Head and Shoulders, Knees and Toes….and Pelvic Floor


My Father-in-law’s favorite joke is to lift his arm only to shoulder level and say “Hey doc! I can only lift my arm this high.” Then as he raises his arm to straight overhead, he says “But I used to be able to lift it this high.”

After ruling out the need for a psyche consult, a doctor would likely send a patient with a shoulder issue to see a physical therapist. Shoulder problems come in many forms. Regardless of the cause, in order to fully rehabilitate a shoulder, the pelvic floor needs to be a part of the rehab plan.

Pardon me? Psyche consults all around!

You can’t address a shoulder problem without addressing joint alignment, and shoulder joint alignment relies on postural alignment. Postural alignment needs a strong Core, and you can’t have a strong Core without a strong pelvic floor. Cancel that consult!

In 2007, a research team lead by Paul Hodges (1) compared how the pelvic floor and shoulder muscles interacted when a study participant lifted their arm in different directions. One of the things they observed was that the pelvic floor engaged before the arm lifting deltoid muscle every time, no matter which direction the arm went.In a nutshell, the pelvic floor, along with the other inner Core components (Diaphragm, Transverse Abdominis, and Multifidus), secure our physical center to create a sturdy anchor for the muscles that support and create shoulder motion before we start moving our arm, every time we move our arm, no matter which way we move our arm.

A paraphrased “Dem bones, dem bones, dem dry bones” ditty highlights this relationship with an anatomy lesson that works from the outside-in. The shoulder bone’s connected to the shoulder blade  The shoulder blade’s connected to the ribcage. The ribcage’s connected to the spine, and the spine’s connected to the pelvis. Muscles help make all of those connections. However, Hodges research demonstrated that the timing of the muscular connections should follow the pattern of the pelvic floor first, securing the pelvis before all other muscle work begins. So we have to reverse the “dry bones” anatomy lesson and move from the inside-out. Secure the pelvis first with our pelvic floor then rehabilitate and train the muscular and structural chain back out to the shoulder. Who’s crazy now??

The pelvic floor’s claim to fame is its role in keeping us from leaking, and it gets a lot of press for providing better sex. However, It is also a powerful ally in the health of our musculoskeletal system. I have highlighted the particular relationship it has with shoulder motion here-if the pelvic floor isn’t working well then the shoulder won’t work well either. The pelvic floor also works in the same way with other body parts- hips, knees, necks, etc. to optimize the function.

So what is a woman who has had a few kids and has a few leaks when she coughs or laughs  to do about her achey shoulder? Start by understanding how the two issues, leaking and achy shoulders, are connected. Also, know that when you go to the doctor to talk to him/her about what are historically perceived as two separate issues- you too may be considered a nut job!  Hand them a copy of this blog with the research reference below. Then ask for an Rx for a physical therapist in your area who can help you from the inside-out!

1. Hodges PW, Sapsford R, and Pengel LH. 2007. “Postural and respiratory functions of the pelvic floor muscles.” Neurourology And Urodynamics 26, no. 3: 362-371



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15 thoughts on “Head and Shoulders, Knees and Toes….and Pelvic Floor”

  1. What a fun, informative post Julie.

    Lest we have hallucis abondonment issues however, might want to add that with a balanced PF the femur rotates to rotate the tibia to supinate the pronated dawgs, allowing hallucis to bear weight and push back up dem bones in static stance or gait.

    The yogi’s directions in mountain pose (Tadasana) to ground the big toe, sense lift through the inner thighs as the tail drops and the heart lifts creating thoracic extension and dropping the scaps down out of the humeri’s (sic) way.

    One caution when working with someone like your father in-law: never, I mean never, pull their finger to fix their arm! ; )
    thanks for the creativity in sharing this insight.
    matt http://www.drofyoga.com

  2. six pack abs says:

    Awesome article, but just curious, what is your main field of expertise? Do you write part time, or are you a professional in your field? I wouldn’t mind reading an About Us section or something to describe what you do so I can better understand your point of view.

