Posterior pelvic tilt is one of the several types of postures that many manual therapists and personal trainers may have learned during their career—along with uneven hips, upper cross syndrome, forward head posture, rounded shoulders, etc. The idea behind learning about these types of posture is to identify potential causes of pain, limitations of movement, and movement dysfunction. Thus, the therapist or trainer is able to form a treatment plan or exercise program that is supposed to “correct” or “fix” the posture and bring the body to “neutral” position.
While these ideas seem reasonable at first, scientific evidence indicates that posterior pelvic tilt and other types of posture may not be as significant to pain and movement as many therapists and trainers believe.
What is posterior pelvic tilt?
The posterior pelvic tilt is where the pelvis is rotated back in the sagittal plane, causing a reduction in the curvature of the lumbar spine and buttocks. Sometimes the pelvic tilt exaggerates the upper spine curvature, making the person appear more hunchback.
The angle of the posterior pelvic tilt can vary among individuals, which is classified as having a tilt greater than 35 degrees posteriorly from neutral pelvic position. Some websites claim that this results in tight hamstrings and weak glutes, core muscles, and hip flexors, while some practitioners believe that correcting pelvic tilts may alleviate back pain and other musculoskeletal pain.
Pelvic tilt origins
The ideas of the posterior pelvic tilt and similar types of postures (e.g. anterior pelvic tilt, lateral pelvic tilt) came from the works of Dr. Vladimir Janda (1928-2002), who was a Czech neurologist who taught undergraduate and graduate classes in various manual therapy schools in the late 20th century. He introduced the concept of functional anatomy, which is like a hybrid of anatomy and kinesiology.
Based on his previous research and studies in motor control, Janda described the patterns of muscles that are hyperactive or hypoactive, which are usually associated with the spine, hip joints, and shoulders. Such relationships eventually became known as “Janda’s Postural Syndromes,” and these include upper cross syndrome and lower cross syndrome.
In a 1978 paper published in The Neurobiologic Mechanisms of Manipulative Therapy, Janda argued that not only joint dysfunction is a primary cause of most types of musculoskeletal pain and movement disorders, but also joint dysfunction in other parts of the body that may manifest into similar problems.
He used headaches as an example where the source of pain could be from the pelvis. A change in the motor system in the pelvis may produce “a chain of reflexes” that affects the entire motor system. Thus, he suggested that clinicians should consider and examine other body parts other than the local symptomatic area.
Janda’s observations led him to postulate that when one group of muscles get tight and/or shortened, the opposing muscles get weak and inhibited, lacking sufficient motor control and coordination to produce movement. Sometimes muscles tighten up in response to certain conditions, such as pain.
He wrote: “It is known that tightness of hamstrings or truck erectors frequently develops in these and similar postural defects, whereas abdominal and gluteal muscles show signs of weakness.”
He described a similar condition in the upper body, where tightness in the upper trapezius, levator scapulae, and chest muscles coincide with weakness in the deep neck flexors and lower stabilizing muscles of the scapulae.
Based on this idea, if you were to have posterior pelvic tilt, your glutes and lower back would be “tight,” pulling your pelvis back and “lengthen” your abs and hip flexors. So, one intervention could be an exercise program that involves stretches to lengthen your “short and tight” muscles and exercises to strengthen your “weak” muscles.
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 posterior pelvic tilt cause back pain?
Not long after Janda had become a household name among manual therapy circles and several textbooks on exercise and hands-on treatments were published based on the cross syndromes, some research in the 1980s found inconsistencies with Janda’s ideas.
A 1986 study of 31 healthy physical therapy students at Virginia Commonwealth University in Norfolk, Virginia, did not find a relationship among abdominal muscle function, pelvic tilt, or lordosis. The research team, led by Martha L. Walker from the Program of Physical Therapy, wrote that patients are often taught to strengthen their abdominal muscles as a way to change their standing posture. However, their experiment does not support this idea.
