Anterior pelvic tilt is one of several types of postures that many manual therapists and personal trainers may have learned and tried to “correct” during their career—along with the posterior pelvic tilt, lateral pelvic tilt, forward head posture, upper cross syndrome, etc.
Its well-known characteristics are described in almost every personal training certification, basic massage therapy education, and physical therapy schools. Many therapists and trainers believe that postures that deviate from the “neutral” spine and pelvis orientation can cause or increase the risk of joint pain, musculoskeletal pain, limitations of movement, and movement dysfunction. And so, they recommend a treatment plan or exercise program that is supposed to “fix” these “abnormal” or “dysfunctional” postures and put the body to neutral as close as possible.
On the surface, these ideas seem reasonable and intuitive, but scientific evidence indicates that anterior pelvic tilt and other types of posture may not be as important as many therapists and trainers believe.
What is anterior pelvic tilt?
In the anterior pelvic tilt, the pelvis is rotated forward in the sagittal plane, causing an increase of the lumbar spine curvature. This position tilts the gluteal muscles upward, exaggerating its round appearance for some people. Sometimes the pelvic tilt decreases the upper spine curvature, making the person appear to have a flatter upper back.
A 2003 French study from Centre des Massues in Lyon, France, gathered data from 160 healthy, asymptomatic subjects and classified lordosis into four types (1-4). The anterior pelvic tilt would fit into Type 4 where the sacral slope is greater than 45 degrees while 35 to 45 degrees is considered a “well-balanced” range for the spine.
Because of pelvis’ orientation, some believe that this is caused by short, tight muscles—such as tight hip flexors and superficial abdominal muscles—which causes the gluteal muscles and hamstrings to be “weak” or “inhibited.”
Anterior pelvic tilt origins
Czech neurologist Vladimir Janda (1928-2002) is often given credit to popularize the concepts of pelvic tilts. Based on his research on motor control and his studies on previous research on pain and movement by earlier scientists, Janda described overactive and underactive muscles of the spine, shoulder girdle, and pelvis can cause “muscle imbalances.” This idea brought forth “Janda’s Postural Syndromes,” which include upper cross syndrome and lower cross syndrome.
In a 1978 paper published in The Neurobiologic Mechanisms of Manipulative Therapy, Janda wrote that there are enough observations in research that muscles “respond to a given situation by tightness,” such as pain, while other muscles react by “inhibition, atrophy and weakness.” Some examples can be found in the hips, knees, hamstrings, and trunk erectors. These patterns can also be found in the upper body, such as tightness in the upper trapezius, levator scapulae, and pectoralis muscles with “weak” deep neck flexors and lower stabilizing muscles of the scapulae.
“Whatever the physiological basis for these changes of muscle function, the clinical fact remains that a developed muscle imbalance should be treated and that muscles in which we find a predominantly static or postural function and which show a tendency to get tight are activated in various movement patterns relatively more than muscles with a predominantly dynamic, phasic function, which show a tendency to get weak,” Janda wrote.
So if you were to have anterior pelvic tilt, your abdominal muscles—particularly the rectus abdominis—and hip flexors (iliopsoas) would be “tight,” pulling your pelvis forward and “inhibiting” your glutes. Thus, exercises that you should do would be to stretch the hip flexors and abs while strengthening the glutes and reducing the curvature of the lumbar spine.
However, pain research at least since the 1980s finds that there is more to pain and treatment than just “stretch what is tight, strengthen what is weak” paradigm.
Does anterior pelvic tilt cause low back pain?
While many therapists and trainers believe that the anterior pelvic tilt increases the risk of low back pain and movement “dysfunction” or believe that there is a cause-and-effect relationship between posture and pain, most of the research since the 1980s do not validate these ideas.
First, shortened or tight hip flexors do not necessarily mean that they are a cause of low back pain, and neither are weak or inhibited hips muscles. A study of 600 young men in the Swedish military fails to find a positive relationship between psoas muscle tightness and back pain. Physical therapist Anna-Lisa Hellsing stated that having tight muscles is the result of “both positive and negative factors.”
