Category Archives: Low Back Reconditioning

Degeneration? More Like Normal Aging

It is absolutely imperative that we fitness industry folks understand that degeneration is a normal aspect of aging. If we told everyone with degeneration not to exercise, everyone would suddenly be sedentary, and a host of greater problems would rapidly arise.

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If you don’t have some signs of degeneration, then you’d be “abnormal.” I’m fairly certain that if all of the people reading this post were to obtain full body MRI’s, evidence of degeneration would show up in multiple regions of the body in 100% of individuals. Want some evidence?

First, let’s talk about spinal intervertebral discs. Around 20% of teens have mild disc degeneration, and 60% of discs of 70-year olds are severely degenerated (Urban and Roberts 2003). If you’re looking at the L5-S1 disc of 70-year olds, over 90% of them will be degenerated (Hagiwara et al. 2014).

Looking at people with zero back pain, 64% have abnormal discs (52% had bulges, 27% protrusions, and 1% extrusions), with 38% of the individuals having abnormalities in multiple discs (Jensen et al. 1994). According to a systematic literature review by Brinjinkji et al. 2015, “The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.”

When looking at arthritis, around 7% of 18-44 year olds have it, and in persons 65 or older, this percentage rises to 50% (2010-2012 NHIS).

If we hone in on the knee joints, 20% of persons under 65 have knee osteoarthrits, whereas 50% of persons over 65 have it (Bhatia et al. 2013). Even 50-90% of athletes with no pain have serious knee abnormalities under MRI (Brunner et al. 1989, Mayor & Helms 2002, Kaplan et al. 2005, Walczak et al. 2008). Regarding meniscal tears, here’s what Dr. Felson had to say: “The rule is, as you get older, you will get a meniscal tear. It’s a function of aging and disease. If you are a 60-year-old guy, the chance that you have a meniscal tear is 40 percent.”

At the hip, 100% of persons older than 60 have acetabular rim degeneration (Leunig et al. 2003), and 63% of gymnasts have signs of ischiofemoral impingment (Papavasiliou et al. 2014).

If we examine the shoulder joints, we’ll see that 31% of persons older than 60 have shoulder osteoarthritis (Chillemi & Franceschini 2013). In 40-70 year old males, 96% have abnormal ultrasound scans – ranging from subacrominal-subdeltoid bursa thickening (78%), acromioclavicular joint osteoarthritis (65%), suprispinatus tendinosis (39%), subscapularis tendinosis (25%), partial-thickness tear of the bursal side of the supraspinatus tendon (22%), posterior glenoid labral abnormality (14%), amongst other abnormalities (Girish et al. 2011). Dr. Andrews found that in healthy professional baseball pitchers, 90% had abnormal shoulder cartilage and 87% had abnormal rotator cuff tendons. For this reason, he stated, “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.”

As you can see, degeneration is not abnormal – it’s a normal process of aging and it shouldn’t be thought of as a reason to stop moving and exercising. Every single one of us have degeneration, yet we still find ways to exercise. Strength & conditioning and sports medicine professionals must embrace this phenomenon and provide recommendations as to how individuals with varying signs of aged joints can continue being active, employ resistance training, and participate in sports in the most optimal manner possible. This requires consideration of total health & wellness, since sedentarism can lead to weight gain and obesity, metabolic syndrome, frailty and sarcopenia,  and depression (for a comprehensive list of reasons why exercise is beneficial, click HERE).

Focusing on people’s degeneration can provide a nocebo effect which is counterproductive and can lead to pain or increased pain. Instead, we should focus on what people can do (not what they can’t), and augment the way we talk about “degeneration” by assuring people that it’s normal and part of getting older. Activities and exercises can be modified so that individuals can well-tolerate them. Knowledge of proper progressions and regressions (I refer to this as, “Movement Pattern Continuums“) in resistance training goes a long way in keeping people strong and healthy.

Props to The Sports Physio Adam Meakins for providing me with the idea for this blogpost.

 

Neural Flossing for the Strength and Conditioning Professional

Neural Flossing for the Strength and Conditioning Professional
By Dr. Chris Leib
www.MovementProfessional.com

Neural flossing is physical therapy technique that uses specific exercises to improve mobility to different tracts of the nervous system. Recently, neural flossing has come into vogue in the strength and conditioning community1-4. The utility of such techniques in this sector, however, are questionable at best.

Examples of the lack of understanding and misapplication of neural flossing are far too easy to come by in the popular fitness media:

  • A post on Livestrong.com1 described flossing of the sciatic nerve as a “massage” for the nerve when it becomes compressed by muscles and/or bones.
  • The Wilmington Performance Lab site2 confidently claimed – without scientific reference – that scar tissue adhesions around the sciatic nerve are the most common cause of sciatic nerve-like symptoms. It went on to add, also without reference, that “fortunately, this compression and poor tissue quality surrounding the nerve can be alleviated in most individuals with neural/spinal flossing.”
The slump test: a common neurodynamic assessment

The slump test: a common neurodynamic assessment

The true value of neurodynamic techniques actually lies in the ongoing assessment process that focuses on an individual’s unique injury-specific symptoms, not so much in the techniques themselves. The trouble is, this process of assessing symptomatic response falls outside of the scope of practice of many of the strength and conditioning professionals promoting these exercises.

In the absence of pain, neurodynamic techniques can indeed be performed safely in a strength and conditioning environment. However, in a healthy individual, the nervous system is dynamic; it naturally moves in conjunction with muscle and joint action. Therefore, neural mobility is often already incorporated into good functional movement and mobility practices through dynamic warm-up, making specific neurodynamic techniques superfluous.

All this being said, with their recent proliferation into the broader fitness community, neurodynamic techniques have become needlessly mystified. I present the concepts below in an effort to erase misconceptions and allow for improved communication and referral networks between coaches and clinicians. I also demonstrate the proper application of the techniques into a dynamic warm-up in a strength and conditioning setting (video #3 below).