In 1990, three physical therapy researchers, led by Jacklyn Brechter (née Heino), did a similar experiment and found no relationship among the range of motion of hip extensors, standing pelvic tilt, standing lordosis, and abdominal function during the leg-lowering test.
The length of hip flexors—specifically the psoas muscles—do not seem to have a strong relationship with low back pain. A 1988 study found no relationship between “tight” hip flexors and back pain among 600 young, Swedish soldiers. Researcher and physical therapist Anna-Lisa Hellsing wrote that having tight muscles is not necessarily good or bad and can be influenced by heavy physical activity, such as military training.
“Experience of pain in the tight muscles themselves during the test differed very much between the subjects, but was not systematically recorded,” she wrote. Hellsing speculated that the study contradicts clinical observations where stretching the hip flexors reduced back pain.
Likewise, a 2002 Iranian study of 600 people from various age groups fails to find a relationship between those with or without low back pain based on the degree of the anterior pelvic tilt, leg length discrepancy, and the length of the iliopsoas and abdominal muscles.
In 2003, researchers from Centre Des Massues in Lyon, France, found that the degree of lordosis among 160 pain-free subjects varies, ranging from less than 35 degrees to more than 45 degrees as the sacral slope.
Given these preliminary studies and evidence, they question the validity of Janda’s Postural Syndromes. A 2014 systematic review, led by Dr. Robert Laird formerly of Monash University in Frankston, Australia, found no difference between subjects with or without low back pain in terms of lumbar lordosis angle (eight studies), hip extension (four studies), and pelvic tilt in the standing position (three studies).
They also found people with low back pain have a reduced sense of proprioception (body awareness in space), tend to move slower, and have greater movement variability than those with no low back pain.
Pain is an experience that is influenced by many factors, a mix of biological, psychological, and sociological factors. To blame posture as the primary cause of pain is to miss out on other possibilities that may contribute to each person’s pain experience.
Do you need corrective exercises for posterior pelvic tilt?
Some physical therapists and personal trainers recommend corrective exercise as a way to “correct” or “fix” posterior pelvic tilts and other types of postures by bringing the pelvis and spine back to “neutral” position. One of the premises behind this approach is that it would bring pain relief and optimize movement patterns by alignment of body structures, such as centralizing a joint or stretching “tight” muscles.
According to an article published in the National Strength and Conditioning Association (NSCA) in March of 2017, corrective exercise is defined as “a system of exercise programming that attempts to correct performance of specified activities based on a specific structured evaluation model to predict injury or poor performance.”
The authors, Dr. Jason Silvernail, Ben Cormack, and Nick Tumminello, wrote that this approach is applied if the clients’ performance does not meet the corrective exercise model’s criteria of “normal” or “optimal.” Thus, it focuses more on an evaluation procedure, such as posture evaluations and movement testing, rather than the client’s needs and behaviors.
This means that clients and patients must “fit” into the corrective exercise model, whatever that may be, while “good personal training” focuses on each person’s ability to perform and unique structure based on accepted human biomechanics and physiology.
Another problem the authors described is that corrective exercise is “exclusive,” meaning that its principles “will only be immediately recognized by other fitness professionals if they subscribe to that particular set of principles.” This is quite different from universal knowledge about exercise, such as the SAID principle, periodization, and muscle physiology.
While there is no research yet that directly compares corrective exercise with other forms of exercise for posterior pelvic tilt, existing evidence in exercise types in relationship with musculoskeletal pain suggests that no exercise type is better than another.
In a 2016 Cochrane Review, the researchers from The University of Sydney in Sydney, Australia, reviewed 29 randomized-controlled trials with a total of more than 2,400 subjects that compared the effectiveness of core exercises with other types of exercises for chronic low back pain.
They found that while core exercises offer some pain relief, based on very low to moderate quality level of evidence, higher-quality evidence found that there are “similar outcomes to manual therapies” and low to moderate levels of evidence found core exercises have “similar outcomes to other forms of exercises.”
