At some point in life, lots of women experience pain in their stomach, back, hips and/or knees. The sources of these pain points may feel elusive, but in many scenarios, there are two culprits to blame. I’m here today to help you identify whether you, or a woman you care about, has one of these conditions.
PAIN SOURCE #1: LARGER Q-ANGLE
Women have wider hips than men. This is not surprising information. In some women, a wider pelvis results in a steeper angle between two landmarks: the ASIS and the patella.
The ASIS stands for Anterior Superior Iliac Spine. Don’t be intimidated – this is easier to identify on your body than it is to pronounce. Place your hands on your hips, like you’re standing with a little sass (thumbs pointing back and fingers forward). Feel where your middle and ring finger fall on the front of your hips. Slide your fingers slightly inwards and you will feel a bony part of your pelvis if you push into your flesh. You found it!
Next, place two fingers on your kneecap. You found the patella! So much easier.
The Q-Angle is an angle measured between these two landmarks. It’s best done by a physical therapist or qualified fitness professional using a goniometer. Yuck, so many dull scientific words.
For a great visual, check out the illustration on this website: http://bit.ly/1CWkk4X (scroll down just a little on the page)
Why is this relevant to you?
If you’ve experienced knee pain or instability, ACL issues, pain with running or jumping, and/or hip pain, then you may have a “large” Q-Angle. This doesn’t mean there is anything wrong with you, so don’t panic! It simply means that your kneecap tends to be pulled at a harsh angle, causing stress on the surrounding soft-tissue structures.
Although it’s super unfair that nature has made women more prone to knee pain than men, there are simple ways to ensure knee health. Here are a few:
1) Strengthen your quadriceps. Your quads are the large muscles on the front side of your thighs. These muscles are above the knee and help stabilize your kneecap’s movement. You can strengthen these muscles through controlled leg extensions, leg presses, and squats.
2) Foam roll your IT bands. Your IT-bands are dense, connective tissue on the outside/lateral aspect of your thigh. Tight IT-bands can add tension and stress to the knee. Since there is already a strong pull on your kneecap based on a large Q-Angle, it’s important not to add any unnecessary tension to the knee.
A foam roller is a cylinder made of densely packed foam. You can roll your body back and forth on the roam roller to relieve tension in any area. It’s like you’re a big ball of dough on a rolling pin! Not what a woman wants to imagine herself as, I know, but the analogy works!
If foam rolling hurts a lot, it’s a sign your connective tissue is really tense and needs this release. You can reduce discomfort by placing one leg in front of the other, distributing your body weight into the assisting leg.
Note: It’s really important that you don’t roll directly over joints. Ouch.
3) Control knee stability during lower body exercises. If you watch yourself in a mirror, or even look down at your knees, while performing a lower body exercise, you may notice that your knees drift slightly inwards. When your knees drift towards one another, it creates stress on the joint capsule. Although this may improve with leg strengthening exercises, it may also be a factor of form.
You can increase your awareness by simply being mindful of your form. If you notice that your knees are drifting inwards, simply exert a little effort and move them wider. It doesn’t have to be excessive. It should feel more comfortable and will help you feel better balanced.
4) Strengthen your “outer thighs.” This may surprise you, but there aren’t any “outer thigh” muscles per say. When you perform exercises to target this area, you’re actually working muscles in the outer region of your hips/gluts. More specifically, muscles called your gluteus medius and gluteus minimus.
A wider Q-Angle means that these muscles are pulled and elongated a bit more than usual, resulting in them being less stable and strong. Since knee health depends a lot on ankle and hip stability, it’s a good idea to strengthen these oft-forgotten muscles. You can do this through side lunges, lateral movements, lying side leg lifts, clams, and more.
PAIN SOURCE #2: DIASTASIS RECTI
Even if your baby-making years are far ahead or behind you, this is relevant information because it may impact you some day, or it may have taken place during pregnancy without your awareness. For women who plan to have children soon, or who are currently pregnant, listen even closer.
We’ve all admired another person’s six-pack at some time or another, right? Well, imagine that the rippled six pack has an enormous split down the middle, separating and pulling the two halves away from one another so that the abdomen looks a little more like two three packs. This is what Diastasis Recti looks like. For a great visual, click here: http://bit.ly/1JQoYaS
Why does this happen?
