The Pelvic Floor: A Missing Link in Back and Hip Pain
Have you ever felt like you have tried everything, but your symptoms still keep coming back?
Maybe you have done physical therapy for your back or hip. Maybe you have seen a chiropractor, had massage, worked on your strength, stretched consistently, changed your shoes, improved your posture, or tried to be more mindful of how you move. And maybe some of it helped. For a little while.
But then the pain came back. Or the improvement did not last. Or you felt like you were always managing the same symptoms without ever really understanding why they were happening in the first place. If that sounds familiar, it does not mean you failed. It does not mean your previous providers missed everything. And it definitely does not mean your body is broken.
It may mean there is another piece of the puzzle that has not been fully evaluated yet. For many people, that missing link is the pelvic floor.
What do we mean by “the missing link”?
When most people hear “pelvic floor,” they think about bladder leakage, pregnancy, postpartum recovery, or maybe pain with sex. And yes, the pelvic floor can absolutely be involved in those symptoms. But the pelvic floor is not an isolated group of muscles that only matters if you are leaking or having pelvic pain. It is part of a larger system that includes your hips, low back, abdomen, diaphragm, deep core, bladder, bowel, reproductive organs, connective tissue, and nervous system.
That means pelvic floor dysfunction does not always show up as an obvious pelvic floor problem. Sometimes it looks like low back pain that never fully resolves. Sometimes it looks like hip pain that keeps coming back no matter how many glute exercises you do. Sometimes it looks like tailbone pain, pelvic pressure, abdominal tightness, constipation, urinary urgency, or symptoms that flare with lifting, running, sitting, stress, or your menstrual cycle. The pelvic floor may not be the only reason (or even the initial reason) someone has pain. But it can be the piece that keeps everything else from working as well as it should.
The pelvic floor is part of your core system
Your pelvic floor works closely with your diaphragm, abdominal muscles, spinal muscles, and hip muscles. Together, these structures help you manage pressure, support your spine and pelvis, breathe, lift, walk, exercise, go to the bathroom, and move through daily life. When this system is coordinated, pressure moves well through the body. Muscles know when to turn on, when to let go, and how to respond to demand. But when one part of the system is not doing its job well, other areas often compensate.
Some people grip their abdominals all day without realizing it. Some hold their breath when they lift or exercise. Some clench their pelvic floor in response to pain, stress, urgency, or years of “holding it together.” Some have scar tissue, abdominal restrictions, constipation, or pelvic floor tension that changes how their body manages movement and pressure. Over time, those patterns can contribute to symptoms that feel like a back problem, hip problem, or core weakness problem. And sometimes, they are.
But they may also be a pelvic floor coordination problem, a pressure management problem, a mobility problem, a nervous system protection pattern, or a combination of these.
What the research says about back pain and pelvic floor dysfunction
This connection is not just something pelvic health physical therapists notice in the clinic. It has been shown in clinical research.
One study looked at women with lumbopelvic pain, meaning pain involving the low back and/or pelvic girdle region. The findings were pretty staggering: 95.3% of the women in the study had some form of pelvic floor dysfunction. More specifically, 71% had pelvic floor muscle tenderness, 66% had pelvic floor weakness, and 41% were found to have pelvic organ prolapse.
That does not mean every person with back pain has a pelvic floor issue. It also does not mean the pelvic floor is always the primary driver of pain. But it does mean this connection deserves attention.
Another large study using Canadian population data found that urinary incontinence and back problems frequently occur together. In that study, people with urinary incontinence were more likely to also report back problems, and this association was seen in both men and women. To us, this reinforces something we see all the time: the body does not separate symptoms into neat little boxes. The bladder, bowel, back, hips, pelvis, abdomen, and nervous system are all in conversation with each other.
So if someone has back pain and also has urinary leakage, urgency, constipation, pelvic pressure, pain with sex, a history of pregnancy or birth, abdominal surgery, pelvic surgery, endometriosis, or chronic stress-related tension, we want to know about all of it. Not because everything is “caused by the pelvic floor.” But because everything may be connected.