A German 2020 systematic review of eight randomized-controlled trials and two controlled trials also found similar results. The authors said that low-quality trials seem to “overestimate” the effects of core exercises on 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.
Posterior pelvic tilt exercise
Exercise can still provide some pain relief and improvement in performance. Although there are no specific exercises that should be followed to the rule, based on the current scientific evidence, you can still explore different exercises to see which ones works for you—for pain relief, less muscle stiffness, etc. If you are unsure about how to do some of these exercises correctly and safely, consult with a qualified personal trainer.
Glute bridges (on floor/ball/bench/single leg)
Glute bridges target your gluteal muscles and can be done on the floor, with a stability ball, or an exercise bench.
You do not need any weights, but if you become familiar with the movement, try it with a dumbbell or barbell. Video via Sohee Fit.
Squats (with dumbbells, barbells, or another free weight)
H3: Doorway chest stretch
This exercise can be also done with one side of your chest at a time.
MacKenzie press-up and similar exercises
Video via PhysioTutors.
McKENZIE OR DIRECTION-SPECIFIC EXERCISES FOR LOW BACK PAINThis video is currently going viral on our YouTube channel! So Facebook here you go…Long et al. (2004) have investigated if exercises that are matched to patients directional preference are superior to unmatched exercises.In 74% of patients with a direcitonal preference, they found that exercises matching subjects' DP significantly and rapidly decreased pain and medication use and improved in all other outcomes compared to the non-matched group.In general – although exceptions are certainly possible – patients with a disc (herniation) issue tend to prefer extension exercises while patients with lumbar spinal stenosis prefer flexion exercises.Watch the video below to get a few exercise examples you can use with your patients in practice on monday!
Posted by Physiotutors on Friday, July 24, 2020
Should I still learn how to fix posterior pelvic tilt?
While much of the scientific literature finds a weak association between posture and pain, biomechanics and structure still matter to some degree, and it depends on context. One potentially valid reason why a posterior pelvic tilt should be “corrected” is because it may increase the risk of having rectal prolapse.
Since the body of research finds no one exercise method is better than another, an alternative to “fixing” posterior pelvic tilt (or any posture) is to perform exercises and activities that you can do and enjoy. These can be gym workouts, leisure activities, and sports.
Since the reliability of locating the bony landmarks to gauge the degree of the anterior pelvic tilt is low, and people with no back pain or pelvic pain have such pelvic tilt, it is likely that research would find similar results with posterior pelvic tilt. Posture assessments, in general, have also been found to be unreliable and irreproducible. A 2018 study with 353 subjects found that “The number of standing phases performed showed no positive effect on the reproducibility” when their posture assessments were performed six consecutive times.
Researchers from the Charité – Universitätsmedizin Berlin in Berlin, Germany, concluded that the variability among the subjects and the repetitions of assessments were not predictable and were random. Chances are, therapists who assess the same person six times would likely get different interpretations.
Although there is a lack of sufficient data that supports the upper cross and lower cross syndromes, Dr. Jason Silvernail, who is a physical therapist practicing in the U.S. Army, said on SomaSimple in 2017 that these models are “useful” because they help people see “how outdated ideas get popular,” and how they continue to be popular “despite changes in the science that should make you reject them.”
“I don’t blame Professor Janda,” Silvernail continued, “he was doing his best with what he had at the time and what he probably [had] felt was an important clinical insight that improved his clinical process with patients.
The nature of pain is complex and there is much to be discovered. With scientific knowledge constantly evolving about pain in relationship with movement and touch, Janda’s ideas should continue to evolve or be replaced with better ideas, similar to how pain science evolved from the early pain theories in the early 19th century to Ronald Melzack and Patrick Wall’s gate control theory of pain in the 1960s.
“Why these crossed syndrome type things make no sense whatsoever but are not going away any time soon,” Silvernail wrote. “People will be talking about this brilliant insight for another 50-odd years.
“I wonder if Janda would [facepalm] if he heard how people were unable to move beyond this idea and had more fidelity to this particular product/idea than to the process he advocated.”
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.