Corrective Strategies For Anterior Tilt (Part 1)
What is an Anterior Pelvic Tilt?
An anterior pelvic tilt (APT) is a commonly seen postural distortion in today’s society. Put simply, this is when the front portion of your pelvis is rotated anteriorly. To easily assess this, you can look at the level of your Anterior Superior Iliac Spine (ASIS) and your Posterior Superior Iliac Spine (PSIS) and see if there is a forward angle between the two.
It has been hypothesized that a primary reason for the increase in APT is prolonged sitting. People spend so much time sitting, whether it is at work on a computer or at home in a chair, our body adapts to this positioning. Because the hip flexors are placed into shortened positions for prolonged periods of time, our nervous system creates the illusion that this pattern is required and creates a bad “habit” within itself. This creates a muscle imbalance between the interaction of the muscles and what we typically use them functionally for. I use this terminology because historically we have called the muscles “shortened” although we know now that the muscles are not truly shortened in fiber length, but are overactive and overstimulated by our nervous system. According to Janda, the typical imbalance we see as a result of this, also known as lower crossed syndrome, includes overactivity of the hip flexors and erector spinae, and underactivity of the gluteal muscles and anterior core. Broken down easily this is:
Image Source – http://i.imgur.com/rsUha.jpg
Overactive:
Hip Flexor Complex
Erector Spinae
Underactive:
Gluteals
Abdominal
Why does this matter in Crossfit?
Image source – http://i.imgur.com/M0rqU.png
Simply put, when you have a structural different, it affects all of the biomechanics of movements. When you have an anterior pelvic tilt, you increase the lordosis in your lower back. This can change the way forces move up and down your spine, and have the potential to increase risk of injury in your lumbar spine. Further, your posterior chain in your thigh is placed on a greater stretch, and you can get the sensation of chronically “tight” hamstrings. You can stretch and stretch, but until you change the angle of your pelvis, the “tightness” will remain. Two basic lifts that are affected by an APT are the squat and deadlift. As we squat, we want to essentially maintain a neutral lumbar spine throughout the movement. As you lower your body, you press your knees out to clear room for your torso. Your pelvis most rotate anteriorly to clear room for the end range of movement. When you have an APT, you already start the motion with your pelvic angled forward. This increases the angle of lordosis from the beginning of the movement. As you lower your body, you pelvis simply doesn’t have room clear the movement. To make the room required, you must either rotate your pelvis posteriorly and go into a “butt wink” or increase the lordosis in your lumbar spine. This can also cause that “pinching” feeling on the deep end of the squat. A recent study that was just published also found that in patients with anterior pelvic tilt, there is a predisposition to externally rotate the femurs.¹ This causes a reduction in internal rotation, and can lead to a greater risk of feeling impingement on the squat. We want to avoid both of these to reduce the risk of injury. Also we worry about an APT when deadlifting. As I mentioned earlier, an APT can tighten the posterior chain, and put the chain at higher risk when performing traditional deadlifts, such as RDLS. With the increase in lordosis, you also can set yourself up for excessive shearing in your lumbar spine. This can be a common cause of low back pain. The angular changes also can lead to losses in strength, placing the muscles in both movements in inopportune positions. A study conducted in 2014 compared the pelvic and lordotic angles of athletes in the 2012 Olympic village in London. 21 elite weight lifters were compared to 45 healthy volunteers. The study found the elite lifters had decreased pelvic tilt angles in comparison to the volunteers and increased lumbar lordosis.⁴
How do we fix this?
First, with any postural condition, I tell of my patients that this is something that took time to develop, and can take time to fix. Although sometimes you can see a quick fix, more than likely this will take time and repetition to correct. To correctly correct, you must obviously first perform an assessment to find out exactly what is going on. You can perform a variety of movement screens, muscle tests, and examinations to assess, and I will leave that up to the practitioner performing the examination to decide exactly what they want to use. I always like to first assess breathing, to ensure that the patient is using diaphragmatic breathing and breathing fully into their abdomen, and not compensating with the upper torso. If they are not breathing properly, odds are their core won’t be activating in the proper sequence either. Next, I’ll look at the flexibility of the hip flexors. I like to do this using the modified Thomas test. If positive, you can see if the lower extremities contribute to the APT, which is most likely.
Image source – http://www.blogcdn.com/www.thatsfit.com/media/2010/06/thomas-test-tight-hip-flexor240wy060110-1275415846.jpg
I also like placing the athlete against a wall, and have them place their arms into full flexion, and see if their ribs flare. This can lead you to an issue in the upper extremity.
I like to use the following sequence to fix this issue:
Inhibit
Mobilize
Align
Activate
Strengthen
Stabilize
Integrate
Please stay tuned for part 2, in which we will go over each of the previous steps in depth with different exercises for each!
References:
1. Ross, J. R., Nepple, J. J., Philippon, M. J., Kelly, B. T., Larson, C. M., & Bedi, A. (2014). Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. The American journal of sports medicine, 42(10), 2402-2409.
2. 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.
3. Choi, S. A., Cynn, H. S., Yi, C. H., Kwon, O. Y., Yoon, T. L., Choi, W. J., & Lee, J. H. (2014). Isometric hip abduction using a Thera-Band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology.
4. Yang, J. H., Barani, R., Bhandarkar, A. W., Suh, S. W., Hong, J. Y., & Modi, H. N. (2014). Changes in the spinopelvic parameters of elite weight lifters.Clinical Journal of Sport Medicine, 24(4), 343-350.
Dr. Michael Nelson, D.C., MHRD, ATC, CES
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