PELVIC FLOOR CONSIDERATIONS A POTENTIAL GAME CHANGER FOR WOMEN’S FOOTBALL?

FIFPRO, the organisation which works as a trade union to unite the voice of professional footballers and their national unions produced a report in 2020 which highlighted that ‘players are the most valuable resource for all football teams and that the athlete is central to the existence of the sport’1. Therefore, for the sport to reach its full potential the player’s potential must be fulfilled. One way of doing this is to identify and implement the best practices in health, safety and performance of the players2. Female footballers, and all those working with them are keen to make this a reality with informed, evidence-based information3. However, females remain significantly underrepresented in sport and exercise science research,4,5 and certain areas remain “wholly underappreciated”, even hidden within sports medicine.

One such area is the pelvic floor and its connected structures and conditions that can result when dysfunctional. Sitting at the base of the pelvic outlet, these structures uniquely serve multiple roles; organ support, sphincteric, lumbopelvic motor control, sexual and sump pump. When this area is not optimally working Pelvic Floor Dysfunction (PFD) can occur. Conditions of PFD include:

• Emptying disorders of the bladder and bowel

•Sexual dysfunction

• Chronic pelvic pain

• Urinary Incontinence

• Anal Incontinence

• Pelvic Organ Prolapse

Typically, PFD has been thought to only affect the perinatal and menopausal population and not necessarily the ‘athletic female’ population. Whilst it is true that females present with higher prevalence of PFD during these key transitional periods of life, females of all ages who participate in sport / exercise have 3 times the risk of experiencing urinary incontinence for example compared to a non-athletic female6. In fact, amongst female athletes, PFD is one of the most common concerns over the lifespan of female athletes7 and yet it is not considered within key documents that support female athletes’ health8

But, what if, consideration, prevention and management of PFD could optimise and unlock the true potential of all female footballers, see them return to football postpartum better than ever before, future proof their health and in doing so empower

Muscles of the pelvic floor complex

Anterior Urogenital triangle and inspire girls and women who follow football to take their pelvic health more seriously?

The Pelvic Floor Muscles - an overview There are many overt differences between males and females and the pelvic floor is a great example of this. The male pelvic floor is invaginated by two openings and therefore less compromised than the female’s pelvic floor, which is invaginated by three, the urethra, vagina and anus.

The pelvic floor complex sits within the bony pelvis and includes muscular tissues of the pelvic floor, their neural connections, and the fascial layers surrounding the pelvic floor muscle fibres/fascicles9. The following muscles in the table below are considered to be those that make up the perineum and pelvic floor10:

Bulbosponginosus

Bulbocavernosus

Ischiocavernosus

Superficial transverse perinei

External Urethral Sphincter

Deep transverse perinei

Posterior (anal) triangle

External anal sphincter

Levator Ani Pubococcygeus (which includes puborectalis, pubovisceralis, pubovainalis)

Iliococcygeus

Ischiococcygeus / coccygeus

The pelvic floor muscles are part of the musculoskeletal system and are comprised of predominately 70% slow twitch fibres; and 30% rapid response fibres. It has been recommended to consider pelvic floor muscles within the differential diagnoses of lumbar, pubic, groin or hip pain due in part to the shared muscle attachments of the pelvic floor muscles and groin muscles to the pubic bone and the obturator internus muscles dual functionality; forming part of the pelvic wall (and thus the wider pelvic floor muscle group) as well as being a lateral hip rotator11

Pelvic floor dysfunction - what’s the big deal?

PFD is prevalent amongst the general population with 1 in 4 women reporting symptoms12. Women participating in sport / exercise, especially high impact and strenuous exercise have a higher prevalence of PFD, with 1 in 3 leaking urine during exercise13. 63% of 12–19-year-old amateur soccer players demonstrated objective evidence of UI compared to 25% of similarly aged girls not participating in sports14, whilst a staggering 80% of young, elite, nulliparous gymnasts report symptoms of UI13. UI is not the only type of PFD to affect and impact female athletes. 80% of powerlifters experience symptoms of anal incontinence15 and 7% of triathletes experience pelvic organ prolapse16. However, studies looking at these types of dysfunctions are limited, and further research is required.

