The Hidden Links Between Your Back, Hips & Pelvic Floor

Understanding the Pelvic Floor, Piriformis and Sciatica: Evidence-Based Approaches to Common Problems

Many people live with pelvic floor symptoms, hip pain, or sciatica. These problems can interfere with your everyday life, reduce your confidence and limit your movement. They are often seen in people who have had surgery such as hysterectomy or prostatectomy, in those with chronic back pain, or simply as part of long-term wear and tear.

The good news is that research shows exercise can make a real difference. Simple, consistent training helps muscles recover, reduces pain, and supports long-term health. This blog brings together the some of the research on the pelvic floor, piriformis syndrome, and sciatica alongside my own experience as a Back Care Pilates coach and what I have found works in class. Each section explains what the research says, why it matters, and which movements can help.

The Pelvic Floor

The pelvic floor is a group of muscles that act like a supportive sling. They control bladder and bowel function, provide support for the pelvic organs, and play a role in spinal stability as some of the muscles attach to the spinal column.

Research shows that pelvic floor problems can be more common after certain surgeries - a recent review found that (non-cancer) hysterectomy was linked with higher rates of pelvic floor disorders, including urinary incontinence and pelvic organ prolapse (Chang et al., 2025) 10yrs after surgery when compared with those who had not had this procedure. Some of this may be linked to menopause, but this time frame gives us opportunity to start to put in place muscle strengthening exercises to help lower back and pelvic floor.

Although the risks for men are lower, they are not exempt — we can see an increase in urinary incontinence following prostate surgery that may last some months or longer. Exercises will help relieve this issue and can be done before surgery to lessen this and to improve healing.

Pelvic floor muscle training (PFMT) is proven to help. Alves et al. (2015) ran a randomised controlled trial with postmenopausal women. After a structured PFMT programme, participants showed clear improvements in strength, endurance, and continence compared to controls. To do this, you will need to find yourself a Woman's Health Physio as this is technical and specific training that you will need to work with a professional for. Pilates has a role to help keep the muscles around the floor healthy and strong, and should be done alongside this specific training. However, if you are unable to find a physio, then rest assured that the work we do in Pilates will be of great help.

Similar improvements to pelvic floor strength results are seen in men. Pedriali et al. (2016) compared Pilates-based PFMT with conventional training after prostatectomy. Both methods improved continence recovery, showing Pilates can be just as effective as traditional approaches.

Pelvic Floor Pain and Dysfunction

Pain is often the driver for people to come to Back Care Pilates - but it is also an important and underestimated part of the pelvic floor picture. Many people with persistent pelvic discomfort believe that the problem lies only with the bladder, bowel, or reproductive organs - but in a study by Ross et al. (2021) they indicated that myofascial ( myofascial combines two words: myo, meaning muscle, and fascia, the thin layer of connective tissue that surrounds and supports muscles throughout the body.) pelvic pain – or pain arising from muscles and connective tissue – is common and treatable.

When the myofascial tissues are healthy, muscles contract and release efficiently. But if they become tight, irritated, or develop what are known as "trigger points", this can lead to pain and restricted movement. Unlike pain from an organ, myofascial pain often feels like a dull ache, pressure, or tightness that may spread beyond the immediate area. In the pelvis, this can be experienced as deep pelvic pain, discomfort in the lower back or hips, or even symptoms that mimic bladder or bowel problems.

Understanding the role of myofascial tissues is important because it shows why approaches such as stretching, relaxation techniques, and controlled exercise like the methods that I teach in our Pilates classes can really help. By improving flexibility, circulation, and muscle coordination, these methods reduce tension in both the muscle fibres and the fascia that supports them.

Pilates classes are particularly useful because they encourage awareness, breath, and gentle control. Pilates teaches how to engage and then fully release the pelvic floor in coordination with the rest of the body. This balance of activation and relaxation is vital for those whose symptoms are linked to overactivity or tension.

Hypertonic Pelvic Floor

Pelvic floor problems are not always caused by weakness. In some people, the muscles become overactive and unable to relax fully. This condition called a "hypertonic pelvic floor" and can result in pelvic pain, urinary urgency, constipation, and/or sexual dysfunction.

A hypertonic pelvic floor also needs to learn to relax. With many researchers indicating that there should be movements to reduce tension alongside exercises to keep the muscle health and strong. A hypertonic floor can be both tight and weak, and this is where I think that Pilates really helps. I like to work with gentle movements to improve blood flow, get nutrients into tight muscles, make them more flexible and then work with improving the muscle condition - Pilates encourages a balance of activation and relaxation, which is particularly valuable for those with hypertonic pelvic floor.

Looking after the pelvic floor is not about doing one exercise or following a quick fix. It is about understanding how these muscles work, recognising when they need to strengthen, and when they need to release. The evidence is clear that both men and women can benefit from targeted pelvic floor training, and that Pilates provides a safe and effective way to support this process. By combining awareness, breath, and controlled movement, we can restore balance, reduce symptoms, and protect long-term health. Most importantly, the pelvic floor can change with practice — and taking small, consistent steps now will make a real difference for the future.

