Most therapists are aware of what an anterior pelvic tilt and lumbar hyperlordosis are. We have all seen the diagrams plenty of times demonstrating an anterior pelvic tilt compared with a neutral spine and, of course, a posterior pelvic tilt. However, have you ever stopped to think about what is actually going on within the spine and the muscles, and why this is a pain generating condition.
Plenty of clients have some sort of improper alignment in their pelvis and lumbar spine. (and the rest of the spine too) So, I think it is important to break down the commonly visualized lumbar spine/pelvic tilt graphic to show just how important this is for us therapists and what actually causes the pain associated with it.
Besides tight muscles being potentially sore, why does pain actually develop from anterior pelvic tilt? As massage therapists, we tend to focus our brain power on analyzing musculature (for obvious reasons). However, understanding the other involved structures is also very important as well.
Within the lumbar spine, we have 5 lumbar vertebrae and their coinciding intervertebral joints. These structures are primarily responsible for supporting the weight of the rest of the spine while also providing flexion, extension, lateral flexion, and some rotation. These structures, when healthy, have a mild to moderate lordosis, which enables the body to move easily and pain-free. Altogether a well-designed system for strong and fluid movement throughout the body.
Also present between the lumbar vertebra are the facet joints which form the articulation between the different vertebrae. This is where we will focus on this discussion.
When an anterior pelvic tilt is present, the curvature of the lumbar spine is increased. This creates what is called a lumbar hyperlordosis. When this occurs, the 5 lumbar vertebrae can become locked into an increased arched curve, and the facet joints become compressed due to their location posteriorly on the spine. This compression of the facet joints is where pain can arise.
In a healthy spine, the facet joints enable the spine to move in a free yet controlled fashion with multiple planes of movement. However, as these same facet joints interact with each other in a compressed fashion due to a hyperlordosis, irritation and inflammation occur in and around the facet joints. The longer this compressed functionality is present, the more likely that pain and lasting damage will occur. This can lead to conditions like Facet Joint Syndrome which is the chronic degeneration of these joints due to chronic irritation, and usually a result or coupled with intervertebral disc degeneration (degeneration of the intervertebral disc which results in decreased space between the vertebra, resulting in pain and possibly nerve compression).
So what causes an anterior pelvic tilt and lumbar Hyperlordosis?
Anterior pelvic tilt is caused by muscle imbalances within the lumbar and pelvic region. That is the short answer. Now for the long version.
Ruling out a genetic abnormality where the spine is formed with a deeper lordotic curve, or serious spinal conditions, such as spondylolisthesis and arthritic changes are present, a hyperlordosis in the lumbar spine is usually caused by muscle imbalance. As you may know, weak abdominal muscles coupled with a tight iliopsoas is usually the culprit of an anterior pelvic tilt. We know this. However, what causes these muscles to do this.
One answer to this lies in the ever-easy-to-blame inactive lifestyle. As we sit for multiple hours per day, the core muscles of the body become deconditioned. This is especially true for the abdominals (this includes rectus abdominus, transverse abdominus, and both obliques). These muscles are postural and meant to be used to support the body through all types of movement. Sitting in a soft, supportive chair for the majority of the day does not encourage the conditioning of these muscles. Once these muscles are weak, the body loses its anterior core support, and thus its ability to hold itself in a neutral spine position. This allows for a Hyperlordosis in the lumbar spine.
Another factor that contributes to weak or inhibited abdominal muscles is pregnancy and post-pregnancy complications due to diastasis recti (separated rectus abdominus). Both essentially limit and even eliminate the ability of the rectus abdominus to provide support to the spine leading to potential anterior pelvic tilt and lumbar hyperlordosis.
Excessive belly fat is another common issue which leads to weak abdominal muscles. When the weight of a large belly is present, it changes the body’s center of gravity, pulling the lumbar spine forward and into a deeper lordotic curve. This coupled with added weight can lead to low back pain due to an increased lordosis.
Looking at musculature, the iliopsoas becomes involved when sitting for long periods of time is a daily occurrence. Functionally speaking, when in a seated position, the iliopsoas (as well as anterior adductors and rectus femoris) are shortened. Over time, this shortened length can become “normal” and begin to influence the way the body moves as a whole. Because the iliopsoas attaches to the anterior of the lumbar spine, it begins to pull the spine into flexion when shortened. Because the body needs to stay upright to work optimally, the body compensates by increasing the lumbar lordosis to allow for the rest of the spine to stay upright. Once again, hyperlordosis will be the result.
The combination of weak abdominals and tight iliopsoas muscles results in shortened lumbar erectors (including quadratus lumborum) and weak hamstrings. Now the classic illustration of anterior pelvic tilt is popping into your mind.
Once these characteristics are present, the lumbar spine will be in a hyperlordotic posture and the facet joints will be prone to irritation. Once this begins, the chronic pain cycle will continue as long as the muscular imbalance is present. The longer this posture is present the more chance of facet joint syndrome forming and degeneration within the spine. This is why anterior pelvic tilt is a problem.
So, what is the cure for this type of pain?
The answer to treating a lumbar hyperlordosis is to release the psoas to allow for the spine to return to a neutral posture. This must also be coupled with releasing the spinal erectors, including multifidi and quadratus lumborum. This will allow the lumbar lordosis to relax and return to neutral, allowing for the facet joints to decompress and pain to diminish. By applying manual therapy to these muscles we can cause the hyperlordosis to decrease and pain to be alleviated. These are great treatments; however, the fix does not stop there. In order to truly fix the issue, daily habits of inactivity and postural weaknesses need to be addressed. This means getting your clients off their butts and getting them active.
One of the best exercises for clients with low back pain is walking! It seems like such a simple exercise but truly it does wonders for the human body. In the specific case of an anterior pelvic tilt, it has two benefits for long-term relief. First, it functionally trains the iliopsoas to elongate and not be chronically shortened down. Being in an upright position and using full strides naturally lengthens the psoas in a very functional way. Second, walking uses numerous core muscles which is a problem with our condition. Over time, walking can restore flexibility and strength to the low back, alleviating pain.
Incorporating iliopsoas, adductor, and rectus femoris stretching into a daily routine are very beneficial. This encourages the shortened muscles to elongate and regain flexibility. (See Video below)
Lastly, doing specific abdominal exercises is important. All of the abdominal muscles assist in supporting the lumbar spine. By strengthening these specifically, a strong neutral spine is encouraged.
A Lumbar Hyperlordosis is an important postural condition to be aware of. Treating it the right way is even more important. If we as therapists can treat our client’s pain by releasing correct tissues, we can give them pain relief. If we can also relay the importance of daily exercise (like walking) to enable them to regain natural functionality, then we will have made a difference long-term in their spinal health.
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