The risk factors for PFD can be seen in the table right (modified from NICE Guidelines 202117

The true impact of PFD on female athletes is hugely significant. Many female athletes who experience PFD report feeling negative emotions, predominately embarrassment, followed by fear concern and anxiety18 Strategies to manage symptoms of UI amongst female athletes include the use of pads, prevoiding and limiting fluid intake19. Studies also show that performance is affected and eventually some athletes stop or limit their activity during their sport which is of huge concern20. The societal stigma and taboo surrounding PFD trickles into the sporting world. Shame, inconvenience, fear of surgery and an inadequate knowledge of the pelvic floor and available treatment options may explain why self-disclosure rates for PF symptoms in sports / exercise settings are under reported (<10%)21 and consequently under treated.

It seems highly likely that strenuous, high impact and high intensity exercise may be a risk factor for PFD. The effect of exercise on PFD is yet to be firmly concluded due to knowledge gaps but two hypotheses exist6:

Modifiable

Body Mass Index (BMI) over 25kg/m2

Smoking

Lack of exercise

Strenuous exercise

High impact exercise

RED(s)

Constipation

Diabetes

Non-Modifiable

Age (risk increases with age)

Family history

Gynaecological cancer and any treatments for this

Gynaecological surgery

Fibromyalgia

Chronic respiratory disease and cough

Related to pregnancy Being over 30 year when having a baby

Having given birth before their current pregnant

Related to labour Assisted vaginal birth (forceps or vacuum)

A vaginal birth when the baby is lying face up (Occipito-posterior)

An active second stage of labour taking more than 1 hour

Injury to the anal sphincter during birth

1. Exercise training strengthens the pelvic floor

2. Exercise training overloads, stretches, and weakens the pelvic floor

The latter hypothesis is the most widely accepted. If the pelvic floor complex is functioning adequately, it counteracts the increases in intraabdominal pressure and ground force reactions generated during exercise and maintains continence and support. If the pelvic floor complex is not able to counteract these forces, then PFD may occur6. The physiopathology of PFD in female athletes is multi-layered and complex and likely to involve interrelated neuromuscular, biomechanical, morphological, anatomical, and metabolic factors22

There are many actionable steps that can be undertaken by those working with female footballers to prevent, manage and treat PFD:

1. Education - Knowledge can empower the footballer to understand her pelvic health, recognise that symptoms of pelvic floor dysfunction are ‘common but not normal’ and that they can be prevented / treated.

2. Screening - To bridge the gap whereby PFD is under recognised and under treated, screening for PFD key. The PFD-Sentinel23 is a tool recently developed to aid sports medicine clinicians (eg, musculoskeletal/ sports physiotherapists, sports medicine physicians) in referring female athletes to a PFD specialist such as a urogynaecologist or pelvic health physiotherapist. This step could be a starting point towards early PFD specialist management and should be administered on a regular basis.

3. Pelvic floor muscle training (PFMT) PFMT has been shown to improve the signs and symptoms of PFD24. PFMT as part of all female footballers’ training programs is recommended using the strength and conditioning principles of individualisation, specificity, overload and progression11, especially if they are symptomatic of PFD but even if they are asymptomatic given the forces generated through the pelvic floor complex during strenuous sports.

When teaching footballers how to train the pelvic floor, useful cues like ‘squeeze the anus’ or ‘stop the flow of urine’ (25) have been shown to be effective verbal instructions for correctly contracting the pelvic floor muscles. PFMT should target both fibre types of the PFM. Fast twitch fibres will be targeted by rapid maximum voluntary contractions and slow twitch fibres targeted by slower endurance holds11. Encourage the athlete to engage in focussed PFMT of 3 sets of 8 to 12 sustained close to maximum PFM contractions and one to two repetitions of ballistic PFM recruitments repeated three to four times a week6. PFMT should be carried out in as functional position as possible. Signs of breath holding, firmly squeezing glutes or bracing the abdominal wall may be signs that the training is being carried out incorrectly and onward referral to a pelvic health physiotherapist may be indicated.

FEMTECH is now also being used to guide and provide biofeedback which the athletic population may find useful and motivational when introducing PFMT into their programs.

4. Signposting to and collaborating with pelvic health specialists (eg pelvic health physiotherapists / urogynaecologists)

Individualised assessment and PFMT with a pelvic health physiotherapist is recommended as first line management for some PFD presentations such as UI26. Research illustrates that educational programs and verbal cues alone may not be sufficient to improve voluntary contractions of the pelvic floor muscles27. Therefore, including a pelvic health physiotherapist as part of the sports medicine multidisciplinary team who can assess and treat the pelvic floor complex is important.

Surgery is rarely indicated for this population but signposting to a urogynaecologist may occasionally be of benefit if symptoms are not improving with pelvic health physiotherapy alone.

