Dear Canadian Running,

Recently, you published an article highlighting a post by Emily Infeld, a World Championship 10,000m Bronze medalist, amused by an attentive beau undaunted by a leaky bladder she was too tired to notice at the end of a race. Kudos to her for being forthright about it, because leaks with running ARE quite common. Kudos to her beau, in the picture she posted, for being simply being proud as punch of her amazing accomplishment, because it was worthy of amazement! Kudos to you for bringing attention to the issue that impacts a large number of your readers and that pelvic health physiotherapy exists.

As a sports medicine physiotherapist who specializes in the pelvic health of female athletes, I come in peace! I hope we can open a dialogue about some of the messages and conclusions drawn by the article and, I hope, propel this conversation forward. Specifically, I want women to know they can give max effort in sport and remain dry. In fact, the same strategies we use to improve performance and reduce injury will also improve leaks with running.

Leaks with Running Need New PR

We are ultimately on the same team. We both want to educate, empower and equip women and men to pursue fitness of their choice with vigor, efficiency, effectiveness, and joy…without limitations. For most, it is well understood that pain is the biggest limiting factor runners seek to avoid, treat, eliminate, and/or manage. Folks go to great lengths to find solutions for or prevent pain with running. We change foot strike, strengthening regimens, running form, cadence, shoes, training plans, etc. The list goes on and on, all in the name of pain-free running. However, that same level of understanding for how leaks impact running volume, performance, consistency, efficiency, injuries, and continued participation over a lifetime is still not well understood in the running world. 

Most women simply think: “I’ll just throw on a pad on and keep running”. They do not understand how, for example, their leaks with running may be linked to their hip pain. Or vice versa. Let me explain. The idea that the control of the pelvis might impact what is happening at the hip, seems like a logical anatomical connection to make. Beneath the pelvis is the pelvic floor, the muscle equated with continence. The pelvic floor has muscular links to the hip, through the deep hip muscles in the buttocks. They are intertwined, and so is their health. This leads me to want to understand more about Emily Infeld’s hip surgery noted in the article. 

Leaks with Running are a Signal

Pain and leaks are both signals that the runner is not efficiently meeting the demands of their sport. When we start looking at incontinence as just another signal, it changes the tenor, tone and mindset on how we understand it as athletes, coaches, fitness writers and rehab professionals. 

The signal, or the message, that a report of leaking conveys to me is that my athlete isn’t managing pressure, muscular balance or impact well. This is particularly true for a runner who has never had a baby or is young, such as the physio who weighed in to indicate that she leaked in high school. There is no reason they would have a “weak” pelvic floor. We have new solutions that are far beyond only looking at or building the capacity of the pelvic floor (kegels). Many female runners have tried kegels without success. A one muscle solution will not meet the complex needs of an activity like running. The training program for continence control must match the demands of the type of fitness. We must address leaks with a multifaceted approach that bears in mind all the variables that play into continence control during sport.

A New Approach

We would not ignore pain in an athlete, or encourage them to ignore it. Instead we would explore what variables are contributing to the pain, and see what we could modify. The same approach applies to leaks with running. The athlete, coach and physio would/should ask:

• When does the pain leak occur? Start, middle, end of race? This might speak to the role of fatigue vs form, strategy, compensation or capacity issues.
• If the pain leak is at the end of the race (hinted at in Emily’s account of her exhaustion and leaks), does their form break down with fatigue? 
• In what way does the form break down? Landing errors? Proximal hip control? Loss of torso participation? Excessive motion at the pelvis? Respiratory endurance changes breath patterns? Other inefficiencies?
• Does the pain leak happen during the final sprint to the finish? 
• Is the pain leak occurring, like one of the women in the article, frequently, throughout the run and/or with every run?

Those are different demands on both the physical and continence systems – we must adapt their training to meet each of those challenges in order to keep preparing them for the next level of training-longer races, faster times, more explosive starts, etc. Understanding the demands and adapting training to meet the specific needs within each sport is the heart of sports medicine, we simply need to apply these ideas to running incontinence. In addition, this issue occurs across all forms of female athletics, it is not unique to running.***

“Oh well.”

The athlete, coach, and physio would never say, “Oh well. You’re just at your max threshold you should expect pain there.” Instead their training program should be modified to address these issues to prevent recurrence and continue to reach for new heights. We should approach incontinence with a similar mindset. Focus on building a training program that address inefficiencies  to hit the max effort again, but without a leak. Athletes can perform at their max effort and stay dry. 

I agree that true thresholds exist, records stand for years because we bump up against the limits of our physical form. However, our job as athletes, coaches and physios is to determine if that threshold is imposed by HOW one is trying to meet the demand (either their strategy or compensations to try to push into that threshold) or if they lack the capacity to meet the demand (endurance, strength, range of motion, etc). We can change both of those things. OR we need to acknowledge if the threshold is the true limit of the finiteness of their human form, in which case do we advise the athlete to keep pushing into an activity that recreates the pain (or leak)? Or do we modify the activity-decrease mileage, or speed or change terrain?

Let’s Send a New Message

These ideas need some press, too. Our physio community would love for you to help us spread a new message to your runners. Convincing folks that this is worthy of treating is step one. Teaching them that treating it has relevance for improving their performance, and preventing running injuries is a great way to do that. Running health and pelvic health are intertwined. Help us move this conversation forward and reach female runners with a new message .  

Sincerely,

Julie Wiebe, PT

***You can read previous conversations with CrossFit HQ on similar issues in their sport here, and here.***

 If you would like more information, I have blogs and media interviews on my site that address these issues.

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