Pelvic Tilt Correction Through Physiotherapy

Pelvic tilting refers to the movement of the pelvis in relation to the spine and lower limbs. It occurs when the pelvis rotates forward (anterior pelvic tilt) or backward (posterior pelvic tilt) around a horizontal axis. These tilts affect the alignment of the spine, hips or lower back and are often involved in postural changes and movement patterns.

Prolong sitting and sedentary lifestyle are one of the major causes of muscle imbalance, leading to weakness of pelvic erector muscles, which in turn shortens the muscles that control pelvic tilting. These imbalances cause the sacrum to tilt forward, increasing lumbar hyperlordosis (excessive curvature).

 

There are two ways to describe how the pelvis tilts:

• The position of the top of the pelvis (the iliac crest) relative to a neutral, upright position.
• The position of the bottom of the pelvis (the pubic symphysis) relative to the neutral position.

This distinction is important because different movements or exercises rely on tilting the pelvis in specific ways for safety and efficiency.

 

Types of Pelvic Tilt

Neutral Pelvic Tilt

In this position, the pelvis is balanced and aligned to minimize stress on the body. This is considered the most comfortable and safest position for normal activities like sitting, standing or walking. However, when lifting heavy objects or resisting forces, the body needs to adjust the tilt of the pelvis to reduce the strain on the spine and other structures.

Posterior Pelvic Tilt

When the pelvis tilts backwards, it’s called posterior pelvic tilt. This is the correct pelvic position when performing activities like sit-ups or lifting objects above waist height. It helps protect the spine by preventing excessive arching (hyperextension) of the lower back in these scenarios.

Anterior Pelvic Tilt

When the pelvis tilts forward, it’s called anterior pelvic tilt. This is necessary for exercises like squats, where you lift heavy loads from the ground, or when bending forward to touch your toes. An anterior tilt positions the spine in a way that helps you engage the muscles effectively for these types of movements.
If someone were to squat with a posterior tilt, it could lead to injury because it doesn’t support the spine as well during heavy lifting.

 

Risks of Improper Pelvic Rotation

• Simultaneous spinal rotation with hyperextension or hyperflexion increases injury risk
• Example - various sports and manual activities like rugby, golf, tennis, karate, sit-ups, lifting and digging.

Biomechanical Factors Involved in Pelvic Tilting

Pelvic Position and Lumbar Lordosis

• Studies show that lumbar lordosis is influenced by the ratio of forces between trunk flexor and extensor muscles, rather than their absolute strength.
• Imbalance between these opposing muscles is linked to changes in lumbar curvature and may contribute to lower back pain.

Muscle Length and Pelvic Position

• The iliopsoas muscle length plays a role in pelvic tilt, a shorter iliopsoas is associated with increased lumbar lordosis.
• Hamstrings are important in positioning the pelvis, and stretching these muscles affects pelvic tilt.

 

Causes of Anterior Pelvic Tilt (APT)

• tight hip flexors
• weakness in the rectus abdominis and obliques
• increased lumbar lordosis
• poor posture such as slouching or leaning forward
• high heels
• increase BMI

Causes of Posterior Pelvic Tilt (PPT)

• tight Hamstring
• shortness of iliopsoas
• tight abdominal muscles, particularly the rectus abdominis
• weakness of lumbar extensors erector spinae
• flat back posture
• prolonged slouched position during sitting
• lumbar disc injuries

 

Effects of PPTS on Lumbar and Thoracic Spine

• PPTS affects lumbar spine alignment, which in turn influences thoracic spine alignment.
• Changes in thoracic spine alignment can impact thoracic movement and flexibility.
• Thoracic spine flexion can encourage anterior rotation of the ribs and reduce thoracic mobility.

 

PPTS and Respiratory Function

PPTS is associated with diminished respiratory function. Studies show that key measures of lung function are affected, such as:

• Forced Vital Capacity (FVC)
• Forced Expiratory Volume in 1 second (FEV1.0)
• Peak Flow Rate (PFR)

These measures are important for diagnosing lung function and respiratory diseases. Therefore, PPTS can have a negative effect on respiratory-related health.

 

Diagnoses

Diagnosing anterior pelvic tilt (APT) or posterior pelvic tilt (PPT) in physiotherapy involves a combination of postural assessment, functional movement tests, and palpation. Here's a step-by-step approach commonly used by physiotherapists:

Visual Postural Assessment

• Have the patient stand in a relaxed position, preferably in minimal clothing to see the pelvis, spine and leg alignment.
• Look for lordosis and protruding abdomen. The hips may appear tilted forward.
• The lower back will appear flat and the buttocks will be tucked under. The pelvis will look like it’s tilted backward.
• Check the alignment of the pelvis relative to the spine and legs. In a neutral pelvis, the anterior superior iliac spine (ASIS) and pubic symphysis should align vertically.

Palpation

• Palpate the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS) to assess the relative height of the pelvis.

