I walk onto the platform at Nationals, controlling my breathing, visualizing, feeling the successful lift, confident before I even begin my pull. I grip the bar, settling into my comfortable, familiar, strong start position. “Steady... you have control of this lift,” I say to myself. I take my last breath, brace, and lift off. Keeping the bar close, I extend and explode, pull under the bar, continuing to brace, and then I feel it.  I’m bracing, pushing down and out through the pelvis and I continue to fight and give everything in my body to this lift, including the contents of my bladder. There’s a puddle of urine on the floor, and I consciously try not to slip in it as I steady for the jerk. I try to ignore what’s just happened, but in the back of my mind, always present, are thoughts about that puddle on the platform, even as I tighten my core and load my legs. I dip and drive, thinking about the puddle below me, praying I don’t slip in my own pee with max weight overhead.

I am not the only female competitor in weightlifting who has felt this during competition. Unfortunately, I know I am in good company. You might walk away defeated and embarrassed. You might use your pee as your excuse for your missed jerk. You might acknowledge your pee on the floor, in attempts to let others know that it’s “okay” and you’re not embarrassed, you do what’s necessary to lift your best.
Sometimes it’s a few drops, while others empty their bladders on the platform every attempt. While many assume this has to do with nerves or being well-hydrated, neither are usually the case. Pelvic floor dysfunction is a real epidemic among female athletes across the world. And whether these athletes will admit it or not, it’s both embarrassing and frightening to walk off the platform leaving a puddle of urine behind. These athletes, at some point, may wonder what’s wrong, or how to make it stop. But some may think there’s nothing wrong because it’s common. Unfortunately, just because it’s common, doesn’t mean it’s normal or that it has to happen. When you pee during a lift, you don’t have control over your body.

It’s difficult to come to terms with the fact that you no longer have control over your body when, in this sport, we do so much to control our body. It’s difficult to understand why this one part doesn’t work. It’s difficult to take a step back and accept that you have a problem. It’s difficult to accept dysfunction. But life will change once you accept the need for a change, and your lifting will not only improve, but your quality of life will as well.

It is common—not only in weightlifting, but in general exercise—for women to experience some type of incontinence. It is common to cover it up. It is common to make excuses, and to make fun of yourself, and to try to glorify your issues in attempts to make it seem alright to others on the outside. Incontinence, unfortunately, has become the “norm” for countless women worldwide, but it doesn’t have to be. When something becomes “normal” for a person, it’s simply what they’re accustomed to. They don’t know any other way.

When our body starts to fail, no matter the circumstance, we have an incredible ability to overcompensate in order to complete the task at hand. When compensations are sometimes necessary for a short period of time, they should not become habitual or treated like a solution. For example, when running long and short distances, when jumping rope, or when lifting weights, you might rely on panty liners to absorb leaking in your pants. You might take countless bathroom trips during training and competition in attempts to fully empty your bladder in hopes of preventing the leaking. You might never consider that there is an actual problem because this is normal for female athletes, right? It happens to so many of us. And when something is common, it’s more likely to be deemed as normal. Don’t be fooled. These are cover-ups; they’re not solutions.

There’s more to pelvic floor dysfunction than peeing. Pelvic pain is another often overlooked situation. Sometimes this pain can occur in the coccyx area. It can hinder your squat and leg drive. Sitting for long periods of time can be painful, standing can be painful, and lying down can be painful. We don’t have control over this pain and often, because it is occurring is a strange area, we’re unsure where it’s stemming from.

It was at this point after I had to put my training on hold because I couldn’t squat or sit without pain that I started looking for help. As I had been having pain for over a month, it was obvious it wasn’t going to subside on its own. Thankfully, I had a friend who recently had a pelvic health rotation and graduated with her physical therapy degree. She referred me to Inner Dynamics Physical Therapy, a pelvic floor physical therapy office in Ocean, New Jersey and said to schedule an evaluation there. It was there I met Dr. Tamra Wroblesky, my physical therapist, and she would change my life and lifting career forever.

Dr. Wroblesky’s Account

I first met Katie on September 12, 2016. She came in with severe coccyx pain, as well as urinary leakage every time she lifted heavy. As a competitive athlete, my facility was probably the last place she expected to find herself in. But there we were on a Monday morning, talking about her vagina. She was suffering from pelvic pain, urinary leakage with exercise and overall discomfort, and unsure if she was ever going to return to competitive weightlifting again.

