PELVIC TILTS IN

RELATION TO PAIN

RESEARCH ON PELVIC TILTS IN RELATION TO PAIN

OF-COURSEONLINE.COM | COPYRIGHT 2022
BY CARLI MIESSNER
Contents
Introduction .................................................................................................................................................. 2
Pelvic tilt overview ........................................................................................................................................ 2
Pelvic tilt assessment .................................................................................................................................... 2
Hamstring inflexibility and posterior pelvic tilts ........................................................................................... 4
Anterior pelvic tilts........................................................................................................................................ 4
Femoroacetabular impingement .................................................................................................................. 5
Lumbopelvic pain in pregnant women ......................................................................................................... 5
Femoral and pelvic anteversion .................................................................................................................... 6
Conclusion ..................................................................................................................................................... 6
Reference List................................................................................................................................................ 7
Introduction
This is a descriptive research study that looks at, and summarizes the findings of already existing peer
reviewed articles and secondary sources, most being recently conducted, to create an overview of the
relationship between pelvic tilts and pain.

However, pain has a very broad spectrum, which can be acute or chronic, and can most effectively be
described by understanding of the Pain Cycle, which we will definitely cover in our one of our next
research newsletter summaries. Thus, for the purpose of this summary, we stick to describing pelvic tilts
in relation to different pathologies and physiological conditions.

There has been much speculation on whether pain is a symptom of altered pelvic tilts therefore, we
have created a summarized version of current and previously conducted research studies to guide you in
making a decision backed up by science. Remembering that even though science plays a significant role
in movement analysis, there are many variables that one can add into scientific studies which might play
a role in the outcome i.e. mental state, body composition or type, lifestyle and previous injury that has
not been successfully rehabilitated.

Pelvic tilt overview

Suits (2021) defines the pelvic tilt as the placement of the pelvis relative to the body’s position “in the
sagittal plane about a horizontal frontal axis”. Suits (2021) use the following definitions for an anterior
or posterior pelvic tilt looking at a supine position: “An anterior pelvic tilt is when the ASIS bones are
lower/more backward than the PSIS in the sagittal plane (supine position) or when the ASIS rotates
downwards in relation to the PSIS when moving the pelvis anteriorly. The posterior pelvic tilt is when
the ASIS is higher/more forward than the PSIS in the sagittal plane (supine position) or when the ASIS
rotates upwards in relation to the PSIS when the pelvis moves posteriorly.” (Suits, 2021). It is essential to
assess and evaluate the pelvis as its tilt directly relates to the rehabilitation and pathology of a variety of
hip joint conditions (Suits, 2021). Muscle tone, discomfort, flexibility, bony structural differences all have
an effect on the pelvic tilt (Suits, 2021). Having a basic appreciation and knowledge of pelvic tilts will
benefit the movement specialist, especially in understanding how various musculoskeletal conditions
directly influence the pelvis, lumbar spine, and knee but more importantly the hip (Suits et al. 2021).

Pelvic tilt assessment

Pelvic tilt assessment has been part of the rehabilitation field for a long time and is gradually being
studied more in “medical and laboratory-based biomechanical research” (Suits, 2021; Pierannunzii ,
2017 & Schwarz et al. 2018). Many methods can be used for evaluating the pelvic tilt in a rehabilitation
situation with the most commonly used methods being: hand-held inclinometers; visual assessment;
particular caliper-based inclinometers and smartphone applications. Yu et al. (2020) pointed out that the
Global Postural System, which is a “fairly new computerized photographic postural assessment system”,
also provides reliability in measuring pelvic irregularity. However, Suits (2021) put forward that there
still exists no specific fully agreed-upon method for most effectively assessing pelvic tilts in a clinical and
practical situation.
The pelvic tilt is typically measured in a comfortable upright standing posture, but can also be evaluated
actively where the full functional range of travel of each tilt is observed when standing or in which the
involuntary changes in tilt angle is observed throughout functional activities such as stepping down a
step with one leg (Suits, 2021). However, Suits (2021) suggests that further investigation is still required
to relate certain testing methods to specific individualized functional movements, to investigate
clinically practical testing methods for precisely measuring pelvic tilts, reaction to pain management
interventions as well as the measurement significance for effective rehabilitation.

An imbalanced alignment of the pelvis (in the transverse, sagittal or frontal plane) has been found to be
an expected cause of chronic non-specific (not due to a specific pathology) lower back pain prevalence
and can be one of the main contributors to aches and pain in the lumbar region (Yu et al. 2020). For
example, a lateral pelvic tilt is highly associated with irregular lumbar mechanics, placing abnormal
strain on the body and lower back’s soft tissues during movement which consequently contributes to an
increase in lower back pain (Yu et al. 2020). Yu et al. (2020) concluded that identifying the potential
existence of non-specific chronic lower back pain is more easily done when measuring and addressing
pelvic asymmetry at an early stage.