  3. cna training says:

    Wow this is a great resource.. I’m enjoying it.. good article

  4. Julie Wiebe says:

    Thanks for your question, you can find information on my background in the Bio section of the website http://interiorfitness.com/about/bio/ . I am a sports medicine physical therapist by training and moved into women’s health after the birth of my daughter. Sports med and women’s health are typically considered as separate entities. I have blended these two areas to create a unique approach and perspective on rehabilitation and return to fitness and sport for both women and men. Let me know if you have any other questions.

  5. Julie Wiebe says:

    Matthew, thanks for your response! I learned to avoid the finger pull many moons ago!

    I appreciated your reference to the closed chain connections to the south. I actually like to think of the pelvis as the new “floor” in the closed chain scenario, and I appreciated your recognition of the PF in that system. I wanted to address your reference to the “balanced PF” creating relative supination down the lower extremity chain in stance and gait. My thought or definition of a balanced PF would be that it stabilized and supported relative pronation in the lower extremity as well. For example as seen in gait during the lower extremity shock absorption from heel strike through midstance. Midrange hip rotation, fluctuating between IR and ER, often seen in the sway of quiet standing and in the action of children as they move from a squat to standing activates both PF eccentric and concentric contraction.

    In one of my next blogs, I hope to encourage this kind of dynamic use of the pelvic floor versus the status quo pelvic floor static contraction that is commonly taught-just squeeze the muscles that help you stop pee in a few different positions. This will not encourage the relationship that the pelvic floor has with the lower extremity below, as you discussed, or with the shoulder above. Hoping to push pelvic floor work to a new place!

    Thanks again for your thoughtful interaction with my blog. julie

  6. Physical therapy is very vital now a days, physical therapy deals with an immense range of different conditions,injuries, illnesses and more.

  7. Great post as always Julie, will be linking back on my blog in two days!

    1. Julie Wiebe says:

      Thanks Erson! Much appreciated! Julie

  8. Tom Jennings says:

    Hi Julie,

    Great post! I am an ATC and own a sports performance studio. When evaluating upper extremity injuries I always examine hip stability. I am amazed at the lack of strength in the hip with chronic upper extremity injuries. Thanks for sharing.

    1. Julie Wiebe says:

      Hey Tom! Agreed! Developmentally the link between shoulder girdle and pelvic girdle starts early ( pushing up from prone, rolling, rocking on hands and knees, etc). I like to link upper and lower quarter in every exercise I do. First via the diaphragm and pelvic floor connection and then moving out to more superficial postural muscles from there. Contralateral lats to glutes (ala Diane Lee slings) is a fave of mine for a shoulder issue!

      Thanks for weighing in! Julie

    1. Julie Wiebe says:

      Yes I am on twitter! You can follow me @JulieWiebePT . Thanks!

  9. Tamara Newton says:

    Trying to connect pelvic floor with my moms knee- Basi Pilates student in need of proof;) I know I am right there I just need a lot more proof for the research paper:) please help.

    1. Julie Wiebe says:

      Hi Tamara,

      Sorry, I am not exactly sure what you are asking for. BUt I recently added a blog that discussed the connection between the pelvic floor and the control of the hips for a squat. We understanding in the ACL literature that proximal or central control at the hip is critical for control of the knee. So that PF to hip to knee connection for me is understood best in that group of articles do a search for authors like Hewitt, Zazulak, Powers. They understand proximal control. I am adding the idea that the pelvic floor is part of that chain of control. This is supported by the literature that shows a PF pre-contraction before arm and leg movements as a part of central or proximal control strategy. We now have a study that has shown this is true in running, the PF pre-contracts before heel strike http://www.ncbi.nlm.nih.gov/pubmed/23361854. Check out my recent blog here: http://www.juliewiebept.com/uncategorized/butt-wink-hip-openers-and-the-pelvic-floor/

      I hope that helps! Julie

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