Understanding Back Pain - Anterior Pelvic Tilt
Updated: Mar 26
A large majority of people who contact me, contact me because they have chronic back pain (possibly amongst a host of other symptoms as well). It is an affliction that nearly everyone has in our modern day, Western society.
People get told they have extremely scary sounding and complicated things that are wrong with them; they resign to their fate of a lifelong problem and something being inherently 'wrong' with their backs for evermore . They think there is nothing they can do to aid their back pain and will go down the rabbit hole of immobilisation, painkillers, injections and possibly even surgery.
I want to make the bold claim that the combination of:-
a) someone who is committed to getting themselves better and knows their body WANTS to be free from pain (but just needs to learn a new way of moving)
b) Postural Alignment Therapy can ease the symptoms of back pain in the vast majority of people suffering most types of chronic back pain.*
Most chronic back pain ultimately stems from the positioning of your pelvis (many other types of pain can also be caused by the position of your pelvis - it's really important).
The position of your pelvis is dictated by the muscles that hold the pelvis in place. (The position of your pelvis is also dictated by what your feet are doing, your calves are doing, your thighs are doing, your hips are doing ... but for the purpose of this article, let's stay pelvis centric!)
When the muscles that hold your pelvis in place shift (through tightening/overuse and/or loosening/underuse), the position of your pelvis shifts. This has a ricochet effect on the functioning capabilities throughout your whole body, especially the spine.
The pelvis is the base support for your spine (and many other body parts!) and therefore, when the pelvis shifts, the architectural integrity of your spine is upset and the spine has to shift to try and balance out the new position of the pelvis and to keep your heavy head upright. This creates an unnatural and uneven load through your spine and eventually, pain sets in.
We get very focused on the symptoms of pain that we get diagnosed with (eg. the bulging/herniated disc, the osteoarthritis, the spondylosis etc). Those symptoms are very real: they are very scary and paralysing to experience, but treating the symptoms will not treat the root cause of the pain in the long run. Symptoms often present in areas taking too much load, not the ones not working at all. These bits are the underlying dysfunction causing your problems.
Pumping yourself full of injections (et al) into the area of pain is simply masking the pain. The underlying movement problem that is causing the symptom isn't being treated, you'll be continuing to move dysfunctionally but you just won't feel the pain ... that is, until it hits another part of your body. As an analogy, you're mopping up a drip from the floor rather than fixing the leak.
We are movement machines. We need to move. The human body grows and heals through constant physical stimulation. Our cells and systems literally need movement to work. Without movement, we are starving them of things they need to operate. Keeping still (ever, but especially as part of a recovery programme for chronic pain) makes no sense whatsoever.
I have said a lot of stuff which might not make too much sense or may have made TOTAL sense and you want to read more. So please, get reading below!
If you're thinking -
"Don't be ridiculous! I have a bulging disc which was caused by me bending over to pick up a dog toy once. My back pain has NOTHING to do with the muscles that hold and support my pelvis and my lifetime of habits, it is much more serious than just my muscles! How can it be my muscles when I have been constantly on my feet my entire life? I have never driven in a car, I have never sat down for hours at time, I don't use computers! It is irreversible. This is my life now. My disc is bulging because it is diseased and I am getting older, nothing can be done and I need to take it easy and not move too much."
... that's your prerogative and maybe don't bother reading on!
* P.S - I am not discouraging ANYONE from going to the Drs if you suffer back pain, please go! There may be other underlying medical conditions that are causing your pain. But I also implore you to really ask questions of the medical intervention that is being offered to you as a solution. Ask them WHY the cortisone injections will help improve your movement patterns (which are the cause of the wear and tear) long term? HOW will the spinal fusion help you move more and keep you mobile, when some vertebrae will be glued together prohibiting natural movement? You're your best judge. You know your body and how you feel. Do the answers given satisfy you? Does the methodology make sense for a long term solution to your problem? If you're happy with it, then go with the experts. If you think it's not quite rock solid, please do get in touch before you go ahead with anything which may be irreversible. It's worth a chance even if you're skeptical. The one thing you can't reverse is medical intervention. Also, please read the 'Pain Free' by Pete Egoscue book.
So, to start with, you need to decide if you think you have an anterior or posterior (or neutral!) pelvic tilt. Have a look at this picture. Imagine your pelvic girdle (the triangle in the picture) as a fruit bowl. Does your fruit bowl tilt backwards (like the first skeleton), is it balanced or is it tilting forward (like the third skeleton). Got your answer? (Hint - most people are posterior. Lots of people THINK they are anterior but it's only because they have a stiff lower back, rather than actually having the downward tilt at the front of the pelvis)
Today we look at the Anterior Pelvic Tilt (APT) and why it may cause you pain.
Anterior Pelvic Tilt
If your pelvis tilts forwards, you've an APT. You might look a little bit like this.
If you think about how you sit - do you roll your pelvis forward and is there an arch in your lower back (lumbar lordosis) as you are sat down for 'x' amount of hours each day? An APT is actually a separate postural deviation to lordosis (as one concerns the pelvis and one concerns the lower back) but one often accompanies the other (but not always).
As an APT, you may well be accompanied by thoracic kyphosis, outward turning knees, outwards turning feet and quite a wide stance (however, all these things can be observed with the opposite pelvic tilt, a Posterior Pelvic Tilt too).
There are a number of reasons why you might have an excessive APT but predominantly, the reasons are a combination of a) how you sit b) you sit too much and c) you've created a great deal of strength into this dysfunction - possibly through taking a body that sits too much to lots of exercise and sport.