“Heavy muscular work or strength training, long-standing pain or a poor movement pattern can all result in muscle tightness, probably also depending on genetic factors,” she wrote. Hellsing also noticed that each subject experienced pain in the tight muscles (psoas) differently, but she did not record it.
“The results in this study can also seem contradictory to clinical experience, i.e. that back pain is diminished by the stretching of tight muscles. It does not actually have to be contradictory however, because more flexible muscles probably alter the load from the painful sites,” she concluded.
In 2002, another study with 600 civilians in Tehran, Iran, found no association between low back pain and various structural factors, such as pelvic tilt, foot arch, leg length discrepancy, lumbar lordosis, and the length of muscles (iliopsoas, abdominals, triceps surae, hip adductors). Physical therapists Mohammad R. Nourbakhsh and Amir M. Arab from the University of Social Welfare and Rehabilitation Sciences randomly recruited men and women in their twenties to fifties from five hospitals in Tehran and were categorized into four groups, separated by existence of symptoms of low back pain and gender with exactly 150 people in each group.
They measured the lengths of various muscles, pelvic tilts, feet arch, and muscle strength in the hip flexors, hip abductors and adductors, and abdominals. Although their results found abdominal strength was weaker among those who had low back pain, pelvic tilts and the size of the lordosis showed no association with low back pain. Likewise, there was no association between the size of the lordosis and pelvic tilts and the length of the iliopsoas.
Nourbakhsh and Arab started this study based on the arguments about the cause of low back pain from Robin McKenzie and Paul Williams. McKenzie associated a lower curvature of the lumbar spine and a herniated disc while Williams argued that increased lordosis from weak abdominals and sitting too long are the causes.
In 2014, a systematic review and meta-analysis of 43 qualified studies, led by Dr. Robert Laird formerly of Monash University in Frankston, Australia, found no difference in lordosis angle, pelvic tilts in a standing position, and usage of the lumbar spine or hip flexors during a forward bend between people with low back pain and those without.
Another thing to consider is that pelvic tilt and pelvic anatomy varies among each person. In a 2010 study that was conducted at the University of Salford in Manchester, England, researcher and physical therapist Lee Herrington examined 120 healthy, asymptomatic men and women from ages 18 to 44 by measuring their pelvic tilts.
Among the men, he found that 85% of the 65 subjects had an anterior pelvic tilt, while 75% of the 55 women had the same pelvic tilt.
“It would appear that a degree of anterior pelvic tilt is typical within asymptomatic individuals and that asymmetry of pelvic angle is also not unique finding confined to symptomatic individuals alone,” Herrington wrote. He cautioned clinicians that “care should be taken when applying cause and effect” when they meet a patient with anterior pelvic tilt or hip asymmetry.
The anterior pelvic is measured by identifying the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS) and measuring the angle between the two points with an imaginary horizontal line starting at the PSIS as a reference point.
For pelvic anatomy, a 2008 study of 30 cadaver pelvises found variations in pelvic tilt angles and anatomical landmarks “may result in weaker correlations between pelvic tilt and other clinical measurements” than measuring actual muscle and ligament forces. Lead esearcher Stephen Preece and his colleagues from the University of Salford in Manchester, England, warned that pelvic tilt angle measurements “should not be used in isolation.” He suggests that clinicians should consider various factors when measuring, such as the curvature of the lumbar lordosis and hip joint angle in a standing position.
Finally, posture assessments in general are unreliable and poorly reproducible, according to a 2018 study from the Charité – Universitätsmedizin Berlin in Berlin, Germany. The research team, led by Dr. Hendrik Schmidt, performed six standing posture assessments to each of the 332 subjects after each person performed a series of torso-bending exercises.
After the exercise sequence is done, the researchers measured their pelvic tilts. Not only did they find any differences between those with back pain and those without, joint angles in the sacrum and lordosis also vary and overlap between both groups.