It is not always about weakness
One of the biggest misconceptions about the pelvic floor is that dysfunction always means weakness. That is not the case.
Sometimes the pelvic floor is weak. Sometimes strengthening is part of the plan. But many people with back, hip, or pelvic symptoms also have pelvic floor muscles that are overactive, guarded, tender, or unable to relax well. And here is the part that surprises a lot of people: a muscle can be both tight and weak.
If a muscle is constantly holding tension, it may not be able to generate strength well. If it cannot relax, it may not be able to contract efficiently. If it is always “on,” it may not know how to respond appropriately when you actually need it. This is why “just do Kegels” is not always helpful—and for some people, it can even make symptoms worse.
Pelvic floor rehabilitation is not simply about making the pelvic floor stronger. It is about helping the muscles move through their full range, coordinate with the breath and core, respond to pressure, relax when needed, and activate when appropriate. So if symptoms improve for a while but do not stay better, we want to look at how the whole system is coordinating—not just whether one muscle is strong or weak.
Why hip pain and pelvic floor dysfunction can overlap
Hip pain is another area where the pelvic floor can be easy to miss. The pelvic floor sits close to several deep hip muscles, including the obturator internus, which is a hip muscle that also has a close relationship with the pelvic floor. Pain in this region can feel like deep hip pain, sit bone pain, groin discomfort, tailbone pain, or pain that is hard to pinpoint. Someone may be working on hip mobility, glute strength, or stretching—and those things may help—but if pelvic floor tension, tenderness, or coordination has not been assessed, progress may plateau.
This does not mean every hip issue is secretly a pelvic floor issue. But when hip pain does not respond the way we would expect, or when it overlaps with pelvic symptoms, bladder symptoms, bowel symptoms, pain with sitting, pain with sex, or symptoms that feel deep and hard to reach, the pelvic floor is worth considering and can make a real difference in results.
Where visceral restrictions and scar tissue fit in
Another piece that can be missed is the role of visceral mobility and connective tissue restrictions. When we talk about “visceral” restrictions, we are not saying your organs are out of place. We are talking about how well the organs and surrounding connective tissue can move and glide with breathing, digestion, posture, and movement. Your bladder, uterus or prostate, rectum, intestines, abdominal organs, pelvic floor, abdominal wall, and scars all share space and fascial connections. If there has been surgery, inflammation, constipation, endometriosis, pregnancy, birth, abdominal trauma, or long-term guarding, the tissues in this area may not move as freely as they once did. That can matter for your pain.
A C-section scar may affect how the abdominal wall moves. Abdominal surgery may change tissue glide. Chronic constipation may increase pelvic floor tension and pressure. Endometriosis or pelvic inflammation may contribute to protective muscle guarding. Bladder urgency may coexist with pelvic floor overactivity. Stress and pain can change how the nervous system protects the body. The research on visceral manual therapy for low back pain is still developing, and it is not as clear-cut as the research showing the overlap between pelvic floor dysfunction and lumbopelvic pain. We do have some research looking at visceral manipulation as part of chronic low back pain care, but this is still an area where the evidence is growing. Clinically, though, we often find that when we evaluate the abdominal wall, scars, breathing mechanics, bowel habits, pelvic floor, and visceral mobility together, patients finally begin to understand why their symptoms have felt so persistent or confusing.
Why symptoms may improve but not “stick”
This is something we hear from patients all the time, often after they have already worked really hard to feel better. A patient may say:
“I feel better after an adjustment, but it does not last.”
“My exercises help, but as soon as I return to normal life, the pain comes back.”
“I have done physical therapy before, but we never talked about my bladder, bowels, birth history, scar tissue, or pain with intimacy.”
