5/1/16 Conflict of Interest Disclosure
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Julie Wiebe, PT provides continuing education
courses, live and online, for various academic
institutions, organizations, clinics, and conferences.
FEMALE ATHLETES:
THEY’RE NOT LITTLE MEN
Julie W. Wiebe, PT, MPT, BSc www.juliewiebept.com
Objectives
1. Discuss the unique physical differences and histories of women that can have an
impact on their injury vulnerability, response to rehabilitation, and considerations for
return to fitness and sport.
Who
•  Defining
the
population
2. Explain the interrelationship between the diaphragm, abdominal wall, and pelvic
floor on central stability, breathing mechanics, continence, balance, and performance.
3. Recognize the capacity and need to train the pelvic floor for excursion, eccentric
loading, concentric acceleration, speed, coordination, and timing.
4. Design sport-demand specific programs and incorporate intake suggestions that take
into consideration the challenges unique to the female athlete to promote maximized
results, prevent future women's health concerns, and decrease the need for additional
referral.
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. What
•  Defining
the issues
How
•  Case
Breakdown
1 5/1/16 Defining the Female Athlete
Who is your Female Athlete?
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Anticipatory Core = Continence System
Re-Think the Pelvic Floor
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• 
D
TA
M
• 
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Respiratory Diaphragm (D)
Transversus Abdominis (TA)
Multifidus (M)
Pelvic Floor (PF)
PF
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. Recreational vs High
Intensity
Demand specific (Impact?)
Goal specific
Beliefs/History
Won’t stop vs willing to
stop?
Is your patients/clients
core strategy prepared to
take on that challenge?
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The pelvic floor doesn’t work in isolation to pull off
continence. The team works together to manage IAP
and provide muscular force to close the continence
mechanism and keep us dry.
Same group of muscles provides postural control,
movement support for balance, gait, performance, etc
(ie “core stability”)
Incontinence is one clue that central stability system has
a fault vs just a Pelvic Floor Problem
A dynamic activity is a demand on THE SYSTEM
Isolated muscle work will not address.
2 5/1/16 Gender Differences: Injury Rates
• 
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Women are 2x more likely to
sustain running injuries PFS, ITBS,
tibial stress fracture (Taunton,
2002)
• 
Females are 4-6x more likely to
experience an ACL non-contact
injury.
Gender Differences: Structure
FEMALE
Gender Differences: Structure
Greater hip width to femoral
length angle, (Horton and Hlll,
1989) , static genu valgum
(Benas,1984), and active hip IR
(Simoneau, 1998)
Gender Differences: Structure
MALE
• 
• 
• 
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. Breast development!
Structural shift of rib cage
to accommodate breast
growth
Diminished diaphragm
capacity to set up IAP
stability system
3 5/1/16 Gender Differences: Motor Control
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Gender Differences: Form
Greater frontal plane and transverse
plane (hip ADD/IR, knee ABD/ER)
motion throughout stance phase
(Ferber, 2003)
• 
Same findings for walking and running
(Chumanov, 2008)
ACL lit: Similar LE pattern noted
greater peak hip IR and ADD, knee
valgus and ABD, decreased flexion
(Pollard, 2007; Hewett, 2006)
• 
Greater vertical movement and GRF
than men (Li, 2001) Expected vertical
displacement/bounce 6-8 cm. female
recreational runners 12-14 cm
(Heiderscheit, 2013)
Frontal plane pelvic list (tilt) increased
when running during pregnancy,
unchanged at 6 month F/U (Chumanov,
2013)
Decreased hip extensor moments and
observed increase trunk lean over
stance leg. Proximal control strategy
(compensatory?) (Pollard, 2007)
Incontinence: Prevalence
Incontinence: Prevalence
1:3 women in North America (NAFC)
291 elite athletes, mean age 22, 151 total (51%)
reported loss of urine at varying frequency with
sport and/or daily activities (13 parous, 138
nulliparous). 125 during sport (43%) (Thyssen,
2002)
¨  26% of fitness instructors (including yoga and
pilates) reported varying frequency, volume and
bother. (Bo, 2007)
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Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. ¨ 
Out of 144 nulliparous female university level athletes, 40
total (28%) reported loss of urine at varying frequency (once,
rarely, sometimes, frequently)
Sport specific range
¤  67% gymnastics, 50% tennis, 44% of basketball, 32% field
hockey, 26% track, 9% volleyball, 6% swimming, 0% golf
¤  Activities most likely to provoke incontinence: jumping legs
apart (30%), jumping with legs together (28%), running
(30%), and impact of landing during dismount or flips
(14%)
(Nygaard, 1994)
4 5/1/16 Rethink Pelvic Floor Dysfunction
Postural Response of the PF and
Abdominal Muscles in Women
With and Without Incontinence
What are the issues?