It is noted that pelvic obliquity (lateral pelvic tilt, where one hip is higher than the other) causes
misalignment of the pelvic bones and results in a leg length discrepancy. This consequently places
undue stress on the whole body’s mechanics and results in signs of pain, and has been found to be a
large cause of chronic lower back pain in patients (Fann, 2002 & Nichols, 1960). Leg length discrepancy
has been described by many researchers to occur progressively (usually during early adulthood or late
adolescence), causing regularly occurring or prolonged lower back pain, which is usually aggravated by
sudden trauma or strenuous activities such as lifting something heavy (Fann, 2002 & Nicholas, 1960).
However, a lateral pelvic tilt can also place various other parts of the body under strain, such as the feet,
knees, thoracic spine, and shoulders. Individuals who exhibit pain in the lower back might show more
lumbar spine irregularities due to compensation for the pelvic tilt (Fann, 2002). Leg length discrepancy
has also been associated with disorders in the intervertebral discs and joints changing due to
deterioration (Fann, 2002 & Nichols, 1960).

Lower back pain (LBP) has been treated and relieved by the use of the “posterior pelvic tilt method”
since many years ago, and can still be found in various patient education texts today (Minnicozi et al.
2016, Gracovetsky S, 1989 & McKenzie RA, 1981). The posterior pelvic tilt is typically performed supine,
with the knees bent 90 deg and hips flexed at 45 deg, where one has to press the lumbar spine into the
mat without raising the glutes. Posterior tilting includes some degree of lumbar flexion where the
lumbar lordosis is decreased by almost “flattening” the lower back down to the floor (Minicozzi et al.
2022). For this to occur, it is only natural to assume that some degree of lumbar extensor flexibility is
required, and that lumbar extensor tightness/shortening can also restrict this action.

It is known that posterior tilting is achieved via lower abdominal muscle activation; however, this is a
low load contraction and would not be enough to greatly strengthen the abdominals (Drysdale et al.
2004, Workman et al. 2008 & Veniza et al. 2000). It can thus be naturally assumed that posterior tilting
can be used to rather create awareness of abdominal activation without global muscles kicking in to
assist the low load movement. Posterior pelvic tilt can also be performed in other ways e.g. sitting on
the floor or on a ball to relieve lower back pain.
There have also been some similarities noted between the posterior tilt and the “Abdominal Hollowing”
method which involves no tilting or lumbar flexion. However, hollowing the abdominals produces less
Rectus Abdominus and External Oblique muscular stimulation, showing that abdominal hollowing
doesn’t contract these muscles as effectively or deeply as a posterior tilt would (Drysdale et al. 2004 &
Veniza et al. 2000).

By using the posterior pelvic tilt method, Minnicozi et al. (2016) looked for differences between subjects
with a greater reaction in pain compared to those who react with less pain. Patients with lower back or
lumbopelvic pain were examined using this method once on initial assessment during a chiropractic
session. The amount of pain and disability, the location thereof, chronicity, and other areas of concern
were analyzed before and after a sequence of chiropractic sessions (Minnicozi et al. 2016). It was found
that patients who exhibited more pain in response to the posterior pelvic tilt maneuver had a higher
level of pain overall (lower back pain and pain during daily activities) before the assessment and also had
a worse pre-medical care state (e.g. some had nerve entrapment, neural adhesions, etc.) compared to
those who experienced less pain. However, they found no distinct differences between study groups in
other areas of complaints regardless of age, sex, body mass, and types of treatment received. All
patients typically showed improvements and pain relief using this method (Minnicozi et al. 2016).

Hamstring inflexibility and posterior pelvic tilts

Hamstring tightness and severe lower back pain have been found to be directly related to the pelvic
position. Braman (2016) found that individuals tend to walk with a greater posterior tilt if they show
signs of hamstring tightness. Hamstring activation creates extension of the hip, flexion of the knee, a
posterior pelvic tilt, and in turn lumbar flexion (hypo-lordosis). Tightness of hamstrings is suggested to
thus in turn create compression on the frontal spinal structures, especially the intervertebral discs,
which could later lead to disc deterioration and strain. Hamstring stretching is thus often used to treat
lower back pain. According to Braman’s study (2016), hamstring stretching was beneficial for creating a
slightly bigger anterior pelvic tilt from that posteriorly tilted position when walking, more when bending
forward, and even when just standing. However, the impact that increased pelvic tilt has on lumbar
lordosis still needs to be further researched (Braman, 2016).