That is where looking at the whole system can change the plan. We love collaborating with other providers, including orthopedic physical therapists, chiropractors, massage therapists, physicians, mental health therapists, trainers, and other specialists. We have even had chiropractors tell us that when a shared patient is also addressing pelvic floor dysfunction, their adjustments seem to last longer or be more effective. That makes sense to us.
If the pelvic floor, core, breathing, pressure system, or abdominal mobility is contributing to why the body keeps returning to the same pattern, then addressing those pieces may help other treatments hold better. This is not about saying previous care was wrong. It is about looking at the whole picture and asking whether an important piece has been missed.
What this can look like in real life
Sometimes the missing link looks like the person with low back pain who has worked hard on core strengthening but still holds their breath every time they lift their child, carry groceries, or do a workout.
Sometimes it looks like the person with hip pain who has been stretching and strengthening for months, but no one has assessed whether the pelvic floor is tender, guarded, or contributing to deep hip symptoms.
Sometimes it looks like the postpartum patient who was told everything healed well, but they still feel pressure, weakness, back pain, pain with sex, or a sense that their body does not quite feel connected.
Sometimes it looks like the person with constipation and pelvic pain who has tried hydration, fiber, and exercise, but still strains because their pelvic floor does not know how to relax and coordinate during bowel movements.
Sometimes it looks like the person with an old abdominal scar who has never thought about it because it “healed fine,” but the tissues around it do not move well and their body has been compensating for years.
Sometimes it looks like someone who has been told their imaging is normal, their strength looks good, and nothing is seriously wrong—but they still know something is not right.
These are the moments where a pelvic health lens can be incredibly helpful.
How pelvic health PT is different
Pelvic health physical therapy does not ignore the back, hips, posture, gait, strength, or movement patterns. We closely evaluate those things too because it is all part of the bigger picture. But we also ask questions that may not always come up in a traditional orthopedic setting.
How is your bladder working? Are you leaking? Do you feel urgency or frequency?
Are you constipated? Do you strain?
Do you have pelvic pressure or heaviness?
Do you have pain with sex, tampon use, or pelvic exams?
Have you had pregnancies, births, abdominal surgeries, pelvic surgeries, or injuries?
Do symptoms change with your cycle, stress, digestion, exercise, or lifting?
Do you hold your breath or brace when you move?
Can your pelvic floor relax as well as contract?
Depending on the person, an evaluation may include looking at posture, breathing, spinal mobility, hip strength, pelvic alignment, abdominal mobility, scar tissue, core coordination, pressure management, functional movement, and pelvic floor muscle function.
An internal pelvic floor assessment may be recommended when appropriate, but it is always based on consent, comfort, and clinical reasoning. There are many ways to begin pelvic health care, and you are always in control of what feels right for your body.Your Body Is Not Broken
Signs the pelvic floor may be part of your symptoms
You may benefit from a pelvic health evaluation if you have back, hip, pelvic, abdominal, or tailbone symptoms that have not fully resolved with traditional care. This may be especially true if your symptoms overlap with bladder leakage, urinary urgency, constipation, pelvic pressure, pain with intimacy, pain with sitting, abdominal scars, pregnancy or postpartum recovery, endometriosis, pelvic surgery, abdominal surgery, or symptoms that flare with stress, lifting, exercise, or your menstrual cycle. Again, this does not mean the pelvic floor is the whole story. But it may be an important part of the story. And if no one has looked there yet, it may be the missing link.
You are not broken, and you are not out of options
If you have been dealing with symptoms that do not seem to make sense, it can feel frustrating and discouraging, especially when you have already tried to do the right things. But persistent symptoms do not mean your body is failing. They may mean your body has been compensating for something that has not been fully addressed yet. At Cultivate Your Wellbeing, we look beyond the painful area. We consider how the pelvic floor, core, hips, spine, scars, bladder, bowel, breathing, connective tissue, and nervous system may be working together. Because sometimes the key to helping symptoms improve—and actually stay better—is finding the piece that has been missing. If you feel like you have tried everything but something still is not adding up, pelvic health physical therapy may help you connect the dots.