Before I get any further into Katie’s story, I want to explain that pelvic pain or any form of incontinence should never be worked through. It means something in your system is not working correctly and it needs to be addressed. As a former college tennis player who had severe pelvic pain for too many years, I implore coaches and athletes now to be proactive about their health and get the proper help. Trust me, if everything in your system is working correctly, it will only make you stronger during lifts.
If you are having any form of urinary or fecal leakage, chronic hip pain, groin pain, pelvic pain, coccyx pain, vaginal pain, rectal pain, pain with sex, pain with sitting, pain deep in the squat, or feelings of pelvic pressure, a good pelvic health physical therapist is someone you want to have on your team. We are trained just like any other physical therapist, but have added insight and training into specific muscles surrounding and inside your pelvis. You may have heard us referred as “pelvic floor physical therapists,” but as you read further, you will learn that your pelvic floor (a group of three muscles that lie like a hammock at the bottom of your body) is only one part of the equation.

An important reality: kegels do not fix everything. Do not go to a physical therapist or doctor who starts you on kegels without looking at the rest of your body. As pelvic therapists, we look at the entire athlete to determine what needs to be addressed. Many times, the pelvic floor isn’t the problem and doing kegels will just make things worse. In Katie’s story, it wasn’t even the first part we addressed.
When Katie was sitting in my office, explaining her sharp coccyx pain and urinary leakage, I knew her body was both overworking and underworking. It was my job during her evaluation to figure out those imbalances and begin to calm her system down so that we could ultimately restore movement, coordinate muscles, stabilize, and strengthen her body more effectively. I asked Katie if I could perform an internal exam so I could get a better idea of what was going on with her body, and she agreed. Pelvic physical therapists are trained to perform internal evaluations and treat pelvic muscles both vaginally and rectally as we treat both men and women. It is not necessary to perform internal work, and I’ve had many patients who either wait a few visits before proceeding or skip it completely. Yes, internal evaluations can give us information we simply cannot get anywhere else, but they are only one tool in our toolkit to help our patients.

During internal assessments, we look for weakness, tenderness, pain reproduction, as well as assess the patient's strength and endurance of their pelvic floor contraction or Kegel. Since pelvic pain is complex, it is important to look at each factor and determine where to start with treatment as you cannot strengthen a muscle in spasm.

During Katie’s internal exam, we found out a few interesting things. 1. Her coccygeus muscles (located internally behind the pelvic floor) were extremely irritated and tight, and touching them provoked the pain she felt in her squat. These were muscles that were overworking. 2. Her obturator internus muscle (one of your deep hip rotators, located to the side of your pelvic floor) was also extremely irritated and painful. 3. Her pelvic floor was unable to work effectively because it was being pulled to the back and side by tight muscles that were overworking.

A crucial part of healing Katie was working on calming her fears of pain and discomfort and explain to her what was going on and why this was happening. I told her she would weightlift again, but to give me time and patience as we had to make her body operate as a cohesive system again. Katie came to me as an extremely talented weightlifter who had seen success and exceeded expectations without any formal training of what her body needed to do. Now she had something coming between her and her dreams for her future. She needed guidance to avoid any further roadblocks. It was time to take a step back, breathe, and rebuild. Once I gained her trust and commitment, we began our journey to recovery, health and record-breaking achievements.

Our first few sessions involved calming things down and there are many ways to do this. First, we had to start mobility and stretching, especially hip rotation. We also worked on calming down her pelvic floor, which needed to occur before we could strengthen it. The pelvic floor actually moves in sync with your diaphragm (large breathing muscle underneath your ribcage). When you inhale, your diaphragm moves down and your ribcage expands, and at the same time your pelvic floor is also supposed to move down and relax. I tell my patients deep breathing is like taking your pelvic floor for a walk. No muscle in our body is supposed to stay contracted all the time- everyone needs a break once in a while! When we first started therapy, Katie’s pelvic floor did not move at all. Slowly with the help of internal muscle release, deep breathing, stretching, and mobility work, we began to work on relaxing, and once she mastered that, it was time to move on to strengthening. Our first stop was retraining her gluteal muscles. For so long her pelvic floor had been doing the work her glutes should have been responsible for. It was time to get them firing to provide the support her pelvis desperately needed. Once she started using her glutes more effectively, I finally turned to her pelvic floor.