Criteria for Neurodynamic Treatment

The Maitland Australian Physiotherapy Seminars (MAPS) curriculum describes three major criteria when considering whether neurodynamic treatment would be relevant to a patient’s symptoms:

  1. Does the neurodynamic assessment technique reproduce the comparable sign (the patient’s chief complaint)?
  2. Is the response to the assessment technique different on the side of complaint versus the uninvolved side?
  3. Can the symptom be sensitized (i.e. changed by motion from a distant joint)? For example, is upper arm pain made better or worse with motion at the wrist?

In cases where all three specifications are met, the treatment techniques are actually fairly similar to those used for assessment. Variations are simply made to duration, frequency, and loading strategy (i.e. distal to proximal vs. proximal to distal) based on patient response.

It’s in these subtle adjustments that the techniques become so valuable. It’s also here, in the skilled adjustment process, where the scopes of practice between healthcare practitioners and strength and conditioning professionals diverge.

The Seven Major Neurodynamic Techniques

Below, I’ve put together video demonstrations of the seven major actively-performed neurodynamic techniques described by David Butler in his revolutionary text, A Sensitive Nervous System.

The techniques are as follows:

  1. Upper Limb Tension Test (ULTT) 1 biasing the median nerve
  2. ULTT 2a biasing the median nerve
  3. ULTT 2b biasing the radial nerve
  4. ULTT 3 biasing the ulnar nerve
A relationship between the nerve branches of the upper extremity:

A relationship between the nerve branches of the upper extremity:

The median nerve originates in the brachial plexus (network of nerves in the cervical, pectoral and axillary region) and travels down the front of the upper extremity crossing the anterior shoulder, elbow, and wrist (under the carpal tunnel) and ends in the hand.

The radial nerve comes out of the brachial plexus and travels into the posterior arm and then spirals to the anterior arm before spiraling back to the posterior forearm and wrist.

The ulnar nerve comes out of the brachial plexus and travels down the posteriormedial aspect of the arm, forearm and wrist. Compressing this nerve at the elbow creates “funny bone-like” symptoms.

See video #1 here for a demonstration of ULTT’s:

  1. The straight leg raise (SLR) biasing the sciatic nerve
  2. Slump test biasing the sciatic nerve

sciatic nerve

The sciatic nerve is the largest nerve in the human body. It originates from nerve roots L4 through S3 in the sacral plexus and then crosses the posterior aspect of the hip, knee, ankle and foot (branches into tibial and common fibular nerves once crossing the knee).

  1. The prone knee bend biasing the femoral nerve

femoral nerve

The femoral nerve, the largest branch coming off of the lumbar plexus, originates from L2-4 and then passes the deep anterior structures of the abdomen (psaos and iliacus) and groin (inguinal ligament) and then travels into the anterior thigh

See video #2 here for a demonstration of lower limb tension tests:

Take note of the use of the word biasing when describing the nerves being assessed. Too often we learn movement assessments and techniques under the guise of isolating structures. In the case of neural motion, it’s both scientifically unproven and anatomically impossible to isolate motion to a specific nerve branch. Moreover, from a practical standpoint, it’s not necessary to isolate any structure in order to assess the need for a neurodynamic approach.

complex system pose

In this complex system of systems, is it really reasonable to think we can isolate a stretch to any one specific nerve?

Neurodynamics in Dynamic Warm-up

The third and final video below is a discussion and demonstration of dynamic mobility exercises that incorporate all of the above-mentioned neural mobility techniques. These movements can be used by both clinician and coach – in the absence of pain – as a dynamic warm-up and as corrective counterbalances for chronic positioning (i.e. sitting, standing, etc.).

See video #3 here:

Remember, the value of specific nerve flossing or neurodynamic techniques lies in the assessment process, which should be reserved for the hands of a licensed health care professional only. As a strength and conditioning professional, it’s wise to find a clinician you trust and can build a referral relationship with. This way, your clients can get out of pain faster, and you can get the most of out of their physical performance.

References

  1. http://www.livestrong.com/article/287430-sciatic-nerve-flossing-exercise/
  2. http://wilmingtonperformancelab.com/general/improving-hip-mobility-relieving-sciatic-nerve-pain/
  3. http://www.tacomastrength.com/news/post/neural-flossing-07252012
  4. https://www.youtube.com/watch?v=UoUqfOGuEOU

About the Author

Chris Leib of MovementProfessional.com is a licensed Doctor of Physical Therapy and Certified Strength and Conditioning Specialist with nearly a decade of experience in treating movement dysfunctions and enhancing human performance. He has written for StrengthCoach.com and FuBarbell.com and has a versatile movement background with a variety of certifications as both a physical therapist and fitness professional. Chris considers physical activity a vital process to being a complete human being and is passionate about helping others maximize their movement potential. Be sure to follow him on Facebook and YouTube.

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Special thanks to Travis Pollen of www.fitnesspollenator.com for help turning this piece into something readable and hopefully valuable.

 

Current Position Statement on Anterior Pelvic Tilt

There are many misconceptions in the strength training and physical therapy communities regarding anterior pelvic tilt (APT). In this article, I will post my current thoughts and beliefs pertaining to APT, specifically concerning the questions listed below. Where possible, I will support my statements with scientific references from the literature.

  1. What is APT?
  2. Is APT advantageous from an evolutionary perspective?
  3. Can we fully trust all research measuring APT?
  4. Is APT abnormal?
  5. Does APT lead to low back pain in typical everyday living?
  6. Can APT lead to back injury in heavy resistance training?
  7. Do the spine and pelvis actually stay in neutral during heavy or explosive movement?
  8. Why do ground sport athletes tend to develop APT?
  9. Why do lifters tend to APT during various resistance training exercises?
  10. What strategies can be employed to shift APT towards a more neutral alignment?

What is APT?

Possessing anterior pelvic tilt simply means that your pelvis is tilted forward to a greater degree than what is deemed normal. As you’ll see later in the article, there are issues with classifying anterior pelvic tilt. In the video below, Sam Visnic does a great job demonstrating what anterior pelvic tilt is, however, since he created this video in 2011, some of his opinions might have changed since then. I have different data with regards to correlations to back pain and normal degrees of anterior pelvic tilt, which will be explained below in the article. However, the video does a good job of representing the current prevailing thought process that most manual therapist and sports medicine professionals (including licensed massage therapists, physical therapists, osteopathic doctors, occupational therapists, athletic trainers) share in regards to APT, so it’s definitely worth watching.

