Pelvic tilt
You should be aware of your clients posture, were their weaknesses are. Focus your attention on your clients postural control center, the pelvis. This gets a bit more complex.

We are going to focus on what is commonly referred to as the core. This is not the term I used for the pelvic complex, because it is just one part of the entire core. A better term is the lumbo-pelvic-hip complex. It refers to all the parts that are associated. The major joints involved are the sacroiliac joints, pubic symphasis, and the hip joints. There are about 29 major muscles that influence this region, but for simplicity, we will only focus our attention on the important muscles that have the most influence on distorting posture and causing pain. The muscles of importance are

                                                                                                                                                                                     

 

psoas major
quadriceps
hip adductors
erector spinae
lumbar multifidus
quadratus lumborum
gluteals
hamstrings
rectus abdominus
external obliques
internal obliques 
transverse abdominus

Get out your book to see the location and their orgin and insertions for the muscles listed above

The pelvis can assume many types of malalignments in different planes,  we will now be focusing on the pelvic alignment in the sagittal plane. The most common deviation seen is accessive anterior pelvic tilt. This faulty alignment can be seen in the picture to the right. To measure this, first we must locate 2 main structures,
Anterior superior iliac spine (ASIS), which will be a large bony structure about a 45 degree angle inferior and lateral to the umbilicus. 
Pposterior superior iliac spine (PSIS). Trace the ilium around from the ASIS to the back of your client. It will be seen as a large dimple. 
Now, with one finger on each structure, kneel down and view your client from the side. Which is higher, the ASIS, or PSIS? In most cases, the PSIS is significantly higher than the ASIS. This is called an anterior pelvic tilt. The pelvis is tipped more anterior than posterior. Don’t be mislead, some degree of anterior pelvic tilt is normal. What we are looking for here is excessive tilt, anything beyond 10 degrees.

So now that we have identified the pelvic tilt on our client, what do we do with this information? If you have identified an anterior pelvic tilt, read on. If you have identified a posterior pelvic tilt, you may want to refer to a physical therpist for instruction on exercises and possibly an orthopedic evaluation to rule out any spinal conditions. Posterior pelvic tilts in my experience is relatively rare, although I have gotten a few. Now lets look at the common tight muscles in this malalignment.

The short/tight muscles include:
Psoas major, which by its anatomy can cause increased lumbar extension and hip flexion, causing the pelvis to tip anteriorly. Quadriceps, particularly the rectus femoris, which also contributes to hip flexion. Lumbar erectors, which cause lumbar extension. Quadratus lumborum, if bilaterally tight, can cause increased lumbar extension. Hip adductors, anterior pelvic tilt results in internal rotation of the femur. This will shorten the adductor musculature.

The long/inhibited muscles include:
Gluteus maximus, which causes hip extension and opposes the psoas major. Hamstrings, this muscle can be tricky, It may be weak but appear tight simply because it is a synergist to the gluteus maximus and may be compensating. Deep abdominal wall, this includes the tranverse abdominus, and internal obliques which may become inhibited due to facilitated lumbar erectors.

The main contributor to anterior pelvic tilt is usually the psoas major. If the psoas major is tight, it can disrupt the muscle balance relationships of the entire postural chain. When the psoas is tight, it pulls the pelvis into anterior tilt, thereby increasing hip flexion and shortening all hip flexor muscles. Since the psoas has its origin on the lumbar spine vertebrae, when it shortens, it pulls the spine into extension. This causes the lumbar erectors and quadratus lumborum to shorten. The short/tight muscles will inhibit their antagonists. The gluteals, which contribute strongly to hip extension, will be inhibited by the psoas, causing the hamstrings to pick up the extra force. The deep abdominal wall will be inhibited by the lumbar erectors, and their synergist, the psoas major. Due to the neurological connection, other muscles in the deep stabilization mechanism may become dysfunctional. This may include the pelvic floor and lumbar multifidus.

Excessive anterior pelvic tilt can be caused by seated jobs, faulty abdominal training, poor muscle balance, poor posture, and pregnancy. The problems associated with anterior pelvic tilt can include: dysfunction in the lower extremity low back pain, incontinence, pelvic instability, upper cross syndrome (via the pelvo-occular reflex), and abdominal distention.

Correction of excessive anterior pelvic tilt includes postural cueing, stetching the tight muscles, and strengthening the long inhibited muscles. Postural cueing for the pelvis includes teaching the client how to find a neutral pelvis. This is done by teaching your client to perform a posterior pelvic tilt, then perform an anterior pelvic tilt, then find the position in the middle of the two. Or you could use the test position and instruct your client to tilt their pelvis until the PSIS and ASIS align properly. Remember, tilt the pelvis, not the whole body! Use this procedure in all exercises to re-enforce the motor program. Corrective stretches should be performed prior to initiating any exercises. Stretch the quads, psoas major, hip adductors, lumbar erectors, and quadratus lumborum. Refer to a good stretching book for demonstration. Strengthen the weak muscles by performing exercises that isolate the weaknesses first. I use floor bridging, and supine posterior pelvic tilting. Perform the floor bridges emphasizing an equal glute squeeze. Perform them at 30 second static holds, and then 15 second rests. Repeat this sequence until 3-5 minutes of total tension is reached. Eventually, your client should be able to work up to a static 3-5 minute hold.

The key to posterior pelvic tilting is to not recruit the rectus abdominus, as it will increase thoracic flexion and encourage upper cross syndrome. Lie supine will knees bent and hands under your lumbar spine directly behind the umbilicus. Take a deep diaphragmatic breath and upon exhaling, gently draw the belly button toward the spine and apply a small amount of pressure into your hands by tilting the pelvis posteriorly. This will activate the external and internal obliques to tilt the pelvis. If the rectus abdominus is being recruited, you may be pushing too hard. Hold for 10 s econds, then rest for 10 seconds. This should be repeated up to 10 reps for 2-3 sets. Progress the legs away from your rear end as you improve. Now add these exercises to the ones you have been performing for the upper cross.

Anterior Tilt structures have deep lordotic curves in the lumbars and cervicals. There occiput and parietal bones will feel more convex then a Posterior Tilt. This goes for the sacrum as well - it will be more curved or convex then a PT. Anterior tilts will have flatter arches as they transmit their weight through the front of the calcaneus upon heel strike and weight more forward of their ankle. There will be more of a bend to the knee in standing then the hyper-extended posterior tilt's knees. More tension will be carried in the back in the upper body and in the adductor group and the front of the legs.

           Posterior                        Anterior



Posterior Tilt structures have flatter (straighter) cervical and lumbar curves, and their sacrum and occiput/parietals (near the lambdoidal suture) will also feel flatter. They transmit their weight through their heels and lateral arches and thus have higher arches. They like to hyper-extend at the knee. Tension will be carried more in the deep rotators, gluteals and hamstrings in this type of body. Tension will be more in the anterior structures of the upper body as well. Posterior tilt's have the reverse tilt/shift in the shoulder girdle. They will naturally have anterior tilted scapulas, medial humerus, with a tension in the pectoralis major and minor.