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

Today I have a guest-post for you by Dr. Conrad Stalheim, a CSCS and chiropractor out of Iowa (see his bio below). This is a great article!

Anterior Pelvic Tilt and Lumbosacral Pain as it Relates to the Hip Thrust and Glute Bridge – by Conrad Stalheim

Bret has gone to great lengths to discuss how to properly perform the hip thrust and glute bridge and some common mistakes that can lead to pain and injury. He has also been very clear that this exercise needs to be progressed intelligently like any other exercise.

If you are like me, the only problem is that he has a ton of posts and videos, so I tend to jump to the ones with the 120lb women bangin’ out reps at 250#’s and above and then think that I should go heavy to start.

It never hurts to revisit the basics or gain another intelligent perspective.

This post will address:

1. The biomechanical fault of lumbosacral hyperextension.
2. How that fault predisposes you for pain and injury.
3. How that fault manifests in the glute bridge/hip thrust, deadlift, and various other movements.
4. How I cue and progress individuals in a clinical setting to gain the motor control to activate the glutes and spare the spine.

Remember, the glute bridge is performed with your back on the floor, and the hip thrust is performed with your back elevated.

The Hip Thruster is the best way to do the hip thrust – stable and versatile!

When I first started loading these “heavy”, I hurt myself in what I think is probably the most common injury with this movement.

LUMBOSACRAL HYPEREXTENSION

Extension hypermobility at the lumbosacral joint (L5-S1) is very common. This is one of the joint regions that we commonly see excess motion, which is why it is one of the most common sites of degeneration. When muscles don’t provide the necessary stability, your body will create it another way.

These are some strong indicators that you are prone to or living in a state of lumbosacral over-extension:

1. Significant Anterior Pelvic tilt
2. Tight Hip Flexors
3. Lack of global extension and more of a hinge in one particular spot
4. Weak abdominal musculature – I find it more difficult to evaluate this one, but it is also likely present, and it doesn’t hurt to address it.

aka Lower Crossed Syndrome

I’m actually glad that I hurt myself, as it exposed me for not taking care of a dysfunction that I’ve known about but just didn’t have the motivation to take care of. This isn’t just a hip thrust issue. This faulty movement strategy is going to show up in deadlifts, pull-ups, overhead presses, etc. Watch the video further down if you want to see the same movement fault applied to the deadlift.

I’m not going to go into loading and progressing hip thrusts and glute bridges. As a clinician, I’m generally working with people who are in pain so I’m not throwing a barbell on their hips. I’m all for loading these exercises, and I do so myself, but my particular skill set and objectives with patients is for rehab. Something I have to teach in nearly every case is proper pelvic tilt, spine position, bracing, and motor control to activate the glutes, NOT all the other various compensatory muscles that people activate instead of their glutes.

So back to the issue of lumbosacral hyperextension…

We generally think of mobility as a good thing. The more flexible a person is the better, right?

In the book Movement Impairment Syndromes, Shirley Sahrman writes, “When a system is multisegmented, as in the case of the human movement system, the greatest degree of motion occurs at the most flexible segment. This follows the laws of physics, which states that movement takes place along the path of least resistance. Thus most spine dysfunctions occur because of excessive relative flexibility, particularly at specific segments, rather than at segments of reduced flexibility. The reduced flexibility of some segments invariably contributes to compensatory motion at the most flexible segments.”(1)

Essentially, we would like to see all joints contribute and participate in their role in movement. We do not want to see one joint stand out as the place of excess movement.

Here’s an impressive global extension curve vs a lumbo-sacral hinge.

Clearly the woman in the photo on the left has a substantial amount of hinge at the lumbosacral joint, but she also shows a good example of a uniform extension curve through the spine.

Below is another example. Again we can see more of a uniform extension curve on the left vs. a more straight thoracic spine and greater lumbosacral extension hinge on the right.

This isn’t the best angle but good enough to get the point. The woman on the right actually appears to have pretty decent global extension compared to many but also has enough of a “hinge” to see the difference.

Although everyone needs to stabilize their lumbar spine to get the most out of hip thrusts and glute bridges, you are much less likely to get injured if you don’t have a hypermobile segment, as you will spread the forces out over more segments.

Above you can see some lumbar arching/extension in both pictures, but in the first one, the woman’s ribs are starting to flare upwards and towards her head indicating that she is not stabilized in her spine.The picture on the right shows potentially a little more lumbar extension than we would like to see, but she appears to have her abs engaged and ribs locked down. You can see that her hips haven’t fully opened/extended but she is likely at her hip flexor end-range, and additional extension would probably come from her lumbar spine.

So why don’t we all just inherently adopt a better pelvic position and do this movement correctly?

In a sense, it’s because we’re lazy, not necessarily on purpose but because we don’t know any better.

We tend to adopt positions that allow us to “HANG” on our tissues. We inherently search for stable positions, but creating stability muscularly is more metabolically expensive, so we hang on the “passive” structures like ligaments and joint end-range.

We do this in long-duration, low-load activities like standing and sitting, but we also do this when weight gets too heavy, and our muscles can’t support it.

Our passive tissues can handle this up to a point, and it works to accomplish the task or APPEARANCE of a full movement, but the price can often be pain and injury.

