I’m going to cover some oversights when assessing pelvic alignments.
The most common condition people seem concerned with is an anterior pelvic tilt.
Because the hips are rotated anteriorly and the hamstrings pull the pelvis posteriorly, it’s common to assume the hamstrings are “weak / lengthened” in an anterior pelvic tilt. However, the hamstrings play a role in what happens at the hips and the knees.
If we only look at the hips we’re missing half the picture.
A person who appears to have some anterior pelvic tilt:
May also appear to have some knee flexion going on:
The hamstrings may appear lengthened at the hip attachment, but they are, if anything, shortened at the knee connection. Think of a rubber band, if you pull the rubber band out from one end but bring it in from the other, what happens to it? Nothing. It doesn’t get stretched.
Because muscles aren’t exactly like rubber bands, from the above photos we could deduce: The hamstrings are perhaps underactive in hip extension but overactive in knee flexion. Helping to understand why, “Strengthen the hamstrings” isn’t a solution for an anterior pelvic tilt. Or, contrary to the internet world, why “Just deadlift” does not solve everything. This is the type of person who should probably stop deadlifting for a while. (It promotes lumbar extension / anterior pelvic tilting and knee flexion.)
We need to look at the knees in a posteriorly tilted hip as well. Even though the hamstrings are tightened at the hip attachment, they may be lengthened at the knee attachment. The knees may be in hyperextension:
So again, our rubber band is being pulled from one direction but getting slacked from the other.
What the hell is going on here?
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It’s all relative
When faced with these types of situations we’re forced to asked things such as the following:
- Is the amount of anterior pelvic tilt greater than the amount of knee flexion?
For instance (numbers are for example purposes), if the pelvis rotates anteriorly 5 inches (lengthening the hamstrings 5 inches), but, the knees flex 8 inches (tightening the hamstrings 8 inches), then overall, the hamstrings have been tightened 3 inches (8 – 5 = 3).
- Is the amount of posterior pelvic tilt greater than the amount of knee extension?
For instance, if there’s a posterior pelvic tilt of 5 inches, then the hamstrings are tightened 5 inches. If there’s a simultaneous 2 inches of knee extension, lengthening the hamstrings 2 inches, then they have been, overall, tightened 3 inches (5 – 2 = 3).
Another example. Apparent anterior pelvic tilt with significant hip extension going on:
Even though the presence of an anterior pelvic tilt causes one to assume the hips are automatically in flexion, you can see quite a bit of hip extension going on:
And what extends the hips? The hamstrings. If the hips are in extension the hamstrings may actually be shortened, as well as the glutes, even with an anterior pelvic tilt going on. An APT is not a clear indication the hips are flexed.
The above is a perfect example of someone who reads the internet, deduces they have an anterior pelvic tilt, then goes off and stretches the hell out of their hip flexors, not realizing their hips are already in extension plenty. Where actually, the last thing they need is more hip extension.
Their psoas is not shortened.
The psoas pulls the lower back and femur closer together. While the lower back has been pulled down,
The femur has been pulled back. The rubber band has not been brought closer together. If anything, it has been pulled apart (stretched).
All that hip flexor stretching may not only be not helping, it very well could be making things worse.
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The hamstrings are rarely “weak” in hip extension
Hopefully, now you can see often when the hamstrings appear lengthened they may actually be shortened. Bringing me to my final point: Strengthening the hell out of the hamstrings rarely does anything to help correct issues like the above, especially strengthening them into extension. If anything, the hamstrings are normally too active in hip extension, with the glutes not being active enough. Often it’s actually knee flexion the hamstrings could use more work in.
Get someone to perform knee flexion without their lower back moving and they’ll often struggle like this:
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They’ll really want to move that lower back:
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For those where their knees are held in extension so much (pictures above) they have a rough time trying to flex them.
And it’s not always a strength issue with the glutes. You can see in the above photos some good gluteal definition. By definition, the size of a muscle is correlated to the strength of it. The above people are not necessarily those with atrophied or weak glutes. No, their problem, and many a people’s problem, is not the strength of the hip extensors, but the timing between them. Primarily where the glutes are not initiating hip extension. They’re firing too late. All those RDLs, deadlifts, and heavy squatting, they aren’t getting the job done.
As far as I know the best way to assess what’s going on in hip extension is not pelvic alignment, but to pay attention to the person’s symptoms and, finally, make them move. Pelvic alignment may help, but it’s not your only indicator.
To learn more about correcting an anterior pelvic tilt, I have a program called “8 Weeks Towards Correcting Your Anterior Pelvic Tilt.”