In case you didn’t watch the video, I got you covered. Tilting the pelvis forwards as in the action depicted in the first image below is referred to as anterior pelvic tilting, or anteriorly tilting the pelvis, whereas tilting the pelvis rearward as in the action depicted in the second image below is referred to as posterior pelvic tilting, or posteriorly tilting the pelvis.

Left: Anterior Pelvic Tilt, Right: Posterior Pelvic Tilt

Left: Anterior Pelvic Tilt, Right: Posterior Pelvic Tilt (from Neuman 2010)

Stand up and take a moment to move your pelvis into these positions. Notice the different musculature responsible for producing these motions. If you do them correctly, you’ll feel the lumbar erectors and hip flexors tilting the pelvis anteriorly, and you’ll feel the glutes and low abs tilting the pelvis posteriorly.

Interestingly, if you were somehow able to reside inside the acetabulum of the hips, you wouldn’t be able to discern between anterior pelvic tilt and hip flexion, or between posterior pelvic tilt and hip extension. To quote Neuman 2010:

Theoretically, a sufficiently strong and isolated bilateral contraction of any hip flexor muscle will either rotate the femur toward the pelvis, the pelvis (and possibly the trunk) towards the femur, or both actions simultaneously. These kinematics occur within the sagittal plane about a medial-lateral axis of rotation through the femoral heads. Note that the arrowhead representing the line of force of the rectus femoris in FIGURE 1, for example, is directed upward, toward the pelvis. This convention is used throughout this paper and assumes that at the instant of muscle contraction, the pelvis is more physically stabilized than the femur. If the pelvis is inadequately stabilized by other muscles, a sufficiently strong force from the rectus femoris (or any other hip flexor muscle) could rotate or tilt the pelvis anteriorly. In this case, the arrowhead of the rectus femoris would logically be pointed downward toward the relatively fixed femur. The discussion above helps to explain why a person with weakened abdominal muscles may demonstrate, while actively contracting the hip flexors muscles, an undesired and excessive anterior tilting of the pelvis. Normally, moderate to high hip flexion effort is associated with relatively strong activation of the abdominal muscles. This intermuscular cooperation is very apparent while lying supine and performing a straight leg raise movement. The abdominal muscles must generate a potent posterior pelvic tilt of sufficient force to neutralize the strong anterior pelvic tilt potential of the hip flexor muscles. This synergistic activation of the abdominal muscles is demonstrated by the rectus abdominis (FIGURE 2A). The extent to which the abdominal muscles actually neutralize and prevent an anterior pelvic tilt is dependent on the demands of the activity—for example, of lifting 1 or both limbs—and the relative strength of the contributing muscle groups. Rapid flexion of the hip is generally associated with abdominal muscle activation that slightly precedes the activation of the hip flexor muscles. This anticipatory activation has been shown to be most dramatic and consistent in the transverse abdominis, at least in healthy subjects without low back pain. The consistently early activation of the transverse abdominis may reflect a feedforward mechanism intended to stabilize the lumbopelvic region by increasing intra-abdominal pressure and increasing the tension in the thoracolumbar fascia.

Without sufficient stabilization of the pelvis by the abdominal muscles, a strong contraction of the hip flexor muscles may inadvertently tilt the pelvis anteriorly (FIGURE 2B). An excessive anterior tilt of the pelvis typically accentuates the lumbar lordosis. This posture may contribute to low back pain in some individuals.

Although FIGURE 2B highlights the unopposed contraction of 3 of the more recognizable hip flexor muscles, the same principle can be applied to all hip flexor muscles. Any muscle that is capable of flexing the hip from a femoral-on-pelvic perspective has a potential to flex the hip from a pelvic-on-femoral rotation. For this reason, tightness of secondary hip flexors, such as adductor brevis, gracilis, and anterior fibers of the gluteus minimus, would, in theory, contribute to an excessive anterior pelvic tilt and exaggerated lumbar lordosis.

And here’s another quote from Neuman 2010:

With the trunk held relatively stationary, contraction of the hip extensors and abdominal muscles (with the exception of the transverse abdominis) functions as a force-couple to posteriorly tilt the pelvis (FIGURE 4). A posterior tilting motion of the pelvis is actually a short-arc, bilateral (pelvic-on-femoral) hip extension movement. Both right and left acetabula rotate in the sagittal plane, relative to the fixed femoral heads, about a medial-lateral axis of rotation. Assuming the trunk remains upright during this action, the lumbar spine must flex slightly, reducing its natural lordotic posture. While standing, the performance of a full posterior pelvic tilt, theoretically, increases the tension in the hip’s capsular ligaments and hip flexor muscles. These tissues, if tight, can potentially limit the end range of an active posterior pelvic tilt. Contraction of the abdominal muscles (acting as short-arc hip extensors, as depicted in FIGURE 4) can, theoretically, assist other hip extensor muscles in elongating (stretching) a tight hip capsule or hip flexor muscle. For example, strongly coactivating the abdominal and gluteal muscles, while simultaneously performing a traditional passive-stretching maneuver of the hip flexor muscles, may provide an additional stretch to these muscles. One underlying advantage of this therapeutic approach is that it may actively engage and potentially educate the patient about controlling the biomechanics of this region of the body.

Is APT advantageous from an evolutionary perspective?

No, it’s not. In fact, the opposite is true – posterior pelvic tilt (PPT) is advantageous. As we’ve evolved as humans, our lumbar spines have become more lordotic but our pelvises have become more posteriorly tilted to better conserve energy while standing, walking, and running by allowing us to utilize passive elastic energy storage from stretched soft tissue at the front of the hips. To quote Hogervorst et al. 2009:

When a chimpanzee walks upright, the pelvis is more vertical, but the hip maintains about the same position in the pelvis, i.e., is not extended. This is not caused by a lack of possible extension of the hip joint, but by a stiff lumbar spine that lacks lordosis (extension or retroflexion). The chimpanzee walks with flexion of both hips and knees to compensate the forward bent position of the spine that keeps the centre of mass of the upper body forward (ventral) to the sacrum. This “bent-hip, bent-knee gait” brings this centre of mass closer to the point of ground contact of the feet, but at the price of considerable work for hip, knee and back muscles.

