Pelvic Tilt: Exercising with Low-Back Pain

There are many misconceptions or faulty versions of the pelvic tilt that we have seen over the years. Even our clients that correctly perform a pelvic tilt in a lying position during mat exercises many times have a harder time applying the pelvic tilt to a practical functional activity. Some clients come in knowing how to do some form of a pelvic tilt, some clients come in and don’t have a clue what a pelvic tilt is, but a vast majority of our clients have learned a version of the pelvic tilt that may not be the correct “fit” for them. Actually, there are several different types of pelvic tilt and knowing how to pelvic tilt properly can really help clients with their back pain.

As it turns out the pelvic tilt is the basic core building block of a larger concept called Functional Pelvic Range. And Functional Pelvic Range is a basic building block to establish proper Movement Patterns and proper Body Mechanics with static and dynamic movement. I know that is a mouth full, but my point is to highlight the fact that really the pelvic tilt is not an exercise unto itself, but a motor skill to master and apply to daily movement patterns.

This concept came clear to me when I first starting practicing 18 years ago. I had a patient that came in and had been doing a fairly rigorous Pilates program. She was taught to tilt the pelvis with her exercises and her back was always sore after her program. As she continued to explain what she was doing and demonstrated her version of the pelvic tilt – which is actually a fairly normal way to “pelvic tilt.” She would flatten her back against the mat. The problem was that she was flexion sensitive – meaning her low back did not like flexion and placing her back in more flexion only added to her pain level.

Physiologically speaking flexion is the direction of movement the vertebrae move when the spine bends forward. A metaphorical way to explain how the pelvic tilt can make an effect on the lumbar (low-back) vertebral movement is using an analogy with a Coke bottle. You can open a Coke bottle two ways, one by opening the bottle by unscrewing the cap. Secondly, you can hold the cap stationary and unscrew the bottle from the bottom. Regarding the pelvic tilt, we can put the spine in flexion by leaning forward with our shoulders (i.e. bending over at the waist); or we can flex the spine from the bottom by thrusting our pelvis forward like a pop culture dancer might. When we do a pelvic tilt there is a resultant effect on the spinal vertebrae and knowing which direction the vertebrae move is critical for controlling spinal movement with your activities of daily living.

Spinal injuries can present in many ways. For example, the spine can be painful to movement in a particular direction and not another direction. One of the most common directions of painful movement is flexion because we as humans are constantly bending over. So, to add more flexion with a traditional pelvic tilt to a spine with a flexion-biased injury may just continue to cause pain and discomfort. Interestingly, for our Pilates client in our previous example we were able to teach her a reverse pelvic tilt which really helped her to relieve her pain with exercise and eventually with application to her activities of daily living.

I have other clients who are extension-sensitive or have extension-based injuries. Which would be the opposite of the example above. For clients with this type of injury we would need to teach them a flexion-biased pelvic tilt. Once they are able to master that position with exercise we would then progress them to more functional positions and then more unstable positions attempting to simulate their activity of daily living.

The process of developing the proper pelvic tilt for a client is sometime fairly easy, but many times the most difficult and the most important step in the rehab process. Developing the proper muscle memory for good function pelvic tilt habits is crucial. Another tricky aspect of mastering the pelvic tilt is learning that with different tasks the pelvic tilt may be different and there are exceptions and subtle variations which can be tricky to lean. For example, if a flexion-sensitive patient is engaging in an extension-biased activity that is painful in some way, then that patient may need to position the spine with some small relative amount of flexion to avoid aggravation of the tissue.

In order to help people best with this, we do recommend learning these concepts earlier rather than later. The patient that deals with low-back pain for years and tries massage therapy and other alternative forms of treatment prior to learning good pelvic tilt habits may just end up “kicking the can down the road.” Many times, that approach causes the soft-tissue, facets, discs, muscles, tendons and other tissues more inflamed, degenerative and/or aggravated which makes developing good pelvic tilt patterns much more difficult.

If your struggling with low-back pain and would like to exercise, or if you are struggling with low-back pain with activities of daily living, then set-up an appointment with a knowledgeable physical therapy who’s well versed in understanding the concept of functional pelvic range.