Understanding and Balancing the System
Impact Absorption
Pressure Management
Proximal Hip Control
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Smith et al (2007)
3 groups continent, mildly
incontinent, severely incontinent
Incontinent had > PF and EO
than continent
Consider muscular interaction
Continent demonstrated
balance, efficient, and task
appropriate system
Graphic courtesy of Lee 2001, www.discoverphysio.ca
Teamwork
Teamwork: Piston
Postural and Respiratory Functions
of the PFM
Hodges, Sapsford, Pengel (2007)
•  PFM followed respiratory cycle
• 
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(ant, not post)
PFM expiratory activity more
associated with abs (Piston)
Low-level tonic activity w/bursts at
mov’t frequency
Anticipatory: preceded deltoid
Sjodhal et al 2009 (PF precedes
supine LE movement )
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. Phase-locked parallel
movement of diaphragm and
pelvic floor during breathing
and coughing—a dynamic
MRI investigation in healthy
females
Talasz et al 2011
Int Urogynecol J (2011)
22:61–68
(Used with permission)
5 5/1/16 Excursion = Shock Absorption
Pelvic
Floor
Phase-locked Parallel Movement
of Diaphragm and Pelvic Floor
During Breathing and Coughing—
a Dynamic MRI Investigation in
Healthy Females
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Talasz et al (2011)
Pelvic floor excursion varied but
always cranial on exhale
Quiet breathing: mean 2.1 mm
Forceful breathing: mean 7.0mm
Coughing: mean 3.8 mm
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Brain decides
• 
CORE
Excursion Prepares for Impact
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Pelvic Floor Prepares for Impact
Intra-Session Test-Retest
Reliability of Pelvic Floor
EMG During Running
Luginbuehl et al (2013)
• 
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Increase in minimal EMG
activity during running than
during rest in standing
PFM activity increase 50 ms
prior to heel strike
Curve min to max per step
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. Feasibility of Using a Computer
Modeling Approach to Study SUI
Induced by Landing a Jump
(Zhang et al 2009)
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Bones stopped at impact. Organ and
soft tissue deformation continued with
an opening of the urethra at 2.7 ms
(post-impact), closure at 5.6 ms,
continued organ deformation to 7 ms
Max displacement of posterior pelvic
soft tissue/organs > anterior pelvic
tissues contributed to “funneling” of the
urethra (UD, pubis, ischium, limiting
movement providing ant support)
Under Pressure
Vaginal Pressure During Lifting, Floor
Exercises, Jogging, and Use of Hydraulic
Exercise
(O’Dell et al, 2007)
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Sharp cough 98 (cmH20) (49-130)
Bearing down w/closed glottis 101.7
(45-131)
Lift floor to counter 45#=70.9
(51-120)
Jogging c/15# lift 54.0 (27-73)
Crunch 23.8 (19-76) , w/exhale 12.4
(8-75)
• 
Down Dog 39.1 (26-72)
• 
(Cobb, 2005) Jumping 171 (43-252)
6 5/1/16 High IAP/High Impact
Proximal Hip Control: Pelvic Floor
Abdominal Bracing Increases Ground
Reaction Forces and Reduces Knee and
Hip Flexion During Landing
Anatomy 101: O/I
Ischiococcygeus
(Campbell et al., 2016)
• 
• 
• 
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• 
O: Ischial spine
Effect of Abdominal Bracing (AB) on
lumbar and lower limb mechanics and
vertical ground reaction forces (vGRF)
in drop landing task (40 cm)
I: Coccyx
Levator Ani:
• 
Pubococcygeus
O: Pubic ramus
AB= average 25% MVC
I: Lower sacrum/coccyx
No difference in lumbar motion control