When a human walks upright, hips and knees can be in much more extended positions because lumbar lordosis aligns the centre of mass of the upper body with the sacrum and the point of ground contact. Lordosis was made possible when considerable reduction in height of the ilium “freed-up” the lumbar spine, which itself lengthened when the number of lumbar vertebrae increased to five or six. A larger distance developed between lower ribs and iliac crest, creating a waist in the human trunk (as opposed to the barrel shaped ape trunk). The sacrum broadened markedly and tilted forward (horizontally). Changes in the shape and position of the facet joints further increased lumbar spine mobility. Lumbar lordosis thus benefits energy-efficient upright walking. In humans, standing erect requires only 7% more energy than lying down. Dogs use considerably more energy standing than lying, presumably because they have their hind legs flexed.

The downside of this “mobilization” of the lumbar spine may be a relatively insufficient erector spinae muscle. The potential for hypertrophy is likely hampered by the dorsal position of the transverse processes that developed with the “shortback”. Scoliosis and spondylolisthesis are virtually absent in the great apes. Perhaps these spinal malformations in humans are associated with the length and mobility of the lumbar spine and a relative erector spinae muscle insufficiency.

According to Neuman 2010:

Achieving near full extension of the hips has important functional advantages, such as increasing the metabolic efficiency of relaxed stance and walking. Full or nearly full hip extension allows a person’s line of gravity to pass just posterior to the medial-lateral axis of rotation through the femoral heads. Gravity, in this case, can assist with maintaining the extended hip while standing, with little activation from the hip extensor muscles. Because the hip’s capsular ligaments naturally become “wound up” and relatively taut in full extension, an additional element of passive extension torque, albeit relatively small, may further assist with the ease of standing. This biomechanical situation may be beneficial by temporarily reducing the metabolic demands on the muscles but also by reducing the joint reaction forces across the hips due to muscle activation, at least for short periods.

Can We Fully Trust All Research Measuring APT?

No, we cannot. Research data pertaining to anterior pelvic tilt should be interpreted with caution. Due to normal variations in pelvic shape within the human population, it is quite difficult to accurately determine pelvic posture, so all studies examining APT should be interpreted with caution (Preece et al. 2008).

Is APT Abnormal?

No, it’s not. According to a published study by Herrington 2011, 85% of males and 75% of females presented with an anterior pelvic tilt, 6% of males and 7% of females with a posterior pelvic tilt, and 9% of males and 18% of females presented as neutral. Anterior pelvic tilt is also the most common postural adaptation in athletes according to Kritz and Cronin 2008, and it seems to naturally occur with athletes that do a lot of sprinting. Therefore, it’s actually normal for healthy individuals to possess APT, and the average angle of anterior pelvic tilt ranges from 6-18° depending on the study and methods used to determine the angle, with around 12° appearing as the norm (ex: Youdas et al. 1996, Youdas et al. 2000, Christie et al. 1995, Day et al. 1984).

Sprinters tend to have APT

Sprinters tend to have APT

It is therefore normal to have some anterior pelvic tilt, and you shouldn’t be overly concerned about trying to neutralize your pelvic posture, assuming it’s not severe. To put it another way, if you don’t have some APT, you’re not normal.

Does APT Lead to Back Low Back Pain in Typical Everyday Living?

No, it does not. Studies examining the relationship between APT/lumbar hyperlordosis and back pain have consistently shown no or weak links – here are ten of them but I’m sure there are more (Murrie et al. 2003, Schroeder et al. 2013Nakipoğlu et al. 2008, Ashraf et al. 2014Nourbakhsh & Arab 2002, Youdas et al. 2000Tüzün et al. 1999, Mitchell et al. 2008, Christensen & Hartvigsen 2008, Laird et al. 2014). Again, do not be paranoid if you have some APT; it’s normal and it doesn’t increase the risk of developing low back pain compared to those with more neutral pelvic alignments, assuming heavy and explosive loads aren’t placed upon the structures on a regular basis.

There’s a lot more to low back pain (and pain in general) than meets the eye. Posture, structure, and biomechanics only provide part of the picture. For those interested in learning more about pain, please do the following:

  1. Learn about the biopsychosocial model of pain (as opposed to the postural/structural/biomechanical model)
  2. Follow Jason Silvernail and listen/read his interviews HERE and HERE
  3. Look into the work of Lorimer Moseley and other pain experts
  4. Also follow Greg Lehman (website, Twitter), Todd Hargrove (website, Twitter), Paul Ingraham (website, Twitter), and Adam Meakins (website, Twitter)

Can APT Lead to Back Injury in Heavy Resistance Training?

Yes, it can. However, please understand the difference between exhibiting APT as a posture and anteriorly tilting the pelvis as a movement strategy during heavy resistance training. As eluded to earlier in the article, you should definitely not be worried if you have a little bit of APT posture. There are a hundred thousand athletes practicing or performing right now with APT, and they get by just fine. Believing that APT is dangerous can deliver a Nocebo effect which isn’t good. Slight pelvic tilt is fine, but going too far into APT will usually result in excessive lumbar hyperextension, and going too far into PPT will usually result in excessive lumbar flexion (Levine & Whittle 1996, Day et al. 1984). Hence the term, “lumbopelvic rhythm” – lumbar extension and APT are associated with one another, as are lumbar flexion and PPT. When moving near the end ranges of their postural capabilities, these extreme postures combined with heavy loading can easily lead to injury over time.

Spinal hyperextension under high load can lead to higher incidents of spondylolysis and other injuries to the posterior elements of the spine (Roussoully & Pinheiro-Franco 2011, Alexander 1985). When you lift heavy weights, you usually want to keep your spine and pelvis as neutral as possible. However, there is some wiggle room in that it is possible to slightly tilt the pelvis anteriorly or posteriorly without dramatically affecting lumbar posture (it is my unsubstantiated belief that the sacrum must move with the pelvis which would mostly alter L5-S1 and L4-L5 posture, but L3-L4, L2-L3, and L1-L2 posture could remain relatively unchanged, but this would require study to substantiate the claim), which leads in perfectly to the next section.