See more about that here, or
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Fred
July 27, 2013
Very interesting, thanks – so in this case, what would you recommend to correct the problem?
reddyb
July 29, 2013
Hey Fred,
Which case are you referencing?
Bane
August 4, 2013
Hi,
Very interesting observations. Does it means that in similar case (knees hyper extended with forward weight bearing) out gastroc might require treatment too? Are they being too weak and stretched?
Sincerely,
Bane
reddyb
August 5, 2013
Hey Bane,
I’m not sure what you mean by treatment, but yes, in that case the calves would be on stretch. Treatment could simply consist of not standing with such a forward leaning posture though. Footwear would likely need some attention too.
I’d say the swayback posture is probably more common. That is, the knees are in hyperextension but the feet are plantarflexed. Rather than dorsiflexed, like in the scenario you described.
The prevalence of shoes with heel lifts, which shorten the achilles tendon, makes it unlikely someone is going to have feet held excessively in dorsiflexion.
Joe
September 2, 2013
Nice article, but what would you recommend one do to rid themselves of the sway back (lordosis) ? Thanks
reddyb
September 3, 2013
There’s some thoughts here: http://b-reddy.org/2013/02/20/another-example-of-a-postural-evaluation/
Some common exercises I use:
Flattening the lower back: http://www.youtube.com/watch?v=iY3lmig5fKw
Waking up the psoas: http://www.youtube.com/watch?v=l_E3CbS3g_0
Lessening knee extension: http://www.youtube.com/watch?v=sQtwSLjwUjU
Generating hip and lower back flexion: http://www.youtube.com/watch?v=DSSGeymXUgw and http://www.youtube.com/watch?v=dc3V3f45nOI
More on toddler squat here: http://b-reddy.org/2012/11/26/my-favorite-mobility-corrective-exercise-the-toddler-squat/
A big theme is what does the person have too much / little of? Then, do the opposite. Too much knee extension? Give them more knee flexion. Too much lower back extension? Give them lower back flexion. Too little hip flexion? Give them more hip flexion.
Finally, don’t stand in a sway back posture. Just looking in a mirror and working on how you stand can be beneficial.
Martin C. Kviteberg
March 19, 2014
What stretches and exercises would you use to correct the posture the guy in the first pictures has?
reddyb
March 19, 2014
Hi Martin,
I already responded to your question here: http://b-reddy.org/2013/07/29/better-exercises-to-stretch-the-hamstrings/#comments
Gooner
January 3, 2015
I have an anterior pelvic shift for sure. Not really sure of what type the tilt it is or if even there is one. (Because, excessive, fat around that area which makes it tough to diagnose tilt) . I seem to have a Knee flexion (if that is what it is called) based on the illustrations you’ve shown above. One more hint is – if I decide to completely relax while standing, I am literally unable to as I am falling down on front side. I am not able to ‘STAND’ in a relaxed pose. Looks like I am putting a lot of pressure on the knee (maybe that’s why the knee pain) and\or swaying back my upper body to stay stable.
Hopefully I’ve given good enough details. Totally confused with what is the exact condition of mine, and from where do I start to fix things?
reddyb
January 5, 2015
Hey Gooner,
Sorry but I’d have to see you in some way to be of any help. As you said, it’s quite hard for someone to self-diagnose, which means it’s tough for me to give any comments based only on someone’s self-diagnosis.
Shannara90
March 13, 2015
I’ve seen two chiros, two different LMT’s and no one has been able to help me. The diagnosis is generally the same from everyone. Posterior tilt left hip, anterior right, with a hiked up right leg(functional short leg appearance).
I get EXTREME pain in my thoracic region, under the shoulder blades due to a ridiculously tight erector spinae. I have a hard time breathing without my cervical spine popping(sometimes painfully), 50ish so times a day(not exaggerating).
In general, everyone I see says I have a hardcore anterior tilt. Whenever I stretch my hip flexors, especially my left(in that hip lunge position). I get fire-like nerve pain running from the front hip fold, down my INNER/FRONT left thigh to my knee… Is there anyway I can send you an image to see if you can confirm that I am indeed in POSTERIOR tilt like this post is now leading me to believe?
And no Chiro has seen anything legitimately wrong with my spine physically(just keep getting vertebrae popping out of place). I’m only 22 and it’s ruining my life. Even work is becoming painful now.
reddyb
March 16, 2015
Hey Shannara,
You’re welcome to send a photo. If you want to talk some more, you’re welcome to take a look at this as well: http://b-reddy.org/2014/08/04/phone-video-consultations/
Shannara
March 16, 2015
Ok brother! I’ll email you a picture or two. I will actually look into a video consultation with you as well.
