Are You an Innie or an Outie?

No, I am not referring to your belly button.

I am referring to your vulva – the soft tissues on the outside of your body between your bottom and your pubic bones. Why am I asking this random question? Well, Has your vulva got you feeling pain & unhappiness after riding your bike? 

Addressing this topic is crucial to making it easier for mums to keep participating in mountain biking. Sadly, after experiencing saddle soreness, many women are put off getting on any kind of bike ever again. And no wonder really, because something that wasn’t designed to be weight-bearing – may take up to 40% of her body weight for hours at a time while riding a bike. My desire is to make MTB more accessible for mums, and therefore I am going to address this chronic issue.

But first, let’s understand the vulva and it’s role. The vulva is the outer part of the female genitals. I am pretty sure you know where they are located – but for accuracy, it is located between your sit bones and pubic bones, and includes the opening of the vagina (sometimes called the vestibule), the labia majora, the labia minora, and the clitoris. This area also includes Nerves:(Pudendal nerve) Artery: Internal pudendal artery and Lymph: Superficial inguinal lymph nodes

The Vulva’s role is to protect the internal parts of the female reproductive system (labia majora and minora) play a role in sexual arousal and stimulation (clitoris) facilitate sex, such as through providing lubrication (Bartholin’s glands) and cushioning (mons pubis). One thing is clear – These tissues were not meant for serious compression & friction over long periods of time.

This issue is not just in the “beginner rider” population either. 10% of professional athletes in this study reported actual genital injury. Medically termed “Bicyclists Vulva” this involves compression of the pudendal nerve, neurological damage to soft tissue and lymphatic vessels, chronic swelling of the labia, scars and perineal lesions and lymphatic abnormalities. 

Your Pelvic Bones

Pelves (plural for pelvis) come in all shapes and sizes. Not only that, the pelvis is made up of multiple joints and bones which undergo many changes over time. One common misconception among heaver more overweight women is that they equate the size of the outside of their hips (where they may store some fat) with the size of their sit bones.

Body weight and clothing size has nothing to do with sit bone width.

The symphysis pubis joint are where the illium bones in the front meet together and that we call the pubic bones.   There are two of them that come together making it a joint. Going underneath the pubic symphysis and back towards your bottom, is the pubic rami bones, or ischial tuberosities as some people call them and otherwise known as our sit bones. The sacrum is the triangular bone between the two sides of the flat part across the back of your pelvis (illium bones).  This junction creates the sacroiliac joints (SIJ).  The bottom tip of sacrum is the hinge for the tailbone (coccyx) and the top is where and how the lumbar spine attaches to the pelvis.

The University of Zurich found that with the onset of puberty, the female pelvis expands; and with the onset of menopause, it contracts again. The results of this study suggest that the size, shape and structure of the female pelvis is influenced by hormonal changes in puberty and menopause. And we also know that during pregnancy and birth ligaments stretch and increase the size of the pelvic outlet further… So basically, if you are a teenager, a mama or menopausal, (all stages of life apart from childhood!) these fluctuations of the pelvis may contribute to issues with saddle soreness because the width of the sit bones, the position and function of the SI Joints and the Pubic symphysis will alter how comfortable you are on your current saddle set up.

Birth and Your Pelvis.

I have referenced and researched (see below) many articles on saddle pain for women, and all were excellent! However, I didn’t find any that discussed the pelvic floor or highlighted the impact that pregnancy/birth have on the pelvis.  Which is a problem because pregnancy and birth impact the body in many ways and many women that ride bikes have also been pregnant or given birth at some stage. . .  As we have touched on lightly already, the pelvis goes through so much during pregnancy and birth. For example,

  1. Over-stretching of the abdominal wall and pelvic floor
  2. Changes in pelvic tilt (posture)
  3. Pelvic floor trauma, tearing, scar tissue formation, and nerve damage
  4. During labour, the pelvic bones move backwards, forwards, inwards and outwards. We just assume they go back to their normal position. But, sometimes they do and sometimes they don’t.

During pregnancy, the pelvis adapts an anterior tilt to allow space for the baby and the growing abdominal wall. The symphysis pubis joint aka the pubic bones widen during birth to help make space for the baby to come through the birth canal. The sit bones actually need to splay apart for the baby to exit the pelvis.  During birth, the top of the sacrum needs to first move backwards to allow the baby’s head into the pelvic inlet.  At the same time, the tailbone is moving into the pelvic outlet.  Once the baby’s head hits the pelvic floor muscles and then the bones need to do the opposite motion.

All of this puts a ton of tension on the pelvic floor muscles and the surrounding tissues – which in turn alters how you sit on your saddle, hold yourself upright and how well you pedal your bike.

And before you jump back on your bike after birth, it is really important to have your pelvic floor checked. While an OB-GYN or urologist are can do a basic exam, the most thorough pelvic floor assessments are performed by physiotherapists who specialize in pelvic issues. They will look for tension or weakness patterns both externally (i.e. in the legs, butt, lower back, etc) and also internally. The internal exam is nothing to fear and takes just a few minutes to perform. 