Do the Spine and Pelvis Actually Stay in Neutral During Heavy or Explosive Movement?

Your spine and pelvis never really stay in neutral when performing dynamic movement; that’s a misconception. For example, the spine has been shown in the research to move considerably during exercises and activities that are thought to involve a relatively stable lumbopelvic region, including squats, deadlifts, kettlebell swings and snatches, rowing exercises, overhead pressing, good mornings, strongman exercises, sprinting, and jumping:

As you can see, the spine and pelvis do indeed move during heavy and explosive movement, indicating that the spine and pelvis are used dynamically to generate torque. In fact, during the deadlift, the spine can be used just like a crowbar by relaxing the lumbar erectors and using the hip extensors to “wind up” the spine against the barbell load until sufficient muscle torque is produced to raise the barbell off the ground, thereby relying on the passive structures such as the iliolumbar ligaments for torque generation. To quote Snijders et al. 2004:

For explanation of the loading mode in slouching we compared the spine with a crowbar, using the iliolumbar ligaments as fulcrum and pivot. This comparison illustrates the kinematics as well as the expected force magnification. Characteristic for the crowbar model is forward flexion of the spine combined with backward tilt of the sacrum relative to the pelvis. This loading mode is maximal when back muscle protection against flexion is absent, e.g. in relaxed slouched sitting. In this respect model calculations resulted in iliolumbar ligament stress near failure load.

Regular use of this lifting strategy would therefore be highly recommended if it weren’t markedly more dangerous, as the spine is not well-suited to handle full flexion of the spine. The spine is indeed designed to move during high load and high power sporting actions, but the motion should be limited to mid-ranges. Moving to end ranges of flexion, extension, lateral flexion, and/or rotation is exponentially dangerous and risky. Therefore, it’s wiser to rely more on the active structures (contracting muscles) than the passive structures (stretched erector spinae, stretched spinal ligaments, etc.) for torque generation under heavy loading. What then is the appropriate spinal and pelvic posture for every situation?

The answer to this question depends on who you ask. Stu McGill, the world’s leading expert in spinal biomechanics in relation to strength training, would tell you that the neutral position is always best for spine safety…both neutral spine and neutral pelvis. However, two legendary sports scientists by the names of Yuri Verkoshansky and Mel Siff (also the authors of Supertraining), felt otherwise. According to them:

The pelvis plays a vital role in the ability of the athlete to produce strength efficiently and safely, because it is the major link between the spinal column and the lower extremities… a neutral pelvic tilt offers the least stressful position for sitting, standing and walking. It is only when a load (or bodymass) is lifted or resisted that other types of pelvic tilt become necessary. Even then, only sufficient tilt is used to prevent excessive spinal flexion or extension… The posterior pelvic tilt is the appropriate pelvic rotation for sit-ups or lifting objects above waist level. Conversely… theanterior pelvic tilt is the correct pelvic rotation for squatting [and] lifting heavy loads off the floor. – Supertraining 2009

I’ve asked Stu McGill for his take on this matter and he defends his stance, saying that neutral spine and neutral pelvis is always best. He and Mel Siff were close friends before Mel passed away, and he believes that Mel would defer to his judgement on this topic since Mel (and Yuri) weren’t spinal biomechanists and didn’t study the topic for a living. My thoughts on this matter waiver, and lately I’m more inclined to agree with Stu. However, based on my experience, individuals with flexion intolerant spines seem to benefit from slight APT at the bottom of squats and deadlifts, and individuals with extension intolerant spines seem to benefit from slight PPT at the top of hip thrusts, back extensions, and deadlifts, indicating that ideal posture depends on the individual.

If you agree with Mel and Yuri and you believe that some slight pelvic tilt can help buttress the spine by creating torque in the necessary direction in order to help stabilize the spine and better prevent buckling, just make sure that the pelvic tilt kept in mid-ranges so it doesn’t dramatically impact spinal posture. In conclusion, either keep the spine and pelvis in neutral to the best of your abilities at all times during exercises that require core stability, or allow for some slight APT with the hips flexed and some slight PPT with the hips extended. Obviously, individual differences in anatomy and injury history must be taken into account when making this decision. Later in this article there will be an embedded video which will shed more light on this topic.

Why do Ground Sport Athletes Tend to Develop APT?

Ground sport athletes generally do a lot of running and sprinting. Kritz & Cronin 2008 state:

The advantages of anterior pelvic tilt and resulting lordotic posture are believed to be an increased hip extension, which allows the running and jumping athlete to apply force over a longer time resulting in a greater impulse.

Although the theory provided by Kritz & Cronin is very plausible, it is important to know that elite sprinters do not use greater hip extension ROM compared to novice sprinters, however, there are still a couple of very good reasons why APT could be markedly beneficial for sprinting speed.

The first reason is that the hip is stronger at hip extension when it’s flexed forward. Worrell et al. 2001 showcased the torque-angle curve for maximal isometric hip extension. Essentially, hip extension is strongest when the hips are fully flexed and weakest when the hips are fully extended.

This relationship has been shown to exist in probably 8 different studies that I’m aware of, and I verified this relationship on myself when I was in New Zealand experimenting on the Human Norm isokinetic dynamometer at AUT University. I assumed that since I could hip thrust 600+ lbs but only squat around 400 lbs at the time that I would possess an altered hip extension torque angle curve – one that was more flat or more even throughout the hip range of motion. But this wasn’t the case. I, along with subjects in all the other studies, possessed approximately 2.5 times more hip extension strength at 90 degrees of hip flexion compared to at 0 degrees of hip flexion (neutral position). Since APT is synonymous with hip flexion, this means that the hip range of motion associated with ground contact during sprinting will be stronger in someone with APT compared to someone with a more neutral pelvic posture.

The second reason is that at mid-stance during ground contact in gait, the hip ligaments that resist hip extension pull taut and reduce hip extension power (Simonsen et al. 2012). In fact, they reverse hip extension torque production to hip flexion production, which doesn’t make a lot of sense being that hip extension torque generates horizontal propulsive force into the ground (Huang et al. 2013) and is critical for faster running speeds (Schache et al. 2011). Horizontal force production is critical for faster running speeds as well (Brughelli et al. 2011, Morin et al. 2011, Morin et al. 2012, Morin et al. 2015). An athlete with more APT, or one that anteriorly tilts his or her pelvis to a greater degree when on the ground, will not run out of hip extension range of motion as quickly as an individual with a more neutral pelvic posture when the foot is in contact with the ground during sprinting, which will prolong the production of hip extension torque and subsequent horizontal propulsive force generation.

