Anterior Pelvic Tilt

Anterior Pelvic Tilt (APT) is the tilting of the pelvis in the forward direction more than normal. This gives the affected person a protruded-glutes look
similar to Donald duck. Other visual cues include an increased lower back curvature (lordosis) and sticking out abdomen even if you don’t have a fat gut. Further investigation of the muscular system may also reveal tight hip flexors, gluteal dysfunction or weaker abdominal muscles.

APT is NOT abnormal. In fact it’s a common adaptation in track athletes especially sprinters (Kritz et al.). Females are more prone to APT than males. It is normal for healthy individuals to possess a certain degree of pelvic tilt as established by certain studies (Youdas et al.; Christie et al.; Day et al.; Herrington L). Sedentary lifestyle, poor posture, and inefficient movement patterns are the possible causes. You shouldn’t be too much concerned with the pelvic posture if it’s not excessively tilted or is asymptomatic.

Lower Back And APT

There has been a number of studies to examine the link between low back pain and excessive lumbar curvature (Murrie et al.; Schroeder et al.; Nakipoğlu et al.; Ashraf et al.; Nourbakhsh & Arab; Youdas et al.; Tüzün et al.; Mitchell et al.; Christensen & Hartvigsen; Laird et al.). NO significant relation has been found between the both, which tells that there’s a lot more to back pain than the simple postural imperfections.

However, too much APT results in excessive lumbar hyperextension (Levine et al; Day et al.). This combined with external resistance poses significant risks for the spinal health (Roussoully et al; Alexander). Further compensation patterns can lead to knee pain and other back injuries & musculoskeletal problems leading to further exacerbation of APT. This is a downwards spiral.

Tilted Trouble

Prolonged sitting and poor posture lead to stiff hip flexors, glute amnesia, and low back pain over time. The characteristics of hyperlordosis/APT are lengthened hamstrings & weak glutes, abs/obliques; and stiff hip flexors & spinal erectors (lower back muscles).

This typical pattern is due to a neuro-physiological process called reciprocal inhibition. In this process muscles on one side of a joint relax to accommodate contraction on the other side of that joint. Joints are controlled by two opposing sets of muscles, extensors, and flexors, which must work in synchrony for smooth movement. When a muscle spindle is stretched and the stretch reflex is activated, the opposing muscle group must be inhibited to prevent it from working against the resulting contraction of the homonymous muscle. This inhibition is accomplished by the actions of an inhibitory interneuron in the spinal cord (Wikipedia).

When you’re not in a position to utilize your glute muscles fully due to overly tight hip flexors and lower back along with unsupportive abs; you can’t progress sufficiently on squatting and pulling patterns. So to sort out this issue you need to perform mobility work on the tight & constricted muscles and strengthening work on the weak muscles.

Leveling The Tilt

Strengthening the abs and glutes with individual exercises have shown a significant effect in correcting the APT (Yoo WG). Even though it’s been shown that those with APT do not have weaker abs (Walker et al.) and the range of motion for hip extension is not shortened (Heino et al.), it doesn’t mean that they don’t need to strengthen the abs or require more mobility in hips. In fact, these individuals require more strength and mobility to counter the restrictive misalignment.

Individuals suffering from excessive tilt require to employ following strategies to correct the problem:

  • SMR stretching, massage, and manual therapy have been shown to correct the anterior pelvic tilt angle both acutely and for <24 hours post-treatment (Cottingham et al; Cibulka et al.). You should use SMR and static stretching techniques to relieve the tightness of rectus femoris, adductors, psoas and erector spinae. Following drills are helpful:
    1. Foam Rolling
    2. Hip Flexor StretchHip Flexor Stretch with Reach
    3. Groin Stretch groin stretch
    4. Adductors stretch with forward reach

 

 

  • Strength training for rectus abdominus, external obliques, and the gluteal muscles.
    1. RKC Plank 
    2. Glute Bridge:

    Start with an easy variation focusing on squeezing the glutes hard without hyper-extending lower back. As you get a better control of the movement, progress to single legged or weighted variations.

    3. Hollow Body Hold:

    Start with the 1. position and slowly progress towards 5. till you get a full control over it. There shouldn’t be any gap between your lower back and ground at any time during the hold.

4. Cable Pull-throughs

 

 

  • Better your daily posture by improving awareness of the tilted position and ingrain the correct neutral hip position by practicing repeatedly throughout the day.

Don’t sit or stand continuously for extended periods, keep switching your stance.

