It was the summer of 2013 and my wife and I had just arrived at her sister’s house for the weekend. The next hour was spent standing in the kitchen chatting and catching up before we moved outside to catch the rest of the day’s sun.
Only I couldn’t move.
My lower back was so painful that all I could do was lean against a wall. I couldn’t sit, walk, hobble, crawl, without excruciating pain stemming from my lower back. I sent the others outside and over the next 15 minutes, I was slowly able to increase movement in my hips and start to move around.
It wasn’t the first time this had happened, but it was by far the worst and spurred my 5-yearly trip to the doctors. He though it could be skeletal stenosis (compression of nerves due to a narrowing of the spinal canal) and sent me for an MRI, but thankfully it turned out to be only muscular.
Skeletal stenosis would involve spinal surgery; muscles I can do something with. The cause of the muscle pain was anterior pelvic tilt and whilst I took great care with exercise form and posture in the gym with my own and my clients’ training, I didn’t give it much thought for the other 23 hours of the day.
Cue lower back pain.
The pelvis is the area between our abdomen and thighs, surrounding our hip bones. Anterior pelvic tilt (APT) arises when the front of the pelvis rotates downwards and the back rotates upwards.
The pelvis is the junction box for our spine and legs. If it is out of position, our body must compensate, generally by increasing the curve in our lower spine, to keep our torso upright. As the pelvis supports about 60% of our bodyweight, that’s the cause of lower back pain from APT and what rendered me immobile in my sister-in-law’s kitchen.
APT can also trigger leg and knee pain as, when the hips are rotated downwards, our femurs (upper leg bones) have restricted range of motion, causing knees to buckle inwards unnecessarily when we bend them.
This is easy to establish by either considering your symptoms, or more directly, by assessing the position of your hips.
Symptoms of APT include any of the following, without an underlying injury:
- Lower back pain
- Knee pain
- Neck pain
- Bottom sticks out a lot
- Excessive curvature of the lower spine
These symptoms could also relate to other issues, so if at all concerned, you should speak to your GP or a good physiotherapist.
There are two bony landmarks which should be broadly level with each other:
1. ASIS (anterior superior iliac spine)
This is the front of your hip bone. To locate it, use your hand to find the top of hip (the iliac crest), press firmly and run your fingers forwards along the top of it. As you get to the front of your hip, the bone curves down suddenly and this point is the ASIS. Keep one finger on it.
2. PSIS (posterior superior iliac spine)
This is the back of your hip bone. Starting from the same place as for the ASIS, run your fingers backwards and when the bone drops off, that’s the PSIS. It’s also close to where you have a dimple in your skin. Keep another finger on this point.
In front of a mirror, stand sideways on and look at the relative height of your fingers marking the ASIS and PSIS.
- If the ASIS is lower than the PSIS, you have APT.
- If the ASIS is higher than the PSIS, you have the opposite, a posterior pelvic tilt (much less common, unless you suffer from conditions such as kyphosis).
- If your fingers are at the same height and you are standing as you normally would, your pelvis is neutral and you do not have APT.
It’s a good idea to check the other side as it may not be tilted to the same degree.
If the potential for unnecessary pain isn’t sufficient motivation to do something about APT, it can impact you in various ways when you’re exercising. For example:
The increased forces on your body from running can be multiplied by APT, causing greater knee, lower back and neck issues.
Squatting, deadlifting, shoulder pressing, etc. all increase the downward force on your spine into your pelvis. For example, an 80kg person squatting 100kg increases the weight their pelvis is supporting by a multiple of three. With APT, that’s a significant increase in the stress on an excessively curved spine or degradation in your form by making you lean forwards more. Their knees will also be more likely to collapse inwards.
There is no miracle cure, but with 30 minutes of effort 3-7 times each week, you can start reversing APT. The following programme is covered in more detail in Thrive’s video. It can also be tailored to clients’ needs in their online training programmes where necessary.
The programme has three steps: stretching, strengthening and lifestyle, and all elements can be completed at home without any equipment.
As with any exercise, always listen to your body and don’t push more than you feel is safe. Speak to your GP or a physiotherapist if you need to – what follows is not an alternative to seeking medical advice for long term pain or postural issues.
As the pelvis is pulled down at front, hip flexors muscles (rectus femoris, psoas, iliacus and TFL) will be slightly shorter than they should be. Similar, the raised pelvis at the back means erector spinae muscles (which run along the spine) are likely to be short too.
Holding each of the following stretches will start to lengthen the short muscles, allowing your pelvis more range of motion to become level:
- Hip flexors: 30-60 seconds, 3 times
- Quads (lying): 30-60 seconds, 3 times
- Lower back (seated): 60-120 seconds, 3 times
Lower back (seated)
Muscles work in pairs – as one lengthens, its opposite shortens. In terms of APT, abdominal muscles need to be strengthened and shortened to help pull the pelvis upwards at the front. Similarly, the glutes and hamstrings may also need strengthening at the back.
The following exercises will help strengthen those muscles:
- Hollow kicks: 15-20 slow repetitions, 3 sets
- Glute bridge: 6 repetitions, hold for 20 seconds, 3 sets
- Plank: hold for 60 seconds, 3 times
Please check out the videos on Thrive’s YouTube channel as these exercises are often completed incorrectly. To get the desired benefit, you need to ensure you hips and lower back are in the correct position throughout.
The stretching and strengthening exercises will take 30-40 minutes each day. That still leaves 23½ hours to make improvements to any APT.
- Walking: The pelvis needs to deal with a lot of movement when you’re walking. Consciously use your abdominal muscles to pull your pelvis up at the front into a neutral position all the time. If you feel your back pain return, check your pelvic position as you may have slipped back into bad posture.
- Sitting: If you slouch, it’s likely your pelvis will tilt the other way, but if you sit up straight, you will need to correct your APT. It’ll stop you leaning forwards so much, reducing the stress in your back muscles.
- Resistance training: Whether you’re lifting heavy weights or using your body for resistance, maintaining a neutral pelvis is the right thing to do for pretty much every exercise. Planks, press ups, squats, deadlifts, even triceps dips all become more effective with a neutral pelvis. Still not convinced, think about all the extra effort your core needs to exert to hold position – your core will become stronger too.
- Running: Good running form requires neutral hips. Often when people tire, the first thing to happen is their APT comes back, they lean forward more and running at speed becomes more uncomfortable. Regularly check yourself and adjust your pelvic position as often as you need to.
Back pain is no laughing matter and whilst APT is not the sole cause, it can explain why so many people have niggling pains which are not severe enough to warrant medical review.
But here’s the thing: people forget what it feels like to be pain free; to thrive.
It creeps up over time so we often don’t know we’re suffering. Spend five minutes now to see if you have APT and if you do, book 30 minutes in your schedule to work on the first two steps. Don’t expect an immediate response. It’ll take time, but 30 minutes a day, 3-7 days a week will be worth it.
Step 3 will, after perseverance, become second nature and no effort at all.
You can follow this blog as a video (15 minutes) which takes you through the theory and the exercises in more detail. Alternatively, you can book a call with Thrive and we can chat about your issues and how we can help.
Are you ready to thrive?