These theories need to be substantiated in future studies in order to be considered valid.

In Olympic weightlifting, at the bottom of a snatch lift, APT appears to be a highly important variable for successful lifts (Ho et al. 2007). This is probably due to the tendency to place the lifter in a better position to maximize power output during the 2nd pull phase of the lift. Heel elevation increases APT (Franklin et al. 1995), so it’s a wise strategy to wear heeled shoes when performing Olympic lifts.

Why do Lifters Tend to APT During Various Resistance Training Exercises? 

Any good strength coach witnesses dozens of incidents of APT during resistance training on a daily basis. You’ll commonly witness lifters anteriorly tilting their pelvises during glute ham raises, Nordic ham curls, lying leg curls, planks, ab wheel rollouts, push-ups, hip thrusts, glute bridges, back extensions, squats, deadlifts, good mornings, and bent over rows. The reasons why individuals resort to excessive anterior pelvic tilt during heavy resistance training is multifactorial and dependent on the movement in question and will differ depending on whether the APT occurs during a squat, a hip thrust, or an ab wheel rollout. Interrelationships between relying on the spine and pelvis for stability, relying too much on the hamstrings for hip extension, possessing poor gluteus maximus and/or abdominal strength, possessing excessively tight hip flexors and/or lumbar erector spinae, possessing unique individual hip anatomy, and/or possessing faulty motor engrams must be examined.

In case a list helps you, the reasons why athletes resort to APT are due to a combination of:

  1. Lack of knowledge of sound exercise form
  2. Poor motor control in the lumbopelvic region
  3. Insufficient abdominal/oblique strength and stability
  4. Insufficient gluteal strength and stability
  5. Insufficient hip extension mobility/tight hip flexors

Here I will provide my opinions and elaborate upon the general reasons why APT occurs during various types of movements.

Knee Flexion Exercises: glute ham raise, Nordic ham curls, lying leg curls

During knee flexion exercises, it is very common for lifters to resort to APT. Let’s assume that the lifter indeed understands proper form and isn’t anteriorly tilting the pelvis just because he or she doesn’t know any better. With this assumption met, lifters APT during knee flexion exercises to provide a muscular advantage. Since the hamstrings shorten during knee flexion, their force production potential is diminished. Knee flexion, hip extension, and posterior pelvic tilt shorten the hamstrings, while knee extension, hip flexion, and anterior pelvic tilt lengthen the hamstrings. By anteriorly tilting the pelvis during knee flexion, the length change is mitigated (the hamstrings don’t shorten as much), thereby allowing for better force production. For these exercises, it is natural for a lifter to resort to APT because it improves exercise performance. However, just because a particular technique allows for better performance, it doesn’t necessarily mean that the technique should be used, since it could lead to suboptimal results in strength and mechanics on the field. Therefore, it is recommended that the lifter focuses on motor control drills for the lumbopelvic region and learns how to keep the pelvis relatively stable during these exercises. Exercise difficulty can be regressed, and eventually the hamstrings will become stronger at shorter muscle lengths, thereby solving the problem.

Anti-Extension Core Stability Exercises: planks, ab wheel rollouts, push-ups

During anti-extension core stability exercises, it is also quite common for lifters to resort to APT. Let’s assume that the lifter indeed understands proper form and isn’t anteriorly tilting the pelvis just because he or she doesn’t know any better. With this assumption met, lifters APT during anti-extension core stability exercises for different reasons compared to knee flexion exercises. In the case of these exercises, the abdominals and obliques simply cannot maintain lumbopelvic stability during the exercise, and therefore they “fail” by entering into an eccentric contraction. Eventually, stability will be reached due to 1) bony approximation of the lumbar spine, which happens when the vertebrae get closer together – this provides passive stability, and 2) stretching of the anterior core muscles, which also provides passive stability. For these exercises, it is natural for a lifter to resort to APT because it improves exercise performance. However, just because a particular technique allows for better performance, it doesn’t necessarily mean that the technique should be used, since it could lead to suboptimal results in strength and mechanics on the field. Therefore, it is recommended that the lifter focuses on motor control drills for the lumbopelvic region and learns how to keep the pelvis relatively stable during these exercises. Exercise difficulty can be regressed, and eventually the abdominals and obliques will become stronger and better able to stabilize the neutral lumbopelvic position, thereby solving the problem.

Anteroposterior Hip Extension Exercises: hip thrusts, glute bridges, back extensions

During anteroposterior hip extension exercises, it is also very common for lifters to resort to APT. Let’s assume that the lifter indeed understands proper form and isn’t anteriorly tilting the pelvis just because he or she doesn’t know any better. With this assumption met, lifters APT during anteroposterior hip extension exercises due to 1) weak glutes, especially at shorter muscle lengths (at end range hip extension), 2) substituting lumbar extension and anterior pelvic tilt for hip extension, which provides an illusion that full hip extension or hip hyperextension is reached, and 3) producing a muscular advantage for the hamstrings musculature – by anteriorly tilting the pelvis during hip extension, the length change is mitigated (the hamstrings don’t shorten as much), thereby allowing for better force production. For these exercises, it is natural for a lifter to resort to APT because it improves exercise performance. However, just because a particular technique allows for better performance, it doesn’t necessarily mean that the technique should be used, since it could lead to suboptimal results in strength and mechanics on the field. Therefore, it is recommended that the lifter focuses on motor control drills for the lumbopelvic region and learns how to keep the pelvis relatively stable during these exercises. Hip flexor stretches for the psoas and rectus femoris can be employed if they are limiting hip extension mobility. The arc of motion during these exercises should stop once the hips run out of extension and reach the limits of its mobility. Exercise difficulty can be regressed, and eventually the gluteus maximus will become stronger at shorter muscle lengths, thereby solving the problem.