Kegels are a hot topic in the pelvic world. These are pelvic muscle contractions that help strengthen the sling of muscles at the bottom of your body in charge of holding up major organs, controlling your urination, and contributing to sexual function. 90 percent of the patients who walk into my office do a kegel incorrectly. Don’t squeeze your butt cheeks together to do a pelvic floor contraction! While lying down, try and imagine your pelvic floor as an elevator and gently bring it up to the second floor. Also, keep in mind your pelvic floor is a group of muscles just like anywhere else in the body. Don’t just do one or two every time you think of it. They require proper dosage, just like your workout routine. Please work with your PT to determine the best frequency for you, just like you work with your coach to determine the best weight program. There is no one-size fits all kegel strengthening program for any individual. I tailor sets, reps, hold times, positioning, and rest periods all based on my patient’s body and individual goals.

Once we had taught Katie how to kegel correctly, we needed to coordinate with other surrounding muscles. She worked on contracting her pelvic floor on the exhale while engaging her abdominal muscles (specifically her transverse abdominis or TA). She needed to master this lying down, sitting up, standing, and then while lifting heavy things. This brings us to the importance of tension in a training program. Tension is a good thing because it allows us to load muscles, causing them to micro-tear, and then rebuild to become stronger. Tension equals adaptation. However, tension increased too quickly leads to dysfunction. The same holds true for the pelvic floor. If you are snatching at 70 percent and leaking, your system is not capable of training at 70 percent yet. Drop your weight down until you experience no leakage so your pelvic floor can properly adapt to the right tension. Do not train through incontinence. Remember, incontinence is a sign from your body that something in your system is not working correctly and needs to be fixed. It could happen when you cough or sneeze, jump rope, or sink deep into a squat. It could be the strength of your pelvic floor, your bracing, your breathwork, your thoracic mobility, your positioning… Many times, I’ve had patients come in who have perfectly healthy and strong pelvic floors, but they are chest breathers who hold their breath, and have poor posture that increases their intra-abdominal pressure and makes their pelvic floor work harder than it needs to. There are a million reasons why you could be having incontinence, and a weak pelvic floor is just one. Find the proper help and stop the leak. I was shocked when Katie showed me videos of young female weightlifters posting their leakage during lifts, saying they aren’t ashamed of their pee. There’s nothing wrong with talking about urine, but the only place it belongs is in a toilet.

Speaking of urine, did you know you should be able to hold your pee approximately two to three hours and only go to the bathroom six to 10 times a day depending on your water intake? Did you know your urine stream should be strong and steady, with no dribbling? These are good signs of a healthy pelvic floor. And if we are going to talk about healthy floors, we might as well cover healthy bowel movements. Did you know you should be having a bowel movement approximately once a day and emptying should be quick, complete, and produce a firm log stool? Did you know straining during bowel movements can impact your pelvic floor and hip muscles, which could lead to pelvic dysfunction? Did you know you could go to physical therapy for your constipation? Did you ever think that your bowel and bladder could impact your weightlifting so dramatically?

Katie’s story didn’t just end at kegels. I continue to work with her and her weightlifting coach to address her deficits and improve the quality of her movements. We work on thoracic, abdominal, and hip mobility, as well as core and hip strengthening. We tweak her breathwork and we improve stabilization. We do a million things other than clean and jerks and snatches, but she continues to be patient and puts in the work because she is committed to the process. She lifts heavy without leakage 99 percent of the time now. I am so proud of the results we have gotten thus far and I hope our story inspires others to seek help and put their body first.

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You don’t just get better. Physical therapists aren’t magicians. You, as the patient, have to put just as much work in as the physical therapist. You have to be disciplined and you have to be honest. First, you have to find someone that you’re willing to trust (in the case of Tamra, in ways I’ve never trusted another human being before). Next, you have to dedicate time to focus on your breathing, bracing, and proper kegels and other exercises. Programming them into my warm-ups and cool-downs was most effective for me, personally. Those are the times that I focus on my issues and imbalances the most. Lastly, you have to be patient and kind with your body as it won’t heal overnight. Sometimes you regress and reevaluation is necessary, as with anything. You have to trust in the process. The tools and knowledge you’ll gain along the way are exactly what you’ll need in your future endeavors.  

I’m truly thankful for my pelvic floor imbalances. Without them, I wouldn’t have the body awareness that I have today. In this last year and a half, I’ve learned more about my body, my training, and myself—as an athlete and as a person—than I ever have before. Taking a step back in my training has given me, my physical therapist, and my coach the tools we need to build me up to be the best athlete I can be. This isn’t something you can do on your own—it takes a team.