In the last 20 years there has been an almost 15% increase in female athletes reporting pelvic pain as a result of an exercise related injury in their pelvis or hips. These injuries are often the result of; over-exercising; regularly taking part in high intensity exercises; and taking part in sports, which require a lot of kicking, pivoting, and rapid acceleration and deceleration, such as rugby, soccer/football and gymnastics. As well as causing painful muscles and tendons within the pelvis, high intensity exercises weaken the pelvic floor and allow for pelvic floor disorders such as urinary incontinence to develop.
Pelvic pain occurs in 4% of men in the third decade of life and 5.3 % of those in the fourth decade of life. Nickel et al. reported that 9.7 % of men suffer from prostatitis-like symptoms at some point in life.¹
Gluteal injuries, proximal hamstring injuries, and pelvic floor disorders have been reported in the literature among runners: with some suggestions that hip, pelvis, and/or groin injuries occur in 3.3% to 11.5% of long distance runners.²
Its important to be aware of the possible impact over-exercising can have on your body. Regular exercise is essential in improving cardiovascular health and maintaining strength. However, taking part in certain exercises regularly and with few periods of rest, can lead to injuries that cause chronic pelvic pain. The sports with the highest rates of pelvic pain complaints include soccer/football and running. If you begin to suffer and do not seek treatment early enough, you can be vulnerable to repeated injuries, which can lead to debilitating chronic pain and a potential inability to continue exercising in the future.
Diagnosing pelvic pain as being trauma from over-exercising is difficult, due to the breadth of conditions that can cause pelvic pain and the number of people that exercise. Your doctor will complete a physical examination and discuss your medical and exercise history with you. To confirm diagnosis they will use an MRI (magnetic resonance imaging) or ultrasound to view the soft tissue (including muscles and tendons) and bones.
Treatment for exercise related injuries in the pelvis often begins with rest and recovery. If simple rest does not see a resolution of the pain within 4-6 weeks, you will be offered conservative treatments. These include Physiotherapy, anti-inflammatory medications and pain medications. If conservative treatments fail, surgery can be offered as a final option.
Once you are able to exercise again, a revision of your exercise programme will be essential to prevent the recurrence of your pain.
What are the Symptoms of Over-Exercising?
In the hours and days following an intense workout, you have probably felt sore. You may even have had a reduced range of motion whilst your muscles recovered. However, you quickly recover from these symptoms and are able to exercise pain free again. If you over-exercise, these issues last longer and get worse each time you exercise. You may even have to stop taking part in exercise and can lose mobility in your daily life. Occasionally a sudden movement can 'break the camels back' and cause much greater pain that is harder to recover from.
Over-exercising often causes injuries in the hips and pelvis with conditions usually co-existing. Pain may also be felt in the lower abdomen, back and thighs as a related duller pain. All sources of the pain will need to be treated for an effective relief from symptoms, which may mean an extended treatment programme with multiple parts.
pain that gets worse when exercising - especially during sit-ups, sprinting, kicking and when rapidly changing direction
pain that gets worse when you cough or sneeze
pain that gets worse when having sex
pain that radiates towards the inner thigh and/or lower back and lower abdomen
pain that can last several weeks following exercise
pain and reduced mobility that prevents further exercise and impacts daily life
pain that is worse after sitting still for an extended period
general abdominal tenderness that is difficult to localise
pain that is felt deep within the lower abdomen and pelvis
dull burning sensation around the affected area
tenderness in the affected area
Athletes often question whether their weight gain is a result of over-exercising. Studies state that weight gain in athletes is a result of either an increase in muscle mass from exercise, which is constant and no longer challenging the body. Any weight gain in athletes suffering from an injury related to over-exercising, will be due to the absence of exercise during their recovery, or a side-effect of medication.
What Are The Causes Of Pelvic Pain from Over-Exercising?
Pain from over-exercising is usually a result of a musculoskeletal injury - of the muscles and bones in isolation or together.
The following injuries can occur in isolation or together.