Piriformis

Think of the piriformis as a short strap or elastic band that runs diagonally from the base of your spine (the sacrum) to the outside of your hip (the greater trochanter of the femur). Because it lies deep underneath the glute muscles, it works to improve hip movement and stability.

When this “strap” is balanced, it helps you turn your leg outward and keeps your hip stable as you walk or climb stairs. But if it becomes tight, irritated, or weak, it can press on the nearby sciatic nerve — a bit like a belt pressing down on an electrical cable — and cause pain that feels like sciatica.

The piriformis is a small, deep muscle located in the buttock region.

• The piriformis starts from the internal part of the sacrum at the bottom of the spine.

• It passes out of the pelvis through the "greater sciatic foramen" - the space used by the sciatic nerve - which can explain some of the reasons why irritation of the piriformis can sometimes compress the sciatic nerve and create leg pain.

• It then attaches to the the prominent bony part on the side of the hip at the top of your thigh bone (femur).

• Its primary function is lateral rotation of the hip (turning the thigh outward) when the hip is extended. When the hip is flexed, it assists with abduction (moving the thigh away from the body). It also contributes to stabilising the hip joint by keeping the head of the femur securely in the acetabulum or hip socket.

You may have heard of the "Piriformis syndrome" which is a neuromuscular condition where the piriformis muscle irritates or compresses the sciatic nerve. It is often mistaken for sciatica. Long-term research shows piriformis syndrome accounts for around 6–8% of low back and leg pain cases (Fishman et al., 2002).

Effective treatment goes beyond stretching. Strengthening and movement re-education are critical. Tonley et al. (2010) published a case report showing that focusing on hip muscle strength and correcting movement patterns reduced symptoms and restored function.

Pilates has a role here too. Seong and Kim (2025) found that both mat and barrel-based Pilates increased muscle activity and improved body composition in women. This type of targeted activation helps stabilise the hips and pelvis, which reduces strain on the piriformis.

Piriformis pain can be frustrating - it might feel like sciatica, running from the buttock down the leg. Which is why we always include stretching and strengtheing this muscle in Pilates, as it can help both hip and back pain. Pilates principles of alignment and control can be effective in helping to manage your piriformis-related pain.

Sciatica

Sciatica is known as a nerve pain, usually caused by compression of the sciatic nerve - there are many reasons why this happen. It could be a lumbar disc herniation, but can also result from spinal stenosis or muscular entrapment (Koes et al., 2007) and so it is always worthwhile to get professional help to deal with this first before you come to class. Exercising has been shown to help sciatica - but not in the acute phase, so wait for things to settle before coming to Back Care Pilates.

You may be reassured that around 5% of people experience sciatica each year, and lifetime risk can be as high as 40% (Koes et al., 2007). For some, symptoms become persistent. Long et al. (1996) found that patients with chronic sciatica reported reduced quality of life, high disability, and frequent health care use.

Exercise can help. Pilates has been shown to reduce pain and improve function. Golpaygani et al. (2013) studied patients with disc herniation and sciatica. After a Pilates programme, pain levels reduced and functional ability improved. More recent evidence supports this too. Fitriani and Rosmiati (2024) found Pilates reduced pain intensity and improved movement control in low back pain patients.

Sciatica is not “just back pain”. It is nerve irritation, often radiating down the leg. While some cases resolve naturally, staying active with the right exercise improves outcomes. Resting completely can make symptoms worse. Pilates is effective because it provides both spinal stability and mobility. Controlled, low-load movement supports healing without irritating the nerve further. The aim is not to push into pain but to maintain gentle, pain-free motion. Over time, mobility and strength improve, reducing pressure on the sciatic nerve.

Although the pelvic floor, piriformis, and sciatica may seem separate, they are all linked by one principle: muscles matter. Weakness, tightness, or poor coordination can lead to pain and dysfunction.

The evidence across studies shows that:

• Surgery (hysterectomy, prostatectomy) increases pelvic floor risk, but exercise supports recovery.

• Piriformis syndrome mimics sciatica, but targeted hip strengthening and stretching are effective.

• Sciatica often arises from disc problems, but Pilates-based exercise improves pain and function.

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Across all three conditions, Pilates principles are particularly helpful. Breath, control, and alignment create a safe way to retrain the body.

Living with pelvic floor symptoms, piriformis pain, or sciatica can feel overwhelming. Yet research consistently shows that exercise is part of the solution.

• The pelvic floor responds to consistent training.

• The piriformis benefits from both release and strength.

• Sciatica improves with safe, controlled movement.

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This is encouraging. It means that with the right knowledge and a steady approach, you can take back control of your body.

