Corrective Strategies For Anterior Tilt (Part 2)
Inhibit
To inhibit the overactive muscles, I like to perform a manual psoas release. I like to do this either with Active Release Technique or manually. When performing manually, I have the patient supine with their hip and knees flexed to relax the abdomen. I like to use a closed fist and reach the psoas from the anterior, pushing through the abdomen while the patient exhales. This can take several passes to actually reach the psoas. I then have the patient lightly flex their hip to insure that I am in the right position. I will then have the patient slowly extend their hip, while internally and externally rotating their hip. While keeping constant pressure, I instruct the patient to relax and breathe slowly through the abdomen. I always do this to patient tolerance, and realize that on some patients and some body types, this may not be an appropriate technique. If it is too uncomfortable, I will simply pass this technique.
Next I will use a foam roller, or lacrosse ball to work on the hip flexor complex, quadriceps and the TFL. When rolling, slowly work until they find a “hot spot” and hold that spot for 20-30 seconds. Don’t just roll up and down, this is a misconception about the way to use a foam roller. After about 20 seconds of constant pressure over the “hot spot,” have the patient roll side-to-side over the “hot spot” to attack the spot from all angles.
Mobilize
In this portion, we will try to gain motion in joints that could be restricted. As a chiropractor, I liked to use adjustments to help gain mobility in joints. Joint mobilizations are a great way to increase overall mobility. I also will use Instrument Assisted Soft Tissue Mobilization (IASTM) during this phase. I personally like to use the Functional and Kinetic Treatment with Rehab (FAKTR) technique. I’ve found it be extremely effective in “resetting” any troubled areas. Work from lumbar region, as well as anterior going down into the quads. After this, any of the inhibited muscles from earlier should be stretched. I like to follow any adjustments with a true hip flexor stretch, really focusing on proper pelvic alignment while stretching the hip flexor.
I like to over stretch this position with a jump stretch band, to incorporate the joint capsule as well. When doing this, cue the patient to rotate the pelvis back, “take your fly to the ceiling” and to maintain a neutral lordosis in the lumbar spine. Squeeze your glutes on the same side. Often, we want to overly extend our back to get a better stretch, but if you tilt your pelvis back, squeeze your glute, and use a resistance band you will definitely feel the stretch without losing good positioning. Also, check for restrictions in the upper extremity in the latissimus, which could cause issues as well.
Use your hands to “cue” the curve, keep your chest down, activate your glutes, and maintain a posterior pelvic tilt.
To isolate the rectus femoris more, bend your knee and position it on a bench or box. I like to place my hand in the lordotic curve of my back. This gives me a greater awareness of what the curve feels like, if I don’t have coaching or a mirror.
Align
Here we are making sure that the athlete knows exactly what pelvic position they are supposed to have. Have them perform a cat camel, focusing on the pelvis. Have them rotate their hips all the way anteriorly, as far as they can. Then rotate their hips posteriorly as far as they can. Then find a position somewhere in between. You can also do this lying on your back. Cue this positon over and over, and have the patient find this position again. Finally, have the patient stand and find the position. They can use their hands to find their ASIS and PSIS as another cue.
Posterior Tilt
Neutral
Activate
Focus on both glute and core activation. As I mentioned earlier, you can cater this based on your assessment, but typically I have found both components are involved. If someone has more of an upper torso weakness (ribs flair when raising overhead by the wall) then you can focus more on abdominal work. If you notice a huge deficit in hip flexor tightness, odds are their glutes will be inhibited.
For glute activation, I love to use looped bands. The SlingShot Hip Circle is a great device providing both comfort and a good amount of resistance. This may be too much for some people though, as we are looking to activate the glutes, and aren’t looking to fatigue them. I like to perform 7-8 reps per exercise to activate the glutes. Form is essential when performing these exercises. Don’t arch your back or twist. Work within a comfortable range of motion and perform the exercises perfectly, at a nice even tempo. There are a ton of different glute activation exercises that are available, and as long as you’re trying to accomplish a common goal, any of the exercises will work. Coach the patient with active cues, tapping their glutes and telling them to fire them. You can also use RockTape to increase proprioceptive awareness.