Groin strains - Just under 5% of sport related injuries are groin strains. This is when the group of adductor muscles in the inner thigh tears. The adductor muscles connect the femur bone of the thigh, to the hip joint. They lengthen when you kick, which is when they are vulnerable to strain. Groin strains are most common in sprinters, and other athletes who rapidly accelerate and decelerate such as rugby, hockey and football/soccer players.
Osteitis pubis - Almost 7% of injuries from over-exercising are osteitis pubis. An inflammatory condition where the pubic symphysis joint, which connects both sides of the pelvis, becomes inflamed as a result of repeated stress from it twisting. Osteitis pubis can lead to inflammation in the muscle surrounding the pelvis and be particularly painful in the adductor muscle of the inner thigh and lower abdominal muscles. Osteitis pubis is often experienced by football players (accounting for 5% of football/soccer injuries) and other sports which require kicking or where the pelvis twists for other reasons, such as rugby, basket ball and long distance running. Osteitis pubis can also occur from long term muscle imbalances between the muscles in the hips and abdomen, suddenly resulting in inflammation and pain in the pelvis.
Athletic pubalgia - is a soft tissue injury in the muscles of the lower abdomen and groin, usually on one side of the body. It is often experienced by football players and other athletes who pivot on the spot and quickly accelerate and decelerate. This twisting motion damages the tendons, which connect the oblique muscle of the lower abdomen to the pubic bone, and can lead to them separating. Hip injuries from athletic pubalgia are more common in women than men, and can lead to pelvic floor weakness as the pelvic muscles lose support. It is worth noting that athletic pubalgia is often called a 'sports hernia' in the media, however, it is not in fact a hernia.
Hernia - A hernia can occur when you lift a heavy object, or strain from constipation. During exercise hernias occur most often in the groin, where tissue, or one of the pelvic organs, comes through a weak spot in the muscle layer of the abdomen or pelvis, and protrudes painfully under the skin. It usually occurs after a period of general pain in the groin following exercise. Up to 85% of sports hernia cases are from young men that have exercised regardless of the growing pain. Usually those participating in rugby, football/soccer, hockey and athletics.
Pelvic floor damage - High impact exercises, such as skateboarding, BMX cycling and running, often cause injury to the pelvic floor. These are exercises where the pelvic floor receives high impact as the feet land heavily on the ground. There are some modifications that can be made to these exercises to reduce damage, such as changing posture on a bike (sitting more upright), and wearing specialist clothing, which provides added support to the pelvic floor. However, there is a degree of damage that cannot be avoided and leaves the pelvic floor weak and sore.
Stress fractures - The presence of any fracture in the pelvis or other lower extremities can cause a great deal of pain. They usually occur if there has been a recent uptake of intense activity after a long period of rest, or a long period of intense activity without any rest. This can cause excessive and repetitive stress directly to the bone, which causes micro-fractures. If they are not given time to repair, these fractures eventually develop into larger stress fractures. Most commonly the bones in the thighs, pelvis and lower back are affected from sports such as long distance running, rugby, football/soccer, gymnastics and dance. Women are at a higher risk of developing stress fractures, often due to their relationship with their diet also affecting their bones.
Femoroacetabular impingement syndrome - Also known as hip impingement syndrome, this is when the ball of the hip socket rubs abnormally, causing pain. This is common in male football players and certain martial arts due to the angle of the leg when kicking. Some individuals are more vulnerable to suffering from femoroacetabular impingement syndrome due to the shape of their bones and joints.
Pelvic surgeries - Having undergone a pelvic surgery puts you at a higher risk of developing pelvic floor disorders and chronic pelvic pain in the future. This vulnerability is not exclusive to over-exercising and as such pelvic floor exercises should be pursued following surgery to avoid pain.
Piriformis syndrome and sciatica - Piriformis syndrome is a rare condition in which the piriformis muscle in the buttocks, painfully spasms. It is related to compression of the sciatic nerve, and commonly referred to as sciatica, where pain is also felt in the leg. The compression of the sciatic nerve can be caused by varying other injuries to the musculature, that are caused by over-exercising and muscle imbalances.