Attending a class offers additional benefits. The guided pace reduces the fear of movement, exercises can be tailored to individual ability, and people often feel reassured working in a supportive environment. In this way, Pilates is not simply exercise but a method of retraining the pelvic floor to move, release, and function in balance with your everyday life. I have taught Back Care Pilates for many years, to many people. This can be life changing in a return to movement - having back pain does not mean it is forever - come and see me in class or join me for my half day session on Pilates and your Pelivc Floor.

References

• Alves, F.K., Riccetto, C., Adami, D.B., Marques, J., Pereira, L.C., Palma, P. and Botelho, S., 2015. A pelvic floor muscle training program in postmenopausal women: A randomized controlled trial. Maturitas, 81(2), pp.300-305.

• American College of Obstetricians and Gynecologists, 2004. Chronic pelvic pain. ACOG technical bulletin, 129.

• Butrick, C.W., 2009. Pelvic floor hypertonic disorders: identification and management. Obstetrics and Gynecology Clinics, 36(3), pp.707-722.

• Chang, O.H., Saldanha, I.J., Encalada-Soto, D., Jalloul, R.J., Rozycki, S., Orlando, M., White, A., Yang, L.C., Thompson, J.C., Nihira, M. and Bretschneider, C.E., 2025. Associations between hysterectomy and pelvic floor disorders: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology.

• Degirmentepe, R.B., Gul, D., Akca, Y.M., Cimen, H.I. and Saglam, H.S., 2025. The effects of pilates exercise on female sexual dysfunction in women: a controlled, prospective study. BMC Urology, 25(1), p.67.

• Fishman, L.M., Dombi, G.W., Michaelsen, C., Ringel, S., Rozbruch, J., Rosner, B. and Weber, C., 2002. Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study. Archives of Physical Medicine and Rehabilitation, 83(3), pp.295-301.

• Fitriani, A. and Rosmiati, M., 2024. Implementation of Pilates Exercises to Reduce Pain Scale in Low Back Pain Patient. JURNAL VNUS (Vocational Nursing Sciences), 6(2), pp.48-56.

• Golpaygani, M., Mahdavi, S. and Moradi, L., 2013. The effects of a pilates training program on the function and pain of patients with disc herniation with lumbosciatalgia. Journal of Exercise Science and Medicine, 5(1), pp.41-53.

• Koes, B.W., Van Tulder, M.W. and Peul, W.C., 2007. Diagnosis and treatment of sciatica. BMJ, 334(7607), pp.1313-1317.

• Long, D.M., BenDebba, M., Torgerson, W.S., Boyd, R.J., Dawson, E.G., Hardy, R.W., Robertson, J.T., Sypert, G.W. and Watts, C., 1996. Persistent back pain and sciatica in the United States: patient characteristics. Clinical Spine Surgery, 9(1), pp.40-58.

• National Association for Pelvic Health, 2023. High tone pelvic floor and bowel, urinary and sexual health. NP Women’s Healthcare. Available at: https://www.npwomenshealthcare.com/high-tone-pelvic-floor-and-bowel-urinary-and-sexual-health/ [Accessed 23 August 2025].

• Pedriali, F.R., Gomes, C.S., Soares, L., Urbano, M.R., Moreira, E.C.H., Averbeck, M.A. and de Almeida, S.H.M., 2016. Is pilates as effective as conventional pelvic floor muscle exercises in the conservative treatment of post‐prostatectomy urinary incontinence? A randomised controlled trial. Neurourology and Urodynamics, 35(5), pp.615-621.

• Pelvic Rehabilitation Medicine, 2025. Pelvic floor muscle hypertonia. Available at: https://pelvicrehabilitation.com/conditions/pelvic-floor-muscle-hypertonia/ [Accessed 23 August 2025].

• Ross, V., Detterman, C. and Hallisey, A., 2021. Myofascial pelvic pain: an overlooked and treatable cause of chronic pelvic pain. Journal of Midwifery & Women's Health, 66(2), pp.148-160.

• Seong, D. and Kim, D., 2025. The effects of mat Pilates exercise and barrel Pilates exercise on body composition and muscle activity in adult women. Journal of Bodywork and Movement Therapies, 44, pp.686-690.

• Tonley, J.C., Yun, S.M., Kochevar, R.J., Dye, J.A., Farrokhi, S. and Powers, C.M., 2010. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. Journal of Orthopaedic & Sports Physical Therapy, 40(2), pp.103-111.

• van Reijn-Baggen, D.A., Han-Geurts, I.J., Voorham-van der Zalm, P.J., Pelger, R.C., Hagenaars-van Miert, C.H. and Laan, E.T., 2022. Pelvic floor physical therapy for pelvic floor hypertonicity: a systematic review of treatment efficacy. Sexual Medicine Reviews, 10(2), pp.209-230.

• Vandyken, C. and Hilton, S., 2023. High tone pelvic floor dysfunction: a review of pathophysiology and treatment. Frontiers in Rehabilitation Sciences, 4, 10953682. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10953682/ [Accessed 23 August 2025].