Anterior pelvic tilts

An increased anterior pelvic tilt is known to be predominant, especially in those who are seated for long
periods of time. In this case, it is known that the hip flexors tighten up, pulling the pubic symphysis
inferiorly (down), consequently causing stretched lower abdominal muscles, excessive lumbar spinal
extension (lordosis) and pain in the lower back area. The anterior pelvic tilt occurs due to rotation
occurring around the axis at the tibiofemoral hip joint (Gajdosik et al. 1985). Malarvizhi et al. (2017)
conducted an observational study in which they used a mobile pelvic tilt calculating application to
measure the anterior tilt in both males and females that showed signs of pain in the lumbar spine
region. Their study concluded that there is definitely a greater anterior tilt in patients who show pain in
the lower back, regardless of gender or age (Malarvizhi et al. 2017).
Femoroacetabular impingement
Pelvic tilt changes are interrelated to painful femoroacetabular impingement (FAI), non-specific groin
pain, and also to a painful hip during fundamental functional activities e.g., squats, gait cycles, and
single-leg step downs (Atkins et al. 2020 & Suits, 2021). The studies that Suits (2021) mostly covered
showed that patients with hip/groin pain usually have a bigger anterior tilt or a reduced posterior tilt.
However, he stated that there are still some differences across all studies with regards to whether and
to what degree patients with pain exhibit a greater or reduced pelvic tilt (Suits, 2021).

One study found that FAI patients who have pain may exhibit a decreased anterior tilt, which may be an
adaptation to avoid that pain from increasing by providing the hip a larger available range of motion
during a functional movement like walking (Atkins et al. 2020). On the other hand, some individuals with
FAI perform e.g. squats or step downs with an increased anterior tilt, which can cause faster
impingement and aggravate already existing symptoms (Suits, 2021 and Atkins et al. 2020). The exact
reason as to why the pelvic tilt differs in symptomatic patients is still vague and likely differs over a
variety of populations due to various factors (Suits 2021 & Pierannunzii et al. 2017).

Pelvic tilt changes also directly impact the hip range of motion. It has been observed that an anterior tilt
decreases the range of hip movement until impingement happens, which can lead to a decreased range
of motion sometimes observed in symptomatic FAI patients (Suits, 2021 & Ng, 2018). Due to the
tendency of the available efficient range of hip movement being influenced by the pelvic tilt, it is
recommended that it will be beneficial to specifically measure and target changeable issues that
influence the pelvic position during rehabilitation (Suits, 2021). Pelvic tilts not only affect the
musculoskeletal pathologies and hip ROM, but also affect common rehabilitative treatments, objective
measurements, appropriate muscular activation, and the effective execution of typical exercises (Suits,
2021).

Figure 1 – FAI types (Chris Centeno, 2021)

Lumbopelvic pain in pregnant women

Lumbopelvic pain (LPP) commonly affects women during and after pregnancy by negatively impacting
their functional movement patterns and daily activities. The primary aspects that influence their LPP are
increased joint laxity (particularly in the SIJ), femoral/pelvic anteversion, and changes in physiological
shape and body composition which in turn changes their daily movement patterns causing e.g. changes
in walking speed and pattern (Morino et al. 2017).
From the study they conducted, Morino et al. (2017) concluded that pelvic and lumbar movement
asymmetry during walking influences LPP while LPP affects the torso’s movement during gait and in turn
pelvic misalignment. Pelvic alignment and gait pattern assessment while concentrating on specific
misalignments is thus important for managing pain in the lumbar and pelvic region during pregnancy.

Femoral and pelvic anteversion

Figure 2 - Normative 3D acetabular orientation measurements in a standing position (Thelen et al. 2017)

Femoral/pelvic anteversion which is the internal/forward rotation of the femur in the

femoroacetabular joint changes in response to pelvic tilt alterations (Yang et al. 2019 & Limb
Lengthening 2022). This is vital, especially for individuals who undergo a total hip arthroplasty (THA) as it
influences the prosthesis’s ability to stay stable and the durability thereof, which then affects the
prevention of future hip dislocations (Yang et al. 2019). Various literature support that a greater anterior
pelvic tilt is associated with a decreased pelvic anteversion. A greater femoral anteversion angle is then
accompanied by reduced anterior tilt which would thus be a posterior tilt (Yang et al. 2019). Yang et al.
(2019) suggest that when designing the amount of anteversion in the prosthesis (in the case of a THA),
one must take into consideration certain aspects of each individual e.g. the person’s age, spinal
pathology, spinal surgery history, and mobility of the spine and pelvic region. This will aid in reducing the
chance of pain after surgery, especially during rehabilitation.

Conclusion
According to the findings, it can be said that pelvic tilts can definitely affect the level of pain in a
symptomatic individual. However it is evidently client specific and depends on that client’s physical bony
structures, history of injuries, level of previous pain experienced as well as the level of chronic versus
acute pain.

Immediate relief can be felt with the required alteration of the pelvic position; however, the degree and
duration thereof of this relief is definitely dependent on each individual and must be considered before
setting up a pain relief program.
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