Some exercises I like to do are:
Banded Clamshells (Side-lying, band at knee level)
Banded Glute Bridge (Progress to single leg)
Hip Abduction with the foot internally rotated
Prone Hip Extension while abducting against banded resistance at the ankle
Donkey Kicks
Fire Hydrants
Over time, these should be strengthened as well. For this, I like to use Monster Walks, side steps, and build on the series of activation. Monster walks and side stepping with the band are great exercises. Also, once you have progressed, deadlifts can be great exercises to strengthen the posterior.
For core activation, cuing is vital. Have the athlete pretend like they are pressing out against a band over their entire stomach, not just flexing their abs. Again, if the athlete is not using diaphragmatic breathing, you need to correct this first. It is extremely important to take your time with these. Make sure that you maintain good form throughout the exercises and focus on firing the core throughout. I like to perform stability exercises that don’t involve lumbar flexion and extension, as I try to limit as much of those as I can. Also, functionally, we perform the majority of our core strength in the upright position. Very rarely do you perform a sport or movement in a flexed or extended position. I like to perform basic core exercises: McGill crunches(lumbar maintains lordosis), planks, honey-pots, anti-extension, anti-rotation
Plank/Honey Pot exercises
Anti-extension
Anti-Extention
Anti Rotation
Stabilization
During this phase, I try to disassociate movement of the extremity with the trunk. We want our core to have the ability to maintain good positioning throughout any movement, and this is a great way to learn that. I will start off in a bird-dog position, and have the patient maintain neutral spine while moving through the motion. Once this has been mastered, I will perform perturbation movements on their limbs, while they maintain a neutral position. When done correctly, there should be fluid motion amongst the limbs with no to minimal movement of the pelvis and trunk. A common compensation seen with APT is a rolling of the pelvis when trying to extend the hip. Also, I like to flip the patient over and perform dead bug exercises using the same techniques.
DeadBugs
Bird Dog Upper Extremity Progression
Bird Dog Lower Extremity Progression
Integration
In this phase, we integrate everything we have been working on into movements. In this phase, we perform the basic movements that you are going to perform in the workout, for instance, the deadlift and squat. Start off on the floor with your pelvis in a neutral position and your feet against the wall. Drive into the wall, while abducting your feet (don’t actually move your feet, but pretend like you’re trying to rip a crack in the wall) and lift your back off the floor while maintaining a neutral spine.
I put my hand under my lumbar spine to “cue” the curve.
Maintain the same lordosis through the movement
Focus on keeping perfect pelvic positioning throughout the movement. I also like to use a mirror or video. Finally, a PVC pipe or dow rod down the center of the spine can be a great way to raise the patient’s awareness of their body. RockTape can also be a good internal cue. Have the patient find pelvic neutral, and then perform the movement using a hip hing
When working on the deadlift, I like to start with a kettlebell.
Sometimes, I will also use a banded pull through, if the patient is having difficulty reaching for the hinge. Have the patient perform the movement, using a hip hinge, and keeping a neutral back. Cue any changes needed. The force also pulls at a different angle, forcing you to really focus on keeping a posterior tilt.
I then like to progress to a trap bar. This is beneficial because it keeps the weight more centralized over the lifter, causing less shearing in the lumbar spine.
Finally, progress to a barbell. This is a great way to strengthen the movement we have learned.
When working with a squat, I like to start with assistance, using a band suspended overhead (usually on top of the rack or pullup bar). Have the patient slowly lower their body, again emphasizing perfect positioning. Once this has been achieved, move to body weight. Finally, progress to the barbell.
Special thanks to Cole Streets and Matt DiLallo for sharing so much knowledge with me and allowing me to share it with others.
Special thanks to Cole Streets for helping me take all of the photos.
Special thanks to Richard Pinelli and Elite Strength and Performance in Daytona for allowing me to take pictures in their facility.
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
office number is 864-881-2242.