For a little extra credit, you can check out this video of Kelly Starrett showing this same over-extended pattern with the deadlift. You can learn every movement and exercise individually, or you can learn the concepts, allowing you to self-correct and take care of yourself or your clients.

ADDRESS YOUR TIGHT HIP FLEXORS

If tight hip flexors are an issue for you, you will have to address it in order to really achieve full range of motion on the Hip Thrust. If you don’t, you will either have to stop short of full hip extension range, or you will have to use lumbar hyperextension to make it look like (and make yourself feel like) you are getting full range of motion.

Here’s one way to test for tight hip flexors:

Lying on a table or bench, pull one knee tight to your chest, and let your other leg hang. The hanging leg should easily fall to parallel with the floor.

Keep your lumbar spine flat

(e.g. you shouldn’t be able to slide your hand under your low back.)

Here’s how we address those tight hip flexors:

It’s called the couch stretch, so you don’t have an excuse not to do it. You can literally do it on your couch while you watch tv. Hang out on each side for at least a few minutes every day for a week and see what happens.

Don’t cheat by using lumbar extension like the picture on the right.

This isn’t the only way to accomplish this stretch, but it gives you the basic idea on “opening” the hip up into extension.

After the stretch, I always think it’s a good idea to use that slight increased mobility, and fill it in with some stability work. This should program your brain that you can handle this increased mobility. I’d hit 1-2 sets of 10-15 bodyweight hip thrusts or glute bridges with an emphasis on really squeezing your glutes to get a couple of extra degrees of HIP extension NOT LUMBAR extension.

Groove the Motor Pattern to SPARE your back and better ACTIVATE your glutes.

Since I have a limited amount of time to work with people in pain who are not always the most athletic, I always try to find the most simple and quickest fool-proof cues. But don’t worry, there’s always somebody who will find a way to mess up even the best cues.

As a quick, somewhat related digression, here’s how I generally fit glute strengthening into patient rehab.

Evidence suggests to us as physical medicine practitioners that joint manipulation works quite well for acute episodes of low back pain, as in pain that’s only been around for a few weeks. It doesn’t tend to work as well for chronic cases of back pain such as those who have had pain for months, years, or regularly recurring episodes. (2)

For chronic cases, I have found good success using a manual therapy approach for pain control to start. These are things like joint manipulation, myofascial work, flexion-distraction, and a multitude of other techniques to reduce pain, inflammation, and break the pain cycle. Along with manual therapy, I think it is crucial to address and reduce specific exacerbating factors by teaching general spine/tissue sparing strategies. It generally doesn’t take long for most patients to be able to start working on core bracing and stability techniques. Stu McGill has given us a great resource in his book Low Back Disorders (3) for how to spare the tissues and utilize intelligent progressions of static and dynamic core stability exercises.

Once we’ve learned how to move properly to spare our tissues and create a stable and neutralish lumbar spine, we still need a way to pick things up, move a heavy load, and project ourselves through space. This applies whether you’re an athlete or not. This is where I think Bret is providing a unique and great resource, from primitive glute activation patterns to more advanced, heavy, glute loading exercises.

Clinically, I like to initially teach this movement pattern with your back flat on the ground and making sure you can anteriorly and posteriorly tilt your pelvis. To begin the movement, you want to posteriorly tilt your pelvis and press your lumbar spine flat to the ground. You should feel your abs and core musculature get stiff. Maintain that position as you drive your heels through the ground and lift your trunk off the ground by contracting your glutes.

I personally like to start with my heels fairly close to my butt as I feel that this facilitates more glute and less hamstring activation.

Again, if your hip flexors are tight, then you can’t and shouldn’t go for full hip extension – you won’t get it. But you should work on it, as it’s going to limit glute activation (reciprocal inhibition).(4) You also need this full hip-extension for a functional running stride, golf swing, kettlebell swing, and to be able to move and perform optimally in general.

If this is still a struggle, here’s a trick that makes it almost impossible to hyperextend your lumbar spine. Pull one knee into your chest. I would personally start with my heel closer to my butt than the picture below illustrates. The ball in the hip crease is good for those with a tendency to cheat, but it’s not necessary.

Taking the time to develop the correct motor program with adequate mobility should allow you to progress this exercise safely with better ability to engage your GLUTES and self-regulate for injury prevention.

Remember:

• Gain the motor control/technique to feel these without weight before loading.
• Bret has emphasized the need to find the right height bench for hip thrusts – this is important
• Don’t use a weight or continue a set that you are unable to maintain the posterior pelvic tilt position with.

BIO:

Conrad Stalheim, DC, CSCS, SFMA, is the owner of Iowa Chiropractic and Performance Center. In addition to using manual therapy, he incorporates assessment and treatment of dysfunctional movement patterns leading to pain and injury. He has found it important clinically to increase glute activation and strength, especially in cases of low back pain.

Sources:

1. McGill, Stuart. Low Back Disorders: Evidence-based Prevention and Rehabilitation. Champaign, IL: Human Kinetics, 2007. Print.
2. Sahrman, Shirley. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, 2002. Print.
3. Knierim, James, PhD. “Spinal Reflexes and Descending Motor Pathways.” Spinal Reflexes and Descending Motor Pathways.” Department of Neurobiology and Anatomy – The University of Texas Medical School at Houston, Web. 03 Apr. 2013.
4. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141(12):920–8.