Other issues from over-exercising include permanent changes to your heart and cardiovascular system (including heart arrhythmia, which is an irregular heartbeat), problems with the visceral nervous system (that conduct pain sense from the internal organs to the central nervous system), and core muscle injuries.
To read about other causes of pelvic pain, visit the Causes and Diagnosis of Pelvic Pain page.
How to Treat Pelvic Pain Caused by Over-Exercising
The treatment for pelvic pain depends on the injuries causing it. If there is any uncertainty, further diagnostics will be taken, including an MRI scan or ultrasound to review the structure of the pelvis.
For the first 6-12 weeks of recovery, treatment will be conservative (using non-invasive therapies) and concentrate on resting. If the pain goes away after this period, and does not return when exercising again, then the treatment is considered a success. Only when the pain returns or is not relieved within the 12 weeks, will surgical treatment options be considered.
Professional athletes may be unwilling to take time out from exercise during their sports in-season. If this is the case, your doctor will recommend treatments to relieve discomfort as far as possible, until a period of rest can be planned. Medically the advice is to rest as soon as possible, to allow recovery to begin and prevent injuries from worsening. This may be resting from the offending sport, which caused the injury, as well as associated exercises. Or avoiding all exercise until the pain has been relieved.
Conservative Treatments Include:
Rest - Taking time off from exercise is the quickest way to reduce and recover from your symptoms. It is important that you gradually progress back into exercise after resting and avoid heavy weight strength training, repetitive movements, and movements that require deep hip flexing. If your pain returns, consider avoiding certain exercises and seeking further treatment.
Physiotherapy - aims to re-balance and strengthen the muscles, whilst avoiding unnecessary mobility too early in your recovery. It will concentrate on stabilising and strengthening the core, retraining the posture and creating normal mobility in the hips and pelvis. This may include stretches, massages and light exercises to maintain cardiovascular fitness. A significant improvement in the symptoms is usually felt after 6-8 weeks of physical therapy. The Physiotherapist will also advise on how to avoid further muscular pain when you return to exercise.
Progressive rehabilitation programme - This is often managed by a Physiotherapist, Physical Therapist or Biokineticist. They will advise on and assist with the best strengthening and flexibility exercises to help you recover without causing further injury, while monitoring your recovery and helping get you back into your desired exercise in the most sustainable and safe way.
Anti-inflammatory medication - Usually non steroidal, these drugs reduce the inflammation in the affected area. They are generally not used if you are suffering with stress fractures, as studies suggest they inhibit the bones from healing.
Pain killers and crutches - Often ibuprofen is used to manage pain. Crutches are often provided for stress fractures of the hips and thighs, as there is less pain when weight is taken off these areas. Compression boots can be used to reduce the pain from stress fractures in the ankles and feet.
Corticosteroid injections - Steroids replicate the effects of the bodies normal hormones, which reduces inflammation. When injected into affected joints or muscles they can relieve pain and stiffness.
Neuromuscular electrical stimulation (NMES) - A course of daily electrical stimulation over 6 weeks has been clinically proven to provide lasting improvements to the speed and quality of recovery from muscle pain. NMES promotes circulation and increases muscle power and endurance. Electronic toners, which use NMES, are often used to build muscle tone and strength in individuals, which are unable to exercise. Electronic pelvic floor toners like the V for Men and Ultra 20 for women use NMES to relieve pelvic pain and strengthen weakened pelvic floor muscles.
Cryotherapy and cryomassage - is the practice of putting the body under extreme cold temperatures, such as an ice bath, to reduce inflammation. A daily cryomassage, where ice and cold products are applied to the affected area, have shown to be able to relieve muscle pain within two weeks.
When conservative treatments have been followed for 3-6 months and the pain still remains, injuries are deemed chronic. It is at this point that surgery will be considered as a treatment option.
Although surgeries can have high success rates in getting patients back into exercise for the first year, undergoing any surgery should be a carefully considered decision. Any surgery in the pelvic area can lead to pelvic floor disorders, where nerve damage occurs and the pelvic organs receive scarring. In addition, the success of pelvic surgeries can be lost over time and are not a permanent resolution to the problem. If you continue to exercise in the same way, the injury will still likely recur.
