain, especially on my right side. And it’s only by the grace of GOD, that something told me to look at your feet, your arches have dropped. And I was just in disbelief. Then I went on line to search and see the effects of fallen arches, and there you were with this information. This information needs to be publicized more. This is very, very important information, that I’m sure more women and men need to know. I want to know much more. Thank You for sharing this vital information and please continue to update and share your findings.

  • Thank you for your contribution. The feet, legs and hips are all so important to look at when dealing with pelvic floor issues.
    You can read more in the books Alignment Matters, and Move Your DNA (a whole chapter on the pelvis), both by Katy Bowman. Good luck.

  • I have had pelvic pain since December.2016. In Dec.2017 I developed foot pain…I went to a podiatrist and got better shoes but still have foot pain…..is the foot pain related to the pelvic pain. What can I do?

  • Very interesting, I am the male of the species, I had my prostate surgically removed a few years ago, by the way I was 79 today, I’ve had bladder problems ever since not too serious but it’s there, a few weeks ago I investigated walking and found out about heel and toe walking, I tried it and it made my foot pain go away but I got a bonus, my bladder leakage has definitely improved, not gone away but not as bad by some way, so correct walking does help the pelvic floor, great post, thanks.

  • Could foot alignment be causing my hypertonic pelvic floor? I have tried so many things including pudendal injections.

  • Best to see a RES in your area. I’m not licensed to diagnose and can only give movement advice. But sometimes making these changes help with things you’d never associate with your positioning.

  • Thank you for the comment. Interesting. Definitely look into Katy Bowman’s books if you haven’t already.

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