Types of Saddle Pain

Sit bone pain

Sit bone pain feels like bruising on the bony prominences underneath your bottom. For most people it goes away on it’s own as the body gets used to biking, a new saddle or bike set up. Sit bone pain, although uncomfortable is actually kind of a good thing because you want your contact points with the bike to be skeletal and not soft tissue. When you are in the proper riding position, your sit bones should be taking most of your weight…however, there can be hardening of the tissues around these contact points leading to calluses, scar tissue and sometimes bursitis. And although your sit bones are the correct points of contact with your bike, there will still be compression which limits blood flow and can lead to numbness and nerve damage. Known as bicycle seat neuropathy, it is caused by repetitive micro trauma from friction and vibration between the saddle and sit bones. 

Managing sit bone pain:

  • Blood flow is essential to this area, so get out of the saddle as much as possible. 
  • Bike fit is essential to get all the contact points (saddle, pedals, and handlebars) correctly set up for you before worrying too much about the saddle. Once those contact points are set to the right positions, then it’s time to start thinking about the saddle itself. There is no point buying an expensive new saddle if you do not have a correct bike fit that is going to force you in a poor riding position anyway. 
  • A popular choice for women riders is to place gel cover or purchase a super wide saddle because they assume that more padding is going to equal less of a sore bottom. But less is actually more in this case.  The saddle itself only needs to be as wide as the sit bones (the correct points of contact) and choosing a saddle that is too wide for you will force a larger area of contact and the potential to cause more friction and rubbing in the groin, inner thighs and soft tissues. 
  • Wear a chamois that has padding around the sit bones and not anywhere else.

Saddle sores 

First, a saddle sore is really a pressure sore. A sore is basically an infection. On the surface, a saddle sore looks like an infected pimple or an ingrown hair. These can range from hard painful lumps, fluid-filled cysts and abrasions. Saddle sores occur when the skin and tissues are continuously subject to heat, moisture (such as sweat or urine), chafing and pressure. The chafing can be from the skin rubbing on the saddle, the lining of your chamois or clothing. Many women find riding with a menstrual pad also causes chafing.

Doc Edwards suggests considering looking at these possible causes particularly if saddle sores have suddenly popped up but you are an experienced rider:

  1. The inners of a seat do not last forever. When foam loses its form, the pressure patterns change on your contact points, and what may have been the perfect setup is suddenly not.
  2. If you ride in cleats have they worn out? Worn-out cleats or shoes can change your pelvic position and your contact points & pressure distribution? Whatever happens in the foot affects what is above.
  3. If you recently changed soaps and your skin is sensitive, this may predispose to irritation and saddle sores.

And in addition to that, could it also be:

Your time of the month? The onset of menopause? Changes in estrogen affect every system in the body. And with the onset of menopause and at certain times during your menstrual cycle the estrogen levels dip, the pelvic floor tissues often get thinner and dryer leading to less cushioning and more sensitive skin.

Managing Saddle Sores: 

To reduce the risk of worsening or developing saddle sores 

  • think two keywords: clean and dry. 
  • Don’t wear underwear as well as chamois. 
  • Use a chamois cream
  • Get a bike/saddle fit
  • Get out of the saddle as much as possible. Consistent flat riding can the worst in terms of saddle soreness, 
  • Shower and change as soon as you finish your ride. 
  • Many people swear by tea tree oil
  • See a doctor right away if your sores are accompanied by fever, chills etc.

Soft Tissue Pain

Soft tissue is the area mentioned earlier – the outer parts of your genitals – the opening of the vagina, the labia and the clitoris that get squished between the bike seat and our pelvis when we ride, most commonly from an aggressively forward-leaning posture. Soft tissue pain is really painful and can include skin sensitivity and numbness, labial swelling and enlargement, vaginal irritation and even infection.

Note: Please Do not douche in the hope of preventing or treating an infection. Douching your vagina upsets the balance of bacteria and can cause infection (thrush and bacterial vaginosis). A healthy vagina has good and harmful bacteria in a perfect balance. 

Cobb Cycling was the first to discover the differences of the “innie and outie” anatomical issue and it’s role in soft tissue pain for women who ride bikes. They developed all different types of saddles for women because they recognised women’s pelves and vulvas come in all different shapes and sizes. For example; 

  • For the women who are considered ‘Outies’, the vulva and the labia are much more pronounced and exposed, The clitoris also may be a physically larger area and tend to like the wider nosed saddles,
  • For the ‘Innies’, the vulva, the labia, and the clitoris tend to be more enclosed or drawn up internally so that the crotch area is smoother. The innies will have a smaller exposed soft tissue surface area like the narrower nose models.

A saddle with a cut-out section down the middle may also give women some relief from soft tissue pain. Other considerations when choosing a saddle that is right for you is the length and shape of the nose, saddle tilt, foam density and your style of riding (XC, enduro, DH, Gravel etc). Actual width from sit bone to sit bone is a major point of concern when purchasing a new saddle. You can ask your women’s health physiotherapist to measure your sit bone width for you.

I don’t recommend any particular saddle due to the major differences in soft tissue anatomy, pelvis shape and size, sit bone width, possible conditions and pregnancy/postpartum adaptations. However, I am really impressed with the variety and devotion to comfort for women by Jcob seats.