Athlete

“Far too often we see women having to make a choice between motherhood and their career. It would be very sad to lose out on the talent we have because they feel like they can’t do both.”

Sydney Leroux Dwyer United States Orlando Pride (Twitter Feb 2020)

Pregnancy and motherhood were once seen to mark the end of a female footballer’s career but in recent years footballers like Alex Morgan, Sara Bjork Gunnarsdottir and Melanie Leupolz have demonstrated that motherhood and a career in football can co-exist particularly if the right support is provided.

Guidance28 supports the safety and benefits of prenatal exercise but this is primarily limited to the general obstetric population. As discussed previously athletes have a higher risk of PFD than non-athletes and there is also an increased prevalence in postpartum women compared to nulliparous women. An online questionnaire of 881 highlighted that when running, 29% of postpartum runners reported symptoms of urinary incontinence. Interestingly, it also showed that up to 84% reported musculoskeletal pain. Vaginal heaviness and fear of movement were two symptoms that were a barrier to returning to postpartum running29. Postpartum women have also been found to have reduced abdominal wall strength postpartum regardless of delivery which may contribute to poor trunk control, and suboptimal return to sport30. Addressing these concerns as well as considering breast health, physical deconditioning, hormonal changes, psychological well-being, and sleep is essential when returning any postpartum player back to football.

The narrative around perinatal care is changing. Pregnancy and childbirth can be seen as an opportunity to prepare and ready the athlete for impending physical and psychological changes; a proactive rather than reactive approach to athlete care31. Every woman’s recovery timeline can vary and is unique and her postpartum return to sport must be given time and rehabilitation considerations just like any other significant musculoskeletal injury. The 6Rs framework31 (see figure 1) has been proposed to guide multidisciplinary teams in preparing, returning and optimizing perinatal athletes for their sport. It suggests an individualized, wholesystems, biopsychosocial model of care32 and encourages the MDT working with the athlete to include a specialist pelvic health physiotherapist, midwife, obstetric and gynaecological consultants so that all perinatal considerations including pelvic health are catered for. By taking an approach like that suggested within the 6Rs framework, it is likely that we will continue to see women return to their football optimally, successfully, and indeed better and stronger than ever before.

Future-Proofing the female footballer’s pelvic health - The perimenopause and beyond Menopause; defined as the permanent cessation of menses33, typically occurs between the ages of 42 and 58 years. During the early transition to the menopause, the perimenopause, females experience physiological and hormonal changes that impact on multi body systems including the urogenital system. A decline in estrogen affects the endopelvic fasica, levator ani, and uterosacral ligaments by altering structure and or function34 These changes can cause or exacerbate PFD. Armed with this knowledge, it is important that those working with female footballers educate about these inevitable changes. These changes are unlikely to occur before the footballer’s retirement (although Premature menopause affects 1% of women under the age of 40 years) but encouraging players to adopt a proactive, preventative approach to their pelvic health whilst young, screening them regularly for signs and symptoms of pelvic floor dysfunction and incorporating PFMT into their training programs is essential to futureproof their pelvic, physical and mental health.

Pelvic floor dysfunction is prevalent amongst female footballers. PFD can impact a player’s physical and mental health, affect their performance and potentially be a barrier to play. Knowledge gaps still remain around this health area but it is highly recommended that those working with female footballers screen for signs and symptoms of pelvic floor dysfunction and educate in order to destigmatize and demystify these common but not normal conditions. Expanding the multidisciplinary team to include specialists like pelvic health physiotherapists/ urogynaecologists will enrich and allow for effective measures to prevent and manage symptoms of PFD. By adopting this approach we are one step closer to ensuring that the full potential of all players is reached.

The perinatal period is a time of huge change for female footballers but shouldn’t be a time where female footballers consider leaving the sport because of these changes and uncertainty around how to return to sport optimally (unless they choose to do so). Considering the perinatal period within a Return to sports framework, like the 6Rs allows for a proactive approach that will return the player back to her sport, in hope stronger than ever before.

Beyond the player, pelvic floor issues are of huge concern to all women working within football, including coaches and referees and a similar approach to their pelvic health should be adopted. Beyond football, pelvic floor dysfunction is a public health concern. Most women ignore or even put up with pelvic floor dysfunction. Many consider it too embarrassing to discuss, many do not realize that there is so much that can be done to prevent and manage symptoms and the fallout from this is huge! If football takes the lead in pelvic health management and opens the conversation around pelvic health the impact on female health worldwide could be remarkably positive and a likely game changer for 51% of the world’s population!

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