Understanding the Pelvic Floor: Insights from a Pelvic Floor PT with Kelly Ruther
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Most people have heard of the pelvic floor. Almost nobody could explain what it actually does. In this episode, Dr. Lara and David sit down with Kelly Ruther, a pelvic floor physical therapist based in Holland, Michigan, to fix that — starting with a correction David needed personally: this isn't a women's-only topic.
What the pelvic floor actually is
Kelly's explanation starts with a trampoline. The frame is the bony pelvis. The springs are the surrounding muscles — hamstrings, inner thighs, abdominals, diaphragm — that support the whole structure. The mesh itself is the pelvic floor: the only muscle group in the body with a hole in it, functioning less like a bicep that simply contracts and relaxes, and more like something that absorbs downward force — a sneeze, a jump, a cough — and rebounds.
The frame, the springs, and the mesh are all interconnected. Weaken or misalign one, and the others compensate, often unsuccessfully. Drop enough weight on a trampoline, as Kelly puts it, and it doesn't matter how strong the mesh is underneath.
What dysfunction actually looks like
The symptom list is longer than most people expect: urinary leaking (both stress incontinence from physical exertion and urge incontinence from a false urgency signal), fecal incontinence, constipation from a pelvic floor that won't relax, pain with intercourse, erectile dysfunction, pain with ejaculation, inability to orgasm, pelvic organ prolapse, and unexplained back, hip, or groin pain.
David's reaction was blunt: half those symptoms are things no one wants to talk about. Kelly's response gets at something real — these are conditions that happen in private, so they carry a shame that has nothing to do with their actual severity or cause. A dysfunctional knee doesn't carry the same stigma as a dysfunctional pelvic floor, even though the underlying mechanism — a muscle group not doing its job — is functionally identical.
Why it's rarely just one thing
Ask what causes pelvic floor dysfunction and the honest answer is: almost anything, because nothing in the body works in isolation. Overactive or underactive glutes, imbalanced inner thighs, stiff ribs or upper back creating excess downward pressure — all of it feeds into the same system. Kelly describes the core as a soda can: deep abdominals on the sides, the pelvic floor as the bottom, the diaphragm as the top. Dent the can anywhere and the whole pressure system loses integrity.
This is why Kegels — often the only intervention most people have ever heard of — are rarely the answer. Kelly hasn't prescribed Kegels in isolation once in ten years of practice. Strengthening the pelvic floor by itself ignores the springs surrounding it, and in patients with an already overactive pelvic floor, Kegels can actively make things worse.
Diaphragm work: useful, but not the whole story
The diaphragm and pelvic floor move together — both descend on the inhale, both should rise on the exhale, creating a pumping motion that also assists digestion. When the ribs sit in a flared position (common postpartum, but not exclusive to it), the diaphragm gets stuck in a contracted state. That contraction pulls on the lower back, recruits the neck and shoulders to compensate, and can cascade into jaw tension entirely disconnected from where the problem started.
Kelly is careful here, and it's a distinction worth sitting with: diaphragm work has become something of a new Kegels — trendy, oversimplified, presented online as the single fix. It's a genuinely important piece. It is not the whole puzzle. Anyone claiming a single root cause for pelvic floor dysfunction, or any complex condition, is optimizing for virality rather than accuracy.
How an evaluation actually works
Kelly's practice uses what she calls the Ruther Method — developed over ten years of clinical work layered onto her PT training. The process starts with pelvic and rib cage position, then muscle length-tension relationships (longer isn't automatically better; overly lengthened muscles can present as functionally weak), then the pressure system as a whole, then compensation patterns, then retraining through what she calls neuroplasticity — essentially teaching the nervous system a new default pattern.
Internal assessments, when indicated, aren't performed on day one. Comfort and trust come first. When appropriate, they help pinpoint exactly which muscles are overactive versus underactive, but they're a tool for efficiency, not a requirement.
How long it actually takes
Objective, measurable improvements typically show up on day one. Meaningful symptom relief — actual reduction in leaking, pain, or discomfort — usually appears within four to five visits. Full resolution, the point where the nervous system has genuinely adopted the new pattern and the problem isn't likely to return, tends to land around 14 to 15 visits.
The exercises themselves are minimal by design — typically two, sometimes three, built directly into the gait cycle so that walking itself becomes the therapy. Ten minutes a day, twice daily, structured around a patient's actual routine rather than demanding they carve out separate time. When patients struggle to fit it in, Kelly builds the exercise around something they already do — brushing their teeth, for instance — rather than adding another item to an already full day.
Pregnancy and postpartum: start earlier than you think
Kelly's pregnancy program addresses common symptoms — pubic symphysis dysfunction, round ligament pain, back pain — but the real value is preventive. Labor and delivery strategies focus on teaching the pelvic floor to relax, not strengthen, since the uterus, diaphragm, and abs do the actual work of pushing. A pelvic floor that's tense during delivery doesn't help the process; it works against it, and often contributes to tearing.
Kelly has treated women through multiple pregnancies who report their fourth delivery — the one where they'd finally started pelvic floor PT — was markedly easier and the postpartum recovery notably faster than the first three.
Dry needling, explained
Dry needling uses very thin acupuncture-style needles inserted directly into a muscle knot or trigger point — no injection involved. A trigger point is essentially a portion of muscle stuck in contraction, cut off from adequate blood flow, allowing pain-causing chemical byproducts to accumulate. The needle stimulates blood flow to the area, prompting the muscle to release. It's fast and often dramatically effective for the specific knot — though if the underlying imbalance that created it isn't addressed, the knot can return.
Kelly's own story
Kelly's path into pelvic floor specialization started with her own unexplained pain — a middle-of-the-night episode severe enough to send her crawling to the bathroom, followed by a clear pelvic ultrasound and a tentative diagnosis of a ruptured ovarian cyst that kept recurring. Her own research led her to pelvic venous congestion syndrome — blood pooling because an overactive pelvic floor was restricting venous return — something she had never encountered in her physical therapy training, despite already being a licensed PT. Facing a high insurance deductible and $450-per-visit specialist costs, she pursued the certification herself, resolved her own condition in roughly three months, and built a specialty around what she'd had to learn from scratch.
What Kelly wants people to remember
The pelvic floor is only as strong as the system surrounding it. Treating it in isolation — the Kegels-only approach most people default to — misses the actual mechanism most of the time, and can make overactive cases worse rather than better. The earlier someone seeks care, the less compensation and structural change has had time to set in — but Kelly is clear that it's never too late to start, even for patients in their 50s and 60s who've lived with symptoms for decades.
Vitals & Values is the podcast of Concierge Medicine of West Michigan, hosted by Dr. David Roden and Dr. Lara Baatenburg. New episodes available wherever you listen.