Don’t sleep on your stomach.

Don’t hyper-extend or sit back excessively while doing Squats, Deadlifts or Rows. Mind your pelvic posture and use right cues with the help of your coach.

References
  • Alexander MJ. Biomechanical aspects of lumbar spine injuries in athletes: a review. Can J Appl Sport Sci. 1985 Mar;10(1):1-20.
  • Ashraf A, Farahangiz S, Pakniat Jahromi B, Setayeshpour N, Naseri M, Nasseri A. Correlation between Radiologic Sign of Lumbar Lordosis and Functional Status in Patients with Chronic Mechanical Low Back Pain. Asian Spine J. 2014 Oct;8(5):565-70.
  • Christensen ST, Hartvigsen J. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):690-714.
  • Christie, H. J., Kumar, S., & Warren, S. A. (1995). Postural aberrations in low back pain. Archives of physical medicine and rehabilitation, 76(3), 218-224.
  • Cibulka, M. T., Delitto, A., & Koldehoff, R. M. (1988). Changes in Innominate Tilt After Manipulation of the Sacroiliac Joint in Patients with Low Back Pain An Experimental Study. Physical Therapy, 68(9), 1359-1363.
  • Cottingham, J. T., Porges, S. W., & Richmond, K. (1988). Shifts in pelvic inclination angle and parasympathetic tone produced by Rolfing soft tissue manipulation. Physical therapy, 68(9), 1364-1370.
  • Day, J. W., Smidt, G. L., & Lehmann, T. (1984). Effect of pelvic tilt on standing posture. Physical Therapy, 64(4), 510-516.
  • Heino, J. G., Godges, J. J., & Carter, C. L. (1990). Relationship between hip extension range of motion and postural alignment. Journal of Orthopaedic & Sports Physical Therapy, 12(6), 243-247.
  • Herrington, L. (2011). Assessment of the degree of pelvic tilt within a normal asymptomatic population. Manual therapy, 16(6), 646-648.
  • Kritz, M. F., & Cronin, J. (2008). Static posture assessment screen of athletes: Benefits and considerations. Strength & Conditioning Journal, 30(5), 18-27.
  • Laird RA, Gilbert J, Kent P, Keating JL. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014 Jul 10;15:229.
  • Levine, D., & Whittle, M. W. (1996). The effects of pelvic movement on lumbar lordosis in the standing position. Journal of Orthopaedic & Sports Physical Therapy, 24(3), 130-135.
  • Mitchell T, O’Sullivan PB, Burnett AF, Straker L, Smith A. Regional differences in lumbar spinal posture and the influence of low back pain. BMC Musculoskelet Disord. 2008 Nov 18;9:152.
  • Nakipoğlu GF; Karagöz A; Ozgirgin N. The biomechanics of the lumbosacral region in acute and chronic low back pain patients. Pain Physician. 2008 Jul-Aug;11(4):505-11.
  • Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther. 2002 Sep;32(9):447-60.
  • Roussouly P, Pinheiro-Franco JL. Biomechanical analysis of the spino-pelvic organization and adaptation in pathology. Eur Spine J. 2011 Sep;20 Suppl 5:609-18.
  • Schroeder J; Schaar H; Mattes K. Spinal alignment in low back pain patients and age-related side effects: a multivariate cross-sectional analysis of video rasterstereography back shape reconstruction data. Eur Spine J. 2013 Sep;22(9):1979-85.
  • Tüzün C1, Yorulmaz I, Cindaş A, Vatan S. Low back pain and posture. Clin Rheumatol. 1999;18(4):308-12.
  • Walker, M. L., Rothstein, J. M., Finucane, S. D., & Lamb, R. L. (1987). Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance. Physical Therapy, 67(4), 512-516.
  • Yoo WG. Effect of Individual Strengthening Exercises for Anterior Pelvic Tilt Muscles on Back Pain, Pelvic Angle, and Lumbar ROMs of a LBP Patient with Flat Back. J Phys Ther Sci. 2013 Oct;25(10):1357-8.
  • Youdas, J. W., Garrett, T. R., Egan, K. S., & Therneau, T. M. (2000). Lumbar lordosis and pelvic inclination in adults with chronic low back pain. Physical Therapy, 80(3), 261-275.
  • Youdas, J. W., Garrett, T. R., Harmsen, S., Suman, V. J., & Carey, J. R. (1996). Lumbar lordosis and pelvic inclination of asymptomatic adults. Physical therapy, 76(10), 1066-1081.

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