Is it still a dollar a minute?
Guessing you use either paypal or dwolla for payment?
Thank you for the reply btw! Very much appreciated brother.
reddyb
March 17, 2015
Yep, $1 / minute. I typically go with paypal.
You’re welcome.
Mike
December 20, 2015
I don’t understand this article, the causes of APT have been proven in literature. With APT the chances are it started off as one issue, perhaps shortened Hip Flexor muscles, however over time (for example chronic sitting, perhaps 8 hours a day), everything else has been brought into the equation. The cause of APT is conclusively: Short Psoas, Quads, Erector Spinae and Weak/lengthened/inhibited: Glutes, abdominals and Hamstrings. If you strengthen the muscles that are lengthened and weak, you allow the tight muscles to relax. The body is a kinetic chain, if you discover something is tight, 9/10 there will be something else that’s elongated/weak.
reddyb
December 22, 2015
Hey Mike,
-When someone sits, their pelvis is often in *posterior* tilt. Sitting does not guarantee anteriorly tilting the pelvis.
-I address the length statements in the post. The pelvis is not the only element of the hips.
-I will add “short quads” doesn’t make sense. The quadriceps are four muscles, and one of them is a two joint muscle. Saying all the quads are short in an anterior pelvic tilt is flawed as three of the quadriceps don’t connect to the pelvis. What the pelvis is doing is irrelevant to 75% of the quads.
And considering what happens to the knees while seated -they’re flexed- that would mean 75% of the quads are being stretched in someone sitting for 8 hours a day…
Same thing follows when you say the abdominals are lengthened. The abdominals are not a muscle. They’re a group of muscles. In an anterior pelvic tilt, the internal obliques are shortened, not lengthened.
And let’s say this logic of strengthen this / stretch that was all that was required. So, we have someone who stands with an anteriorly tilted pelvis and we say, stretch the spinal erectors a ton. When sitting the spine is typically flexed. (It’s not too common to see people sitting with an extended lumbar spine, even if they have APT standing, though it can happen.) When laying down, the spine is also often flexed. (Fetal position for example.) So the erectors are in many cases already being stretched for a minimum of 16 hours a day. In this instance, do they really need more stretching?
Point being that type of strategy is a hope strategy. A simpler approach would be “Hey, when you stand, don’t have an anterior pelvic tilt.” Then you could cue the person to pull their stomach up and in, or whatever the cue is you like. It doesn’t make sense to rely on the roundabout way, not even knowing if you’ll get to the destination, when you could just go straight to the place.
Kevin Gibbs
April 28, 2016
Hi Breddy (I guess this is your name?)
I’ve been looking into PPT for quite some time. My mind is boggeld, however, so I do require some help with this. Firstly, when in PPT, is your hip actually flexed? I mean, it certainly doesn’t look like it’s extended, even though muscles that cause extension are activated.
Also, how much would it cost to have you review and correct something I’ve written?
Thank you
reddyb
May 1, 2016
Hey Kevin,
My name is Brian.
I’m not sure where you’re getting the hips are flexed in a posterior pelvic tilt? The lower back is in flexion though.
For reviewing something, I usually go $1 per minute.
Kevin Gibbs
May 1, 2016
Hi again.
Guess my confusion started when I thought about the fact that deadlifts and glute kickbacks are both extension exercises. Albeit I guess the latter is also a lumbar flexion exercise whilst the fomer is a lumbar extension exercise. Right?
Where could I send my word file and specific requests?
Thanks!
reddyb
May 3, 2016
Hey Kevin,
Those would both be lumbar extension oriented, though I’d argue for kick backs, the back really shouldn’t move at all as the glutes are the focus. However, in reality the back often moves some during that, and when it does it’s into extension.
b-reddy@hotmail.com
Kevin Gibbs
May 3, 2016
Hi again.
Agreed. It ahould not move, but in reality it basically always does. Still confused a tad, though surely if the beginning and end of the lumbar spine come closer together it is flexion?
So, where could I send that word file of mine? Any email?
reddyb
May 5, 2016
Not exactly. Looking at which way the spine arches is probably an easier way to look at this.
Spine goes down = extension. Spine goes up = flexion: https://www.youtube.com/watch?v=4W6u0kLAya0
Left my email in the last comment. It’s b-reddy@hotmail.com
Kevin Gibbs
May 6, 2016
Oh woopsie. Must have missed that part. Anyhow, will send it to you!