Axial Hip Extension Exercises: squats, deadlifts, good mornings

During axial hip extension exercises, it is also very common for lifters to resort to APT. Let’s assume that the lifter indeed understands proper form and isn’t anteriorly tilting the pelvis just because he or she doesn’t know any better. This is important to consider because many individuals have been taught to APT considerably during these movements, since this has been the prevailing cue over the past decade – think “chest up,” which emphasizes thoracic extension but will often bring the lumbar spine and pelvis into extension along with it. I still use this cue all the time with my clients, but “ribs down” has become popular too in the past couple of years, which emphasizes stabilization of the lumbar spine and is to be used with individuals that are prone to excessive spinal hyperextension during axial lifts. At any rate, assuming that individuals are aware of proper technique, lifters APT during axial hip extension exercises due to 1) producing a muscular advantage for the hamstrings musculature – by anteriorly tilting the pelvis during hip extension, the length change is mitigated (the hamstrings don’t shorten as much), thereby allowing for better force production, 2) substituting lumbar extension and anterior pelvic tilt for hip extension, which provides an illusion that full hip extension is reached, and 3) weak glutes (mostly in the case of the deadlift), especially at shorter muscle lengths (at end range hip extension), and 4) better passive force production at the bottom of the lifts – APT will lead to a greater stretch in the glutes, hams, and adductors, which increases muscle force production via elastic recoil. For these exercises, it is natural for a lifter to resort to APT because it improves exercise performance. However, just because a particular technique allows for better performance, it doesn’t necessarily mean that the technique should be used, since it could lead to suboptimal results in strength and mechanics on the field. Therefore, it is recommended that the lifter focuses on motor control drills for the lumbopelvic region and learns how to keep the pelvis relatively stable during these exercises. Exercise difficulty can be regressed, and eventually the responsible muscles for carrying out these exercises will become stronger at the appropriate muscle lengths, thereby solving the problem.

What Strategies can be Employed to Shift APT Towards a More Neutral Alignment? 

The vast majority of people don’t need to stress about their pelvic posture; they’re within the normal range and they aren’t in danger of experiencing injury. However, certain individuals will benefit from actively attempting to shift their postures towards a more neutral alignment, or at least from improving their motor control and stabilization strategies during exercise. Most manual therapists will recommend manual therapy such as massage or self-myofasical release (SMR) along with static stretching in order to improve APT postures. These methods can certainly help, but they pale in comparison to proper strength training in terms of efficacy in altering posture. So definitely do your stretches, but make sure you strengthen the proper muscles, especially at their respective suggested muscle lengths. It is recommended that the following strategies be employed for improving APT:

  1. SMR for the rectus femoris, adductors, and erector spinae
  2. Static stretching for the psoas, rectus femoris, adductors, and lumbar erector spinae
  3. Strengthening the abdominals and obliques, especially via posterior pelvic tilt
  4. Strengthening the glutes, especially via posterior pelvic tilt and at end-range hip extension
  5. Being mindful of using APT postures throughout the day and also during resistance training

Case studies by Yoo 2014 and Yoo 2013 have shown that strengthening opposing lumbar and pelvic force couples will lead to marked changes in lumbopelvic posture. Strengthening the abdominals and glutes will cause APT to move to a more neutral position, and strengthening lumbar erectors and hip flexors will cause posterior pelvic tilt (PPT) to move to a more neutral position. It’s important to note that studies such as Walker et al. 1987 have shown that those with APT are not weaker in the abs and studies such as Heino et al. 1990 have shown that those with APT do not have less hip extension ROM, but to alter pelvic posture, you’re probably going to need to get even stronger at shorter muscle lengths and longer hip flexors and erectors, in addition to modifying daily postural habits. Stretching is also important. Below is a video that shows various ways of improving hip extension mobility through hip flexor stretching, with special techniques such as tilting the pelvis posteriorly to increase the effectiveness of the hip flexor stretch.

It is vital to possess powerful hip muscles to dynamically propel the body as well as strong lumbopelvic muscles to stabilize the core. But strong muscles isn’t enough. You also need plenty of technical practice to ingrain proper movement patterns. Here’s a good video to watch pertaining to the lumbopelvic hip complex during squats, deadlifts, hip thrusts, and back extensions.

As I stated above, even though possessing anterior pelvic tilt is normal and you shouldn’t be overly concerned about it, some individuals with excessive and painful APT should strive to better neutralize their pelvic postures. Moreover, individuals that utilize excessive anterior pelvic tilting strategies while resistance training will want to learn how to better control the pelvis. In my opinion, the best way to combat APT is by focusing on increasing posterior pelvic tilt strength via the following abdominal and glute exercises: American hip thrusts, back extensions with a rounded upper back, glute bridges with a flattened lumbar spine, RKC planks, and hollow body holds. The videos below will be useful:

Conclusion

APT does not provide a muscular advantage during walking, but it does during sprinting and Olympic lifting. More individuals have APT than PPT or neutral pelvises, indicating that it’s normal to exhibit some APT. APT does not lead to low back pain in everyday living but it can lead to low back injury during sports or resistance training if excessive and not kept in check. The spine and pelvis move during heavy and explosive movement, indicating that they are used dynamically to generate torque, however, their motions should be kept in midranges; end ranges of spinal and pelvic motion are risky and dangerous under high loads. The reasons why athletes and lifters rely on APT during sports and exercise depends on the motion and exercise in question and is multifactorial. Resistance training, motor control training, static and dynamic stretching, and manual therapy should all be used to augment pelvic posture or pelvic mechanics during exercise if it is deemed safer or more advantageous.

As I learn more over time, I will update this page and keep it current.

Recommended Reading

Don’t Be Donald Duck

Why do I Anterior Pelvic Tilt?

Courageous Conversations With Coaches: Anterior Pelvic Tilt With Elsbeth Vaino

A Better Way to Teach Barbell Glute Bridges and Back Extensions

Weightroom Solutions: The Hyperextension-Prone Lifter

Anterior Pelvic Tilt and Lumbosacral Pain as it Relates to the Hip Thrust and Glute Bridge

 

What To Do When an Exercise is Causing Pain or Injury

Some lifters are very lucky. They train year after year, decade after decade, performing every popular resistance training exercise, and their bodies handle it like a boss. These people have anatomies that are well constructed to tolerate full range of motion exercises in every direction at every joint. However, other lifters are not so lucky, and they inevitably encounter exercises in their training that don’t seem to agree with their structures.