Pelvic Floor Pain

Could saddle pain actually be pelvic floor pain? Or at least contribute to it? Or vice versa? The pelvic floor muscles are located inside the pelvis, but pain associated with the pelvic floor can extend anywhere in the pelvic region including into the butt and deep into the belly. Repetitive straining, stress, compression, discomfort and pain will provoke a guarding/gripping response in the pelvic floor muscles which can result in chronic muscle tension as well as the development of painful trigger points. This may lead to:

  • Constipation
  • Incomplete Emptying Of The Bowels
  • Straining When Emptying The Bowels
  • Pelvic Pain
  • Low Back Pain
  • Hip Pain
  • Coccyx Pain
  • Painful Sex
  • Vaginismus
  • Urinary Incontinence
  • Incomplete Emptying Of The Bladder
  • Slow Flow Of Urine
  • Hesitancy Or Delayed Start Of Urine Stream
  • Urinary Urgency
  • Urinary Frequency, And
  • Painful Urination
  • Urinary Tract infections.

For more information regarding the Hypertonic Pelvic floor click here.

Pelvic floor pain from biking can also be associated with scar tissue aggravation from vaginal childbirth, episiotomy, gynaecological surgery, menopause or pelvic organ prolapse.

Some prolapses may be so advanced that the prolapsing tissues actually sit outside or at the entrance to the vagina, urethra or rectum, which may create another point of contact and friction with the saddle. A pessary could be worthwhile wearing during riding to literally lift and help support the prolapsing organ and tissues.

In short – if you have ever given birth (vag or C-section), had surgery “down there”, or are going through menopause AND you ride a bike – have your pelvic floor checked. While an OB-GYN or urologist can do a basic exam, the most thorough pelvic floor assessments are performed by physiotherapists who specialise in pelvic disorders. They will look for tension or weakness patterns both externally (i.e. in the legs, butt, lower back, etc) and also internally. The internal exam is nothing to fear and takes just a few minutes to perform.

TIP: Find a saddle that works for you and that allows you to relax your pelvic floor muscles (as a pose to tensing up) on the bike

Pubic bone pain 

Women who experience pubic bone (AKA pubic symphysis joint pain) pain may be sitting too far forward on the saddle and/or have an anterior tilted pelvis (duck bum) which puts pressure on the pubic joint instead of the sit bones. Being in the wrong type of saddle may also aggravate pubic bone pain (like bruising) particularly if the saddle has a high rise at the front end or is tilted so that you are pushed forwards towards the nose of the saddle. As mentioned earlier, the pelvis naturally adapts an aggressive anterior pelvic tilt in pregnancy. and this is contributed to by stretching and weakening of the abdominals, which remain post-birth (unless rehabilitation is undertaken to train and strengthen them).  Pubic symphysis dysfunction is common in women who are pregnant due to they hyper mobility of the joint, and this may remain for months after giving birth.  Whether or not you have some pubic bone separation/SIJ dysfunction/ coccyx rotation from pregnancy or birth may also contribute to pubic bone pain during riding.

Other Causes of Saddle Soreness

Poor Core Strength 

Core strength is basically the ability to hold your self upright or in certain positions for a long period of time or while under load. The true core includes the pelvic floor group, the deep lower abdominals, multifidus and the diaphragm. It does not refer to the “six pack” abs.

the True core

No matter how specific your bike fit is, as riders we have a lot of control over how we sit on the bike. If you are sitting poorly due to a lack of core strength then an expensive saddle won’t be as beneficial as it could be. Core strength, shoulder stability, neck and postural strength to is huge in terms of bike positioning, allowing you to control the tilt of your pelvis while your legs are spinning in circles, ensure efficient energy use, support the upper body on the handlebar and to optimise performance. As fatigue sets in you may lose lumbo-pelvic stability, leading to hips see-sawing in the saddle, (hello friction and saddle sores!) loss of energy transfer from the legs and more pressure on certain contact points due to a slouch or lack of ability to hold yourself upright. 

Note: Simply lenghtneing your spine and sitting tall is enough to engage the core, and training yourself through core exercises will enable you to do this for longer periods of time and more efficiently. 

Please dont “hold your abs tight” or clench your pelvic floor while your ride hoping that this will engage your core. For more information about how to activate your core click here. 

For core strengthening exercises specific for biker mums, click here

Reducing the Damage

Thankfully, mountain bikers spend a lot more time out of the saddle than roadies or gravel riders. Our body position on the bike is also less forward-leaning, but soreness still happens.

Thorough care of any lesion of the vulvoperineal region is important. Elevate the lower limbs during rest periods for lymph drainage of the perineum and pelvis. Swelling may be reduced by applying cold compresses on the region after training and women’s health physiotherapy can stimulate lymph drainage pathways. And please don’t suffer silently, 

“Learn to be open about pain and swelling. Silence, secrecy and shame only exacerbates the problem” says UK Olympic cyclist Hannah Dines in 2019 who put up with the pain and swelling until it because a massive lump that never went away. 

Was this article helpful? Please comment below. 

Xx ali

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