Naturally, humans should have a little bit of APT in the pelvis. It helps us walk and move as a bipedal primate. Having a little bit of an APT is correct, but the issue is when we spend a significant amount of time sat down with an APT, as this really exaggerates and locks in the excessive curve and puts pressure on the lower spine.
When your pelvis tips forward, it affects the position of the base of your spine and pushes it forwards too. The pressure in the lumbar spine can then also force your thoracic (upper) spine into kyphosis to try and balance out your spine. Your back now is pushed into a more severe 'S' shape than is natural. This means your lumbar (lower) spine and pelvis is in a state of frequent (if not constant) extension, which it isn't designed for and this is why pain might set in.
No part of our body is designed to be permanently locked in a one position. A lumbar spine and pelvis which cannot return to neutral or flexion, will be one that creates biomechanical problems (and vice versa - A Posterior Pelvic Tilt).
From a skeletal system perspective, you can see in this picture why you might start having back problems (there's too much pressure in an area which isn't designed to have constant pressure on it) and also hip problems (there's too much pressure in an area which isn't designed to have constant pressure on it). Also, check out the compensating kyphosis on this guy.
If we sit for too long with our lumbar spine hyper extended, our muscles get frozen in this position. They are merely doing exactly what they are supposed to do - adapting to the load and demand you have put on your body. This means it is hard to then unfreeze them when we take our bodies out of our chair and go elsewhere.
Lots of really sporty and fit people have an APT (like this 'triangle man' below).
This is because lots of sports and activities call for a degree of APT and therefore, lots of sporty people will be frequently doing activities which put their bodies into a state of APT, and this, over time (combined with their sitting habits/desk job), gets locked in by their muscles, as the muscles adapt to the load and demand.
You might say, but if lots of sporty and fit people have APT, doesn't that mean it is good?
No. The problem is that -
a) sporty people still lead generally sedentary Western lives.
b) lots of sports are very high intensity/repetitive which drive strength into a dysfunctional body.
Sporty people are often asking demands of the human musculoskeletal system that the body isn't designed to do at the level and frequency that we do it nowadays (PLUS they are using bodies that have spent much of a lifetime sat down).
30,000 years ago, when people were living the life our bodies have evolved for, there wasn't time for bodybuilding, ultra marathons and Crossfit! When someone becomes very keen on 'their' sport it is likely they are not getting a sufficient variety of movement to restore musculoskeletal equilibrium (unless they are actively pursuing a real mix of sporting activities which ask for a completely different musculoskeletal load and demand).
So, whilst people with APT may be strong in many ways, the compensation the APT has caused (the lumbar lordosis) is an architectural weak spot waiting to crumble.
At some point, we will try and take the frozen APT to a sport it isn't functional enough for (eg. trying to do a yoga move which requires sudden lumbar flexion) or try and do something our body isn't functional enough for (eg. bending over to pick up a dog toy), and the APT will cause a spasm or another problems.
We will blame that sport, or blame bending over, but in reality it is a lifetime of having an APT which is the problem.
Functional bodies are supple and really strong (and real strength is not merely having bulging superficial muscles - real strength is having joints in the positions they should be in and muscles which all work in synergy). A fully functional body has very few 'awkward' positions that could cause a massive problem. Our body is perfectly designed to move 'awkwardly' on a temporary basis, if we are moving functionally the majority of the time. The problem is that too many of us are not functional the majority of the time and we are occasionally putting demands on our dysfunctional bodies that they are simply not capable of, which causes pain. We blame that movement/sport rather than the dysfunction itself. We have had the dysfunction for so long that we have become blind to it.
We need to treat the muscles which are locking your body into lumbar extension and get them moving enough to allow you to get them into lumbar flexion.
I don't want to confuse anyone with long, Latin names and, to be honest, it isn't that important you know. All the muscles work together and there is no point isolating or focusing on one specific muscle, as it is better to focus on how to get the whole frozen area to move in synergy, but, just in case you're interested, people with an anterior pelvic tilt will generally have a loose rectus abdominis (responsible for lumbar flexion), loose glutes (hip extensors) and loose hamstrings (also hip extensors). They'll generally have tight spinal extensors (which keep the back upright) and tight iliapsoai (the primary hip flexors, which are constantly contracted as you sit down with an APT - you can see in this picture how a tight psoas pulls the spine together).
(To reiterate - These muscles not working in synergy as they should do, locks the lumbar extension into place and over time, will cause chronic pain due to unnatural loading and a deviation from the correct architecture of the spine.)
It is all about waking up the muscles and not about fiddling with the skeletal system. Specifically, in the case of APT, it is about teaching your body to move comfortably into a state of lumbar and pelvic flexion. Once you can do this, the rest will follow. I have put links to four videos below with suggested positions/exercises for people with an Anterior Pelvic Tilt.
You need to gently remind the frozen muscles surrounding the pelvis of what they should be doing and hopefully, once they have woken up and you're a bit more functional, change some of your habits so it doesn't happen again.
It is not about quitting your job and living like a caveman, it's about giving your body enough motion to keep your joints and muscles happy in the manner for which they are designed.
Postural Alignment Therapy/The Egoscue Method will give you a very gentle, physical programme (perfectly adapted your body's limitations and dysfunctions - it will not hurt you and will never ask more of you than what you are capable of doing) which will wake up the muscles and start to restore your correct, functional postural alignment and relieve you of pain you may have been told is inevitable. You will begin to permanently fix and change your posture and pain!
Four videos to help with an Anterior Pelvic Tilt - PLEASE LISTEN to your body. If any of them cause you pain, they aren't the move for you and please don't do them!