“An irreproducible standing posture can lead to false radiological measurements, incorrect diagnoses and possibly unnecessary treatment,” they wrote.
Corrective exercises for anterior pelvic tilt and back pain
Some physical therapists and personal trainers recommend corrective exercise as a way to “fix” the anterior pelvic tilt and other types of postures by bringing the pelvis and spine back to “neutral” position (as least as close as possible).
Because the premises behind corrective exercises are based on Janda’s postural syndromes and structural and biomechanical factors, there is likely little or no need to do them—unless you actually enjoy doing them.
Research that compares different types of exercises for chronic low back pain found that no exercise type is superior than another, and nearly all types of exercise can reduce low back pain.
In 2012, a Chinese systematic review of five randomized-controlled trials with more than 400 subjects total found that core exercises “more effective in decreasing pain and may improve physical function” than general exercise in reducing low back pain in the short-term. However, in the long run, there was no difference between the groups.
In 2014, an Egyptian systematic review of 34 trials (with nearly half of them being randomized-controlled trials) with more than 2,500 subjects total found that the quality of the evidence that favors core exercises over manual therapy and general exercise for low back pain was “low.” The data is similar to the Chinese review where core exercises seem to be better general exercise in the short run but not the long run.
Since more systematic reviews (one in 2016 and 2019 (with 89 trials and more than 5,000 subjects total)) also found similar results, it is likely that specific exercises would not be necessary to reduce low back pain.
Although there is a lack of sufficient evidence to support the premises of corrective exercise for pain relief and structural alignment, personal trainer Nick Tumminello said corrective exercises might be useful for providing a “framework for exercise prescription” or for clients who want to be evaluated to a specific program.
“There’s nothing wrong with this approach as long as professionals don’t make claims for injury prevention or athletic performance that the scientific evidence doesn’t support,” Tumminello wrote. “Using corrective programs as a start point or template would be perfectly defensible if the trainer acknowledges the problems with identifying ‘dysfunctions’ and sticks to the science when it comes to claims of prediction and performance.
Because chronic low back pain stems from multiple causes (biopsychosocial), exercise in general can be one economic and plausible way to reduce and manage the pain symptoms, likely even among those with an anterior pelvic tilt.
Anterior pelvic tilt exercises
Since the body of research indicates that nearly all types of exercises can provide some degree of back pain relief, perhaps some of the anterior pelvic tilt exercises that are often recommended could still be of some benefit.
Although there are no specific exercises that should be followed to the rule, you can still explore different exercises to see which works for you. If you are unsure about how to do some of these exercises correctly and safely, consult with a qualified personal trainer.
Kneeling hip flexor stretch
Glute bridges, pelvic thrusts
Video via Sohee Fit.
Deadlifts target your glutes as well as strengthening your torso. Nick Tumminello offers tips for non-athletes and non-powerlifters to do a basic deadlift.
Various single-leg exercises ideas (intermediate to advanced levels)
Single leg training offers many unique benefits compared to bilateral leg training and biomechanically single leg squats are very different. I recommend doing unilateral training to develop more balanced and functional leg musculature. The exercises are easy to modify to target different parts of the legs which is why they are great for fixing muscular imbalances in the hips and legs.Single leg exercises also require balance and stabilization and as a result there will be a great carryover to athletic movements. You can start by adding a couple of variations to your routines and progress from there.For more information, here is a comprehensive single leg squat video (6 best single leg squat exercises) ➞ youtu.be/7UJLJl3qUaU
Posted by VAHVA Fitness on Friday, April 7, 2017
Should I still learn how to fix anterior pelvic tilt?
With the existing evidence, you probably do not need to learn how to fix your anterior pelvic tilt. In some cases, it is a normal variation of the human body and most people can adapt to different demands that their body undergoes.
Like the shape of the pelvis and its bony landmarks, each person’s pain experience differs because it is shaped by biological, psychological, and sociological factors. An alternative to fix the anterior pelvic tilt is to focus on doing exercises and activities that you can do well and enjoy consistently.
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A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.
An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014.
When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.