When a woman gains weight with pregnancy and extra pressure is placed on the abdomen as it stretches, the core muscles are under great strain. The six-pack muscle naturally stretches with a growing uterus, but in the case of Diastasis Recti, the connective tissue that coats your core (the linea alba) gets stretched to a greater degree. The split can sometimes appear as a ridge in the abdomen and can be felt by placing fingers into the crevice. Diastasis Recti is usually diagnosed when the space is two finger widths.
What are the consequences?
Diastasis Recti can compromise a woman’s overall core strength, leading to secondary conditions that challenge overall health and wellbeing. Some women also experience a post-pregnancy “pooch” that they just can’t seem to get rid of because it isn’t a factor of weight loss. Diastasis Recti may present with multiple other conditions such as:
- Back pain and instability
- Compromising posture
- Pelvic floor dysfunctions Hernia
- Pelvic pain and instability
- Gas and Digestive problems
- Fecal incontinence (Constipation)
- Pelvic floor dysfunction (SPFD)
- Urinary incontinence
- Pelvic organ prolapsed
One of our readers shares her personal experience…
When Jenna knew something was wrong:
“Sometime in the middle of my third trimester (while pregnant with my first child), I realized that I had Diastasis Recti. I was only aware of the condition because of my background in nursing school. The particular activity that made me aware of my abdominal separation was trying to sit up in bed (the wrong way). As my stretched-out abs attempted to engage, I saw what looked like a mountain ridge down the middle of my abdomen. This was a little frightening to see and though I was not experiencing pain, I could tell something was not right. When I mentioned this event to my caregiver, I received no concern and no education was given regarding how to protect myself when bearing weight or how to properly exercise my core post pregnancy.
Roughly two years later, I gave birth to my second child and suffered three tears. Even after my injuries healed, my pelvic pain lingered. It was noticeable with long periods of standing at my kitchen counter or when taking long walks outside. The pain was especially acute when I would sit up from a reclined position in bed after nursing my newborn for night-time feedings. I made an appointment to discuss the pain with my provider. She recommended pelvic physical therapy for my ‘pubic symphysis dysfunction.'”
How Jenna got better:
“I am so thankful that I took this recommendation! My pelvic PT taught me about the anatomy of the female pelvis and how childbirth impacts and often compromises core strength. I learned how to measure my diastasis recti and what exercises I could practice to help approximate the abdominal muscles. I learned how to protect my core by creating a “pelvic brace” for exercising and weight lifting. I also learned the proper posture for carrying my baby, how to get in and out of bed, and safe body mechanics for lifting my car seat.
Over a five week period, my pain significantly improved and was rarely noticeable! Only after a two week period of not exercising did my pain return (minimally). I discovered the reason for this is because I’m still breastfeeding my baby and this allows the relaxin hormone to linger, thereby creating instability at the pubic symphysis and also making it difficult to build muscle. While breastfeeding, maintaining my core stability means that I have to exercise regularly (4-5 times a week) and practice Kegel exercises daily. If I can commit to these practices, I remain pain free!”
Thank you, Jenna, a million times over for sharing this personal journey!!! It takes a lot of courage to share it and no doubt other women will benefit from hearing it.
How do I exercise to prevent or correct Diastasis Recti?
If you believe that you have diastasis recti, then I suggest you work with a reputable physical therapist for at least a few sessions, to get on the right track. As mentioned in the former testimonial, it’s important to learn proper biomechanics for sitting up in bed, lifting heavy objects, and bracing your core during exercises. A great place to start is by checking these exercises, performed by my lovely former colleague, Alison, and presented by my wonderful friend and former PT Cari: http://www.releasept.com/videos/low-back-core/ (The first nine videos work on core bracing in a gentle, but effective, way.)
Jenna’s PT, Stephanie Fournier, has also been extremely generous with her time, and has offered us some answers to important questions about this condition. See her interview below.
INTERVIEW WITH WOMEN’S HEALTH CLINICAL SPECIALIST
1) How many women do you encounter postpartum who have severe pelvic and core instability, and/or a diagnosable condition?