Incline-Press

Before I go further, I’d like to expound upon the topic of pain. It is important for lifters to know that anatomy isn’t automatically to blame when pain arises. Biomechanics, structure, and posture can indeed cause pain, especially with regards to heavy and explosive strength training, where large loads and stresses are placed upon the body. This is even more pertinent with regards to powerlifting and maximal strength training, where large emphases are placed on setting PRs and progressive overload.

However, in the grand scheme of things, biomechanics, structure, and posture only encompass small portions of the entire pain picture, which involves biological, psychological, and sociological components. Moreover, sometimes there are other culprits, for example, poor program design, deconditioned muscles, or suboptimal technique.

That said, I would like to be very clear about something. No exercise is worth doing if it consistently causes pain or injury. This applies to squats, deadlifts, Bulgarian split squats, bench press, military press, chin ups, dips, curls, and even my pet exercise: hip thrusts. There are plenty of ways to hammer the muscles, and you’ll see better progress over the long haul by focusing on the exercises that best agree with your body. A body that is free of pain is a happy body. Pain alters muscle activation and can create compensatory movement, which can lead to problems elsewhere in the body. Therefore, you want to avoid stubbornly grinding through painful exercises.

deadlift

What do Try Before Eliminating an Exercise

If an exercise is causing problems, here are the various strategies that you should attempt before throwing in the towel:

See a Doctor or Physical Therapist

This is the obvious answer. Try to find one that regularly works with athletes and lifters.

Perform a more comprehensive warm-up

Prior to lifting, experiment with self manual therapy, dynamic mobility work, static stretching of antagonists, low-load activation work, and/or more specific warm-up sets

Go lighter with a focus on using excellent form

Several ways could work here, but you could use around 80% of typical loads and perform the same number of reps with better form. Or you could use around 65% of typical loads for higher reps with better form. Finally, you could use around 50% of typical loads and perform pause reps or dynamic effort reps with better form.

Reduce training frequency for that exercise

Instead of performing the exercise three times per week, go with once or twice per week to allow for more thorough recovery.

Tinker with form

Alter stance width, foot flare, grip width, grip angle, bar position, depth, and/or posture.

Perform exercises that could improve your form (corrective exercises)

Technique on a given exercise can improve if the poor form is not due to anatomy but is instead due to mobility deficits, joint stability deficits, or poor motor control. Therefore, any exercise or drill that strengthens weak muscles, increases mobility, or improves coordination could lead to better technique. Depending on the particular situation, RKC planks, wall ankle mobility drills, glute bridges, lateral band walks, side lying clams, hollow body holds, prone trap raises, scap wall slides, walking knee hugs, and shoulder towel stretches could be of value.

Experiment with a variant of the exercise

Instead of back squats, go with front squats or box squats. Instead of deadlifts, go with rack pulls or trap bar deadlifts. Instead of barbell hip thrusts, go with American hip thrusts or single leg hip thrusts. Instead of bench press, go with close grip bench or dumbbell bench press. You get the gist.

Perform the movement in a different order in the training session

If you normally perform the exercise in the middle or end of a workout, performing it first could allow you to better focus on form since you won’t be neuromuscularly or mentally fatigued. If you normally perform an exercise at the beginning of a workout, performing it at the end might be of value since you’ll be more thoroughly warmed-up and you might not be concerned with the loads you use since you’ll be too fatigued to consider going for strength records on that lift.

Give it some time

This strategy mainly applies to new movements that feel uncomfortable and painful due to external pressure. For example, when you first start performing high bar back squats, low bar back squats, front squats, and Zercher squats, it hurts because the bar is digging in to the body. The same thing applies to learning the hook grip when deadlifting and with barbell hip thrusts. However, after several weeks, the pain subsides as the body gets accustomed to the stimulus.

front squat

What to Do When Eliminating an Exercise

Hopefully, employing one of these suggestions does the trick. But if it doesn’t and the issue doesn’t clear up, then you should drop the exercise from your program and increase volume with other exercises in order to make up for the eliminated exercise. For example, let’s say that you remove all forms of bilateral deadlifts from your training. Exercises such as front squats, kettlebell swings, single leg RDLs, hip thrusts, glute ham raises, bent over rows, and grippers will allow you to retain most of your deadlifting strength even though you won’t actually be deadlifting, so pick a couple of them that you feel best target your weak links and make sure to regularly include them in your training.

When the issue clears up, don’t rush back into the problematic exercise full bore. Instead, give the body some time to strengthen and the brain some time to build confidence. After a few months, you may go back to the once problematic exercise and see if your body can better tolerate it this time around. Often this is indeed the case, but make sure you adhere to a graded approach and ease back into the exercise gradually. If this occurs, then voila, you’ve solved the problem. But if the exercise still causes issues, then eliminate the exercise again but for a longer period of time – perhaps 6 months or even indefinitely. Strength coach Michael Boyle refuses to allow his athletes to continue to perform an exercise if the athlete has injured him/herself on three occasions with the same movement. Don’t feel bad about eliminating an exercise that isn’t good for your body, you’ll be far better off in the long run.

Don’t stubbornly grind through pain. Work around pain and teach your body to be confident with resistance training. Most serious lifters can’t regularly perform every major exercise. For example, I can’t perform chin ups or dips very often anymore. Although these were two of my go-to exercises throughout my first two decades of lifting, they now irritate my shoulders and arms, so I rarely do them. However, my pectoral, lat, and arm hypertrophy have not suffered because I can still perform heavy bench press, incline press, rows, and deadlifts. Each of my powerlifting friends have certain movements or variations that they have to avoid, and they had to learn this the hard way. Anatomy varies dramatically from one person to the next, so we should hone in on the movements that best suit our musculoskeletal systems.

jerk

Below are three articles I recommend checking out if this article interested you:

Pain Science: An Interview With Pain Expert Jason Silvernail

Why People Must Squat Differently

3 Tips for Faster Strength Gains