1. In APT, the ASIS will be lower than the PSIS.
2. In PPT, the ASIS will be higher than the PSIS.

• Palpate the iliac crests on both sides to check for any asymmetry that could contribute to pelvic tilt.

 

Special Tests

• Hip Flexor Flexibility (Thomas Test): 

This test evaluates the length of the hip flexors, which can contribute to anterior pelvic tilt.

• Hamstring Flexibility (Straight Leg Raise or 90/90 Test): 

Assess the length of the hamstrings. Tight hamstrings are often found in posterior pelvic tilt.

• Modified Ober's Test: 

This assesses the iliotibial band and gluteal muscles, which may be tight in APT.

• Lumbar Curve Observation: 

While the patient is standing, observe the lumbar curve. If it is exaggerated, it suggests APT; if flattened, it may indicate PPT.

Functional Movement Assessment

• Pelvic Tilt Test: 

Ask the patient to tilt their pelvis forward and backward while standing or lying down. Observe the range of motion and control. Difficulty achieving a neutral position or exaggerated movements in one direction can indicate tilt.

• Squat Assessment: 

Instruct the patient to perform a squat while you observe the movement of their pelvis.

1. APT: The pelvis may tilt forward excessively during the squat, and the lumbar spine may arch.
2. PPT: The pelvis may tuck under excessively at the bottom of the squat, flattening the lower back.

Muscle Strength Testing

• Weakness in the abdominals (especially lower abdominals) is common in APT. You can test this through various core stability exercises (e.g., plank, leg lowering test).
• Weakness in the gluteus maximus and hamstrings can contribute to APT. These can be assessed using exercises like glute bridges, leg curls, or manual resistance tests.
• Overactivity of hip flexor and lumbar extensor can contribute to APT, and testing them can identify strength imbalances.

Gait Analysis

Observe the patient’s gait. Anterior pelvic tilt can cause the pelvis to tilt excessively forward during walking, while posterior pelvic tilt can lead to reduced hip extension and a more stiff or flattened back appearance during movement.

Differential Diagnosis

• Lumbar Lordosis (Hyperlordosis)
• Flat Back Syndrome
• Spondylolisthesis
• Lumbar Disc Herniation
• Hip Flexor Contracture
• Sacroiliac Joint Dysfunction
• Lower Crossed Syndrome
• Upper Crossed Syndrome
• Sciatica
• Hip Osteoarthritis
• Lumbar Spinal Stenosis
• Piriformis Syndrome
• Iliotibial Band Syndrome
• Femoroacetabular Impingement (FAI)
• Hamstring Strain

 

Physiotherapy Management of Pelvic Tilt

Effective physiotherapy programs should be tailored to the individual, with targeted exercises that yield maximum benefit in a limited time. Understanding of posture and factors affecting it is important for a physiotherapist before implementing targeted intervention. 

Posture is influenced by sociocultural factors as well as muscular balance, strength and flexibility. The alignment of the spine depends on the pelvic position, influenced by different muscle groups.

 

Pain Management

Pelvic tilt, especially when associated with muscle imbalances and muscle spasm, can lead to low back pain, hip pain, or discomfort in the lower limbs. Modalities like Transcutaneous Electrical Nerve Stimulation(TENS) and Interferential Current (IFC) are used for this purpose.

Stretching and Strengthening Exercises 

Stretching and strengthening exercises can significantly alter pelvic tilt but it is crucial to look for muscle fatigue during exercise, specifically gluteus maximus as it can increase pelvic tilt.

• Hamstring stretching leads to increased anterior pelvic tilt.
• Hip flexor stretching reduces anterior pelvic tilt.
• Strengthening muscles that pull the pelvis upwards (abdominals) and downwards (gluteus maximus and hamstrings) can restore balance in pelvic tilt. The gluteus maximus can be easily voluntarily activated, while abdominal muscles are harder to control during posture correction.

Use of Muscle Synergies to correct Pelvic Tilt

Muscle synergies involve coordinated activation across multiple muscles to achieve a movement goal. These synergies are controlled by the central nervous system and may differ from person to person, even if the movement is the same. Activation of both ventral (abdominal) and dorsal (gluteal) muscles working together helps in pelvic retroversion (posterior tilt).

Therapeutic Interest in Muscle Synergies:

• Different people may use different muscles to correct pelvic tilt, meaning that individualized treatment is crucial.
• If therapy only focuses on strengthening certain muscles, it may not be effective if those muscles are not the ones the central nervous system uses to correct the pelvic position.

 

Anterior Pelvic Tilt and Muscle Groups

The anterior pelvic edge can be lifted by two muscle groups:

• Ventral group: Rectus abdominis and obliquus externus and internus.
• Dorsal group: Gluteus maximus and hamstrings.

Antagonistic muscles like the iliopsoas, rectus femoris, and lumbar erector spinae counteract by increasing pelvic tilt.