First, I would define severe pelvic and core instability as any pain or dysfunction in the postpartum period that is affecting activities of daily living. This could include severe pain, restriction in activities, avoidance of activities, or slowing a woman down in her normal activities. That being said, the exact number is hard to quantify since I treat in an outpatient clinic where I am only going to encounter those women who do have problems (core instability and/or pain) and who are coming to me via doctor or self-referral. However, I do believe that pain and dysfunction in the postpartum period go largely under diagnosed. What I hear most often from patients is that they tried to talk to a friend, family member, or healthcare provider about their pain/instability/limitation and they are told things such as, “That is normal, you just had a baby,”… “It will get better after the pregnancy,”… “You just have to live with it.”
Some research numbers to reflect on:
- Incidence of lower back pain and pelvic girdle pain (PGP) in pregnancy range from 68.5% to 76% in prospective studies (Wang, 2004; Kristiansson, 1996; Ostgaard, 1991). And the incidence of PGP alone in pregnancy was 20%, in one prospective ,study (Vleeming, 2008). Why the discrepancy? Most likely pain is under reported.
- 70% of women experience some sort of lower back or pelvic pain during pregnancy.
- 1/3 of women report severe limitations in activities of daily living as a result of back and pelvic pain (Ostgaard, 1991). The risk for back pain increases postpartum (Ostgaard, 1997).
- Most importantly, women having back and pelvic pain are 3x as likely to have postpartum depressive symptoms than those without pain (Gutke, 2007).
2) How do most women identify that they have Diastasis Recti? What tips do you have for identifying it as early as possible?
Most women that I see in the clinic do not realize that they have a diastasis recti (DrA). Often, they are coming to me for pelvic pain (posterior pelvic girdle pain, pubic symphysis dysfunction, lateral hip pain, or abdominal pain) and it is something that we find during our evaluation. They might have noticed a tent or pooch in their abdominal area with sits ups, supine to sit (getting in and out of bed) but didn’t exactly know what it meant. For identifying early on, women can measure themselves with their fingers or a tape measure or just look at their tummy when they are rolling in bed or sitting up in bed.
To measure; the patient starts in supine with their knees flexed. They can place their fingers horizontally in the umbilicus and raise their head up. They are measuring how many fingers they can place inside the gap in the rectus abdominis. [It should be noted that this finger method is highly unreliable and it is better to use a tape measure, however the tape measure is hard to do on yourself]
Some more research numbers to be aware of:
- 66% of women develop a DrA by their 3rd trimester.
- 39% of women have a significant DrA several years after delivery. Significant is defined as separation of 2.5cm or more (Ranney, 1990).
- More than 50% of women presenting for urogynecological examination presented with a DrA. These are postmenopausal women. Likely, the DrA developed during the child bearing years and never fully resolved postpartum, leading to poor core stability and pelvic organ prolapse (Spitznagle, 2007) .
- DrA is associated with varying degrees of stress urinary incontinence, fecal incontinence, and pelvic organ prolapse (Spitznagle, 2007). This is why treating DrA early on in the postpartum period is so important to me. We could potentially be helping women to avoid major symptoms and even surgery.
Also, Parker (2008) found that women with DrA tend to have higher degrees of pelvic or abdominal pain.
3) How soon after pregnancy can women start working their core muscles again? How do you suggest they start?
I recommend that women return to activity postpartum as they feel comfortable. However, I do have a few recommendations for those women who do have a DrA [separation of 2.5cm or more at the umbilicus, 4.5cm superior to the umbilicus, and 4.5cm inferior to the umbilicus].
- Avoid obliques, regular crunches/situps, and planks until the DrA is reduced to 2.5cm or less OR the woman can affectively activate a co contraction (transverse abdominis + pelvic floor muscle contraction)
- When treating a DrA, I start with initiation of TrA (transverse abdominis) which they can start day one postpartum with or without a c-section
- Progress to DrA curlup (Neville, 2008)
- Various TrA stabilization activities or progressions, depending on the individual
- Consider corset or elastic binder per the individual
- Avoid bearing down (valsalva) and sitting straight up (in bed/jack-knife)
- As always, ensure proper pelvic floor muscle activation (including power, endurance, and coordination)
Thank you, Stephanie, for sharing your wisdom and expertise! You went above and beyond!
If you have any questions about this content and/or exercises to improve your health, then please don’t hesitate to reach out! Upon request, I’m happy to share the medical studies that Stephanie referenced too.
Being a woman can be tough stuff, but there’s no reason why we can’t feel amazing and pain free!
Yours in health and wellness,