I’ve written about excessive hip extension and hip issues quite a bit:
- Looking at pelvic tilts – The hips only tell you part of the story (an anterior pelvic tilt doesn’t mean your hips are flexed)
- My visit to the Washington University in St. Louis
- Correcting a swayback posture by…changing how you sleep?
- Relieving hip pain while walking
- You shouldn’t stretch your hip flexors if you have hip pain
Along with others.
It’s just so common you see people, especially those with hip issues, stand with their hips in extension.
One of the first priorities here is getting the person’s hips out of extension / into some flexion. Suffice to say, telling the person to “Flex your hips” doesn’t get the job done. For most people this doesn’t mean anything. In some of my comment replies I’ve referenced how cueing is an art in itself. Certain cues work for certain people. I’ve primarily referenced this when it comes to how a person processes information. When it comes to getting a person’s hips out of extension though, there’s more to it. How they stand dictates how you cue.
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Cues to get back into flexion
I typically use one of three cues:
- “Push your butt back”
- “Bend your knees a little”
- “Lean your whole body back”
Let’s look at three different people all standing in hip extension:
The idea here is to look at one big principle, “Are their knees behind their hips? / Are their hips in front of their knees?” If so, their hips are probably in extension.
Next, you try to figure out why are their knees behind their hips? Are their hips getting pushed forward, such as in something like a swayback posture? Are their knees getting pushed backwards, such as in hyperextended knees? Or perhaps their entire body is leaning forward.
In order, swayback, knees hyperextended, leaning forward:
You can see how different cues will work for different people. There’s no point in telling this person to lean their whole body back,
a great deal of their body is already perfectly upright:
Nor is there any point in telling this person to bend their knees a little,
as their knees aren’t hyperextended:
You could tell this person to stick their butt out more, but the rest of their upper body will still be tilting forward:
Of course, I picked specific postures to make this simpler. You could very well get someone who has more of a swayback and hyperextended knees at the same time. For someone like that they may need multiple cues. However, the less cues a person can get away with, the better.
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Justin Archer (@ThePostureGuy)
December 9, 2013
I’ve also found that having someone with one or more of the three postural deviations you mentioned above stand with their feet pigeon toed and thighs tight will usually cause their body to be pulled back into alignment and their dynamic tension be restored. Granted the leaning forward posture type might require more spinal erector engagement higher up in the thoracic spine. In with case I’ll have them interlock their hands behind their head and pull their elbows back. Granted people can’t go walking around like this all day, well maybe in L.A., but along with the guidance of a wall (not necessary, but nice when you have one around to use) it’s a great reminder of what it feels like to have all your load bearing joint stacked vertically over one another. Plus it acts as a kind of posture pick me up if you hold the position for 2-3 min at various times throughout the day.
Den
January 31, 2014
Very interesting, I have definitely had some issue around 3).
Justin – great tip, it works for me. But not sure if that stance would bring n other issues? Simply standing with feet closer together works too.
Todd
February 25, 2014
Reading this post, I am curious whether you considered that the hip extension is the effect of postural issues further down the chain. Could the issue begin at the feet? All four people pictured seem to be leaning forward beginning even lower than the knee suggesting that the problem starts at the angle of the ankle. What do you think?
reddyb
February 26, 2014
Hey Todd,
When the hips are in extension the feet are usually in plantarflexion, or vice versa.
However, I’ve never experimented with trying to get the person to dorsiflex their feet in order to correct issues higher up. The cues I go over in this post will help dorsiflex the feet. “Unlock your knees” for example, will bend the knees slightly, helping to alleviate the excessive plantar flexion. But, doing something like telling the person to “Push your tibia forward” I don’t imagine working well. Perhaps you had a different cue in mind?
Lastly, as shown in the female whose entire body is leaning forward, their ankles are actually in dorsiflexion. Getting them to plantarflex their feet more could still cause them to keep their hips in extension. That is, their feet alignment may change but their hip may not.
When it comes to something like this I suppose I’m not so concerned with what area is causing the issue as I am with what most effectively corrects the issue.
Todd
February 27, 2014
Thanks for your response. I guess I was trying to start a discussion and try to get your opinion on what you think is the ultimate cause of the forward posture, which seems to be so common among people with musculoskeletal issues. Why do some people stand and walk straight and others have a forward posture? I like your site because you are working on trying to help people with this issue and seem to enjoy discussing it and learning about it.
As someone who has developed a forward posture over what seems to have been many years and many musculoskeletal issues throughout my body as a result, I don’t feel like it was a conscious decision on my part and so doesn’t seem likely to be fixed by consciously trying to reposition my hips, especially when walking, which is an activity where external forces seem to override any conscious directions. I guess I wonder whether there’s more of a structural issue occurring and a likely place to look seems to be the feet, especially considering that the feet are our only contact with the ground when standing and walking. Are modern shoe wearing feet not clearly different from non-modern non shoe wearing feet? Could this be having an impact throughout the musculoskeletal chain? One can find many before and after pictures on the web of people who have changed their posture but a common denominator is that they all seem to have misaligned toes, fallen arches and so pronating ankles. And so I wonder whether these corrective measures will have lasting effects unless they deal with this structural foot issue. Have you noticed this among your clients? All three above seem to have these issues.