between AB and No AB
• 
Iliococcygeus
O: Reinforced fascial band
AB resulted in peak knee and hip
flexion during landing
I: Interdigitates with Pubococcygeus
• 
Puborectalis
O: Pubic symphasis
AB resulted in significantly greater
peak vGRF
I: Sling behind rectum
Graphic courtesy of Lee 2001, www.discoverphysio.ca
Proximal Hip Control
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Obturator Internus linked to the PF thru
arcuate tendon
Small lateral rotator group has
stabilizing function of hip (similar to RCPowers)
Adductor overflow to pelvic floor
through common insertion at Pubic
Symphasis
Contributes to deceleration of hip IR at
HS to midstance, and acceleration of
ER to create a sturdy lever
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. How?
Static and Functional Assessment
Running Assessment
7 5/1/16 Static and Functional Assessment
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Breath holding for stability
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Bell Rung Up, bum tucked
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Breath pattern, involuntary pelvic floor response (external or internal)
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Pelvic Floor Palpation: Asymm? IT-Coccyx?
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Intake: Side-Right vs Left
Overuse of abs: look for it in prep for movement, throughout gait and
running cycle (kink at top of abdomen)
Glute bulk: Upper glute flat, lower bum present (long mommy bum); No
bum…no Pelvic Floor
Butt wink: When you ask them to stablize in stance (motor control pattern),
and when performing a squat (over-recruited Pelvic Floor)
Single Leg Squat: Femoral IR and adduction, throw their leg to the front to
perform, pelvic drop, pelvic/trunk rotation, posterior tilt (pelvic floor
dynamic/functional eval; pelvic hip relationship)
Intake: Squats and SLSquats
Running Assessment
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Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. Breath
High chest pattern-shallow breath pattern
Rotation through upper chest vs torso
Tucked bums, poor hip extension beyond midstance. No
glute propulsion. (Hamstring pattern)
Stride to the front, COM trailing behind, heavy heel
strikes
Bouncy-up and down, and lateral tilt of pelvis
Poor diagonal weight transfer, check relationship
between contralateral Glute Med/ADD
8 5/1/16 Interventions
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Running Before and After
Find Pelvic Floor (Ski Jump)
Address faulty breath patterns
Address alignment (bells, bums tucked, LE neuro re-ed)
Find Piston, “Blow before you go” exhale before exertion
Change heel strike (get COM over heel)
Lean (strong wind, hiking up a hill) creates rotation and hip
extension (glute propulsion) ** Good for the glutes is good
for the pelvic floor**
Train rotation (knocks out overuse of upper abs, inc weight
transfer)
Lean and breathe (Piston while you run)
Running Before and After
Julie Wiebe, PT 2016. All rights reserved. Distribu<on, duplica<on, transmission, and/
or transfer of materials is prohibited. Double Unders Before and After
9 5/1/16 Prepare for Impact
Final thoughts…
Jump Rope: Timing PF lift with external cue
Squat Taps/Jumping Jack
¨  Squat Jump with a breath hold
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Simultaneous improvement in her musculoskeletal,
performance and pelvic health concerns
¨  Add to intake and clinical interviews
¨  Triage
¨  Know when to refer
Connect: Peace Out
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