So you don’t think each segment (lumbar, thoracic, cervical) should be thought of as separate in their movements as well? I mean, they have lordosis / kyphosis, so certainly if a kyphotic part gets more kyphotic it goes into flexion, where as when a lordotic part becomes more lordotic it goes into flexion?
reddyb
May 8, 2016
I see what you’re saying now. I don’t believe I’ve seen the spine categorized that way. I think it’s easier to view the entire spine as having one flexion and one extension. Where you get into the segmentation is different parts of the spine have different neutrals e.g. a lumbar spine which is flat is flexed. A thoracic spine which is flat is extended.
Kevin Gibbs
May 8, 2016
Yeah, my girlfriend, who is an osteopath, thinks of the back in segments. Thus the confusion. Will be sending you the text next week.
Cheeseburgers
October 17, 2016
To fix it one has to strengthen the core and hip flexors in an eccentric fashion. Also back extensions help I have it from sitting. My glutes are not weak. I can raise my leg to head height from the side and hip thrust 150+KG (could do more but never tried due to pain from the bar on my hip) I find the most relief by doing slow eecentric leg raises on the floor. I try to hkeep the back flat and not use the hip flexors (so to speak) you really feel the deeper core muscles working. Also the adductors which attack to the innominate need to be sorted out. I find if they ware weak in their shortened position it can cause problems.
reddyb
October 18, 2016
Appreciate the comment, but there are some things worth clearing up here.
Sorry if I’m mistaken you’re doing this, but one needs to be careful taking what’s worked for them and generalizing.
Furthermore, the anatomy is off here. You said eccentrically strengthen the hip flexors and core, such as in leg raises:
Let’s say you’re doing these with the lower back flat on the floor (lower back doesn’t move (above video)) as you alluded to. Then that’s not eccentrically loading the core. The core musculature is not changing length, thus it is isometrically strengthening the muscles.
Furthermore, leg raises are a sagittal plane exercise. A lateral tilt is a frontal plane issue. For those unaware:
Doesn’t mean they’re futile, but it’s not the most specific exercise. Certainly not one a person “has” to do.
Strengthening is rarely much of an issue with a lateral pelvic tilt. (Though strength can help many things.) Retraining, and avoiding laterally tilting the pelvis, is overwhelmingly the issue. I often can change someone’s lateral pelvic tilt by having them look in a mirror and adjust. They didn’t get stronger in that 5 seconds though.
Tiancheng Ma
January 26, 2017
The black guy with blue pants has short hamstrings but his psoas arent short. why doesnt he have posterior pelvic tilt instead of anterior pelvic tilt?
reddyb
January 27, 2017
Hey Tiancheng,
I think you’re misreading the post. I’d go though the “It’s all relative” section again.
Bizzy
July 24, 2017
Hey, Brian.
First and foremost I want to say I am blown away by the knowledge on this site.
I have had knee and lower back issues for over 15 years. In my twenties I used to lift heavy on the squats, and I blamed that on my knee issues, but after reading the articles here, I have come to an understanding that my knees were wrongly aligned.
I started getting serious lower-back issues around 21 years of age, and now at 36, I have chronic lower back problems.
Only recently (last 2-3 years) did I find out about pelvic tilt, and that I have a posterior tilt.
10 years of MRI’s, physiotherapists and specialists gave zero results, clearly medicine here in Norway is not as advanced as other places.
The final assessment I got from a physio-specialist was short hamstrings. After that I started stretching my hamstrings and glutes and that helped somewhat.
Now I also need to stretch my hip-flexor(?) (front of pelvis) too from time to time (depending on workout I do), because they get really tight sometimes and that hurts my back as well.
My daily stretching routine is hamstrings and glutes. That actually make my days bearable. But I am NOT getting rid of that damned tilt!!!
Do you have any tips on how to correct my pelvic tilt, because 3 years of training and stretching has not helped with the tilt, just made it bearable.
b-reddy
July 25, 2017
Hey Bizzy (love the name),
Thanks for the kind words.
One of the biggest things I do if someone is having problems from a flat lower back -which tends to go with a posterior pelvic tilt- is address how the person sits. Where something like a lumbar support can be helpful. I talk about this some in this post, where you want to carefully play with where the support is, and how big it is: https://b-reddy.org/2017/01/09/why-you-can-have-lower-back-pain-into-extension-and-flexion/
If you’re having issues locally, you may want to also take a look at this: https://b-reddy.org/2013/06/20/the-remote-client-process/
Rodrigo
May 4, 2018
Hey man, I’m really confused as to whether I have anterior or posterior pelvic tilt. I’ve attached pics. Can you help ?
Thanks
http://imgur.com/a/XwAtP
b-reddy
May 8, 2018
Anterior.