By the way, which one of these pictures demonstrates plantar flexion while standing? Isn’t plantar flexion when the ankle has a greater than 90 degree angle?
reddyb
February 28, 2014
Hey Todd,
I’m not exactly sure what you mean by “forward posture.” Do you mean someone whose entire body is leaning forward? Like the female pictured in this post? The other bodies aren’t fully leaning forward. Only their hips are, in some way, forward.
The ultimate cause of any posture is your body is a reflection of what you most often do with it. If your entire body is leaning forward, then you are leaning your entire body forward a good amount each day. One example of this is tall people. Due to their height, they are constantly looking down at things. Whether it’s the floor or talking to other people. So, at rest, they tend to be leaning forward because this is what they often do. You get what you train. There’s no one reason though. Someone who isn’t tall may still present with the same posture for completely different reasons. Maybe they have a job necessitating leaning forward a lot.
You can imagine this isn’t necessarily a conscious decision. It’s just what the person does to help them interact with their environment. To correct things, that needs to be a conscious process. Just like any habit, it takes time to correct.
I talk at length about footwear and it’s impact on hip positioning in this post: http://b-reddy.org/2013/06/13/relieving-hip-pain-while-walking/
Everyone above but the woman have plantarflexed feet. You can read more about that in this post: http://b-reddy.org/2012/11/26/my-favorite-mobility-corrective-exercise-the-toddler-squat/
Most foot issues are not structural, they are acquired. In some cases, the structure of the foot can be changed, maybe permanently, unless there’s surgical intervention. Extreme cases of hallux valgus are an example. Think women who wear really narrow heels for decades.
There’s no one answer as to whether the feet are the cause or the hips are the cause. One can have an impact on the other. Like I said, I don’t go out of my way to pinpoint one thing to work on. If the feet and hips are both moving funky, I correct both of them. There’s too much interplay between them to ignore one. You can read more about the interaction between the feet and hips in this post: http://b-reddy.org/2013/02/01/can-foot-pain-and-hip-pain-be-related/
Jill
March 17, 2016
Hi! It was amazing to find this post. I literally have the same posture as the woman in picture A. My question is how to fix the posture– because she (and I) have excessive hip extension, is it best to strengthen the hip flexors, such as the iliopsoas, and plantarflexors–the gastroc and soleus, to “even out” the posture? Thank you!!
reddyb
March 18, 2016
I detail which cue I would use to get of the posture. Why strengthen muscles when standing differently would be sufficient?
Judy
May 19, 2016
January 2014 suffered unreal groin pain following many trips to my basement putting away seasonal decor….Mri revealed tendon “tears”in gluteus minimus, medius and at the insertion of the greater trochanter &herniated discs L1-5 (L5S1 known since 2010)
Rest,drugs, PT for months,injections…..remain in serious pain and a limited life
H E L P.
reddyb
May 20, 2016
Hey Judy,
Would take a look at this: https://b-reddy.org/2013/06/20/the-remote-client-process/
Jonny Wang
April 30, 2020
for example of where pelvic tilt is in correct position but knees and hips are hyperextended is this structual issue and we cant correct hyperextension problems?
b-reddy
May 1, 2020
Hey Jonny,
If someone is having issues with just the hips / knees being into hyperextension, I simply cue them “bend your knees a little.”
Nothing structural is going to prevent them from getting out of that hyperextension.
Jonny Wang
May 1, 2020
am still curious if person has structural pelvic problem like his Asis is way lower then Psis but spine has normal curve wont it influence on other joints or compensate something bent knees which can be determined as structural stance ? or its just problem at knees not from Asis? Thanks for response
b-reddy
May 3, 2020
If you’re asking can one person’s neutral knee position possibly be a bit more bent or extended than someone else’s, then sure. But you’re probably going to have to take out a goniometer to spot that most of the time. (Not worth it in my opinion.)
This just doesn’t really happen much with the joint you’re referencing- the knee. You don’t get much variability in how much (healthy) people can bend or straighten their knees. (I’m not saying you can’t find some outlier out there. Or, if you work with say, cerebral palsy patients.) You might get one person who can hyperextend 5 degrees while another can hit 10 degrees. It’s not like there’s a lot of people out there able to hyperextend their knee 50 degrees. Same thing with flexion.
The same thing is true of the spine, though there can be extreme examples that are easier to find. That is, you don’t get, in everyday, healthy, people, some enormous variability in how much they can flex or extend their back. You can find gymnasts who have extreme ability, but that extremeness is usually present in flexion AND extension. So it doesn’t impact their neutral in the manner you’re thinking about.
In your example, if you got someone with an usual discrepancy in their spine or hip resting position, because their spine or hips had an unusual difference in how much they could flex vs extend or vice versa, then yes, that could impact their resting knee position.
(I talk about this in a less dramatic fashion here: https://b-reddy.org/can-foot-pain-and-hip-pain-be-related/)
Whether you would want to change that or not is something you’d have to address for the person’s specific situation. For instance, a person with scoliosis has a different spinal resting position. While we usually leave it alone in that position, we don’t always.
In contrast, you can get enormous variability in how much people can rotate their hips. See: anteversion and retroversion, which then clearly can impact someone’s resting position. Frankly, even these aren’t super common. It’s even less common that you’ll see it to where it dramatically impacts someone’s resting position. (Of course, if you’re a physical therapist specializing in the hip, then you might see it much more regularly.)