It should be noted that not all injuries can be resolved with surgery, and in this situation further diagnostic tests should be undertaken to determine if there are other causes of the pain.
These other causes could include:
Hernia - An operation can reinforce the muscles in the posterior (back) abdominal wall. This surgery may involve surgical mesh being applied as added support. 90% of patients that undergo this surgery, return to sport within 12 weeks.
Femoroacetabular impingement syndrome - Open femoro-acetabular surgery aims to improve the range of movement in the affected hip. The hip is dislocated and relocated in an open surgery. Over 25% of patients require further surgery to remove screws in the year following surgery, and over 10% require further surgery due to a permanent loss of mobility.
Following surgery and 4-6 weeks rest, you will be offered a programme of physical therapy. This can include pain and inflammation management and massages, as well as light exercise such as walking. in addition to the rest period, if your surgery was open, it can be a month or two more before you are able to return to exercise. If you had a laparoscopic (keyhole) surgery, you will likely recover quicker and, on average, patients return to exercise a fortnight earlier.
To read about other treatments available for pelvic pain, visit the pelvic pain treatment page.
How to Avoid Over-Exercising
You may be thinking "how can exercise be bad?", "what is excessive working out - is it every day?", "is there really such a thing as doing too much?" Unfortunately there is.
Your muscles need time to recover and strengthen between periods of exercise. Introducing a variety into your exercise routine, of varying muscle groups and intensities, can reduce the risk of over-exercising. There are also foods and supplements that can improve your recovery and allow you to exercise more frequently.
Its important to learn what your bodies limit is and speak to a professional trainer or health specialist for advice.
Periodisation - This is an approach to exercise which maximises the positive impact on your body, whilst avoiding the damage that comes with over-exercising. It is a technique usually related to strength and conditioning exercising such as lifting weights. It is based on the knowledge that your muscles experience small tears as you exercise. These need to be rested and allowed to heal before they are put under strain again. The muscles within your pelvis are like all others - they must be allowed to rest to heal and become stronger. Include varied activities into your exercise routine. Ensure you are working out each muscle evenly and not spending too much time concentrating on one part of the body. A Biokineticist will be of great help here.
Creatine supplementation - Creatine is a supplement that helps muscles build tone quicker. Creatine is naturally found within the body, and regenerates adenosine triphosphate (ATP), which is essential for carrying energy around the body.
Protein supplementation - Muscles are predominately made of protein. To recover from the damage that occurs to your muscles during exercise, a source of protein, such as whey protein, allows your muscles to recover faster from exercise.
Calcium supplementation - Calcium is essential for strong bones to prevent stress fractures.
Vitamin D supplementation - Vitamin D helps keep your muscles toned and healthy when you are exercising, it is essential for general musculoskeletal health. Most people are deficient in vitamin D and require supplementation to get the optimum dose. Vitamin D slows the natural ageing of the skeleton and can reduce the rate of fractures as you age.
Strengthen your core - Having a strong core improves your posture, and provides better support to your organs to prevent muscle imbalances.
Avoid large meals before exercising - Eating or drinking a large quantity before exercising can lead to digestive pain and exercise related transient abdominal pain (ETAP), more commonly known as a stitch.
Warm up - Its important that you avoid muscle stiffness as you exercise. Warming up adequately can be all you need to do to avoid injuries recurring.
Flexibility exercises - Particularly of the adductor muscle in the inner thigh to prevent strain when it is lengthened.
Correct any muscle imbalances - Compliment your exercise routine by taking part in yoga, Biokinetics or Pilates and other exercises that require balance to correct muscle imbalances.
Exercise with proper technique - Most injuries occur through poor technique over an extended period of time. A Biokineticist or Pilates instructor can help you improve your exercise technique.
Take adequate rest periods between exercises - Stress fractures are most common in athletes that continuously train with little to no breaks. If you exercise too intensely and too often, you will not give your muscles time to recover and actually cause more damage than good.