We might see someone whose pelvic tilt looks fairly normal in a static posture, but when they do a squat, their technique might be that they really exaggerate that anterior pelvic tilt and that lordosis. And so that's why it's really important not just look at static postures, but to look at what's happening with the pelvis and the hip joint position when you're moving into dynamic tasks.
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SPEAKER_00:In this episode, we're joined by Dr. Alison Grimaldi, who takes us through the controversial topic of pelvic tilt and acetabulum loading. Alison starts by guiding us through the dynamic assessment of pelvic tilt and how this can affect other structures around the hip joint. We also discuss how changing an individual's pelvic tilt can impact their pain and range of motion during functional tasks such as squatting. Dr. Alison Grimaldi is an Australian sports physiotherapist and the practice principal of Physiotech Physiotherapy in Brisbane. with an extensive clinical experience and a special interest in hip, groin and pelvic pain. She has completed a Bachelor of Physiotherapy, a Master of Sports Physiotherapy and a PhD through the University of Queensland where she continues her research interests as an Adjunct Senior Research Fellow. Alison beautifully highlights in this episode that although pelvic tilt may not be important with every patient we see, it is most certainly worth some serious consideration for joint and soft tissue loading around the hip and pelvis and that for some patients can be highly impactful. My name is James Armstrong and this is Physio Explained. So welcome to the podcast, Alison. It is really, really good to have you on. So thank you for joining us today.
SPEAKER_02:No problems. Thanks, James. And thanks, Physio Network, for the invitation to be with you today.
SPEAKER_00:Wonderful. So we're going to dive straight into the topic of pelvic tilt, which is a hot topic and divides some of the clinicians out there. But I thought it'd be really good today to get a bit of information from yourself around what are we talking about with pelvic tilt and some of the implications to our patients of that. So let's set the scene first of all, Alison, if you could cover what are we looking for when we're talking about pelvic tilt?
SPEAKER_02:Okay, so we generally talk about pelvic tilt in the sagittal plane, so AP. but also of course in the coronal plane. So they're the main planes that we talk about pelvic tilt in. And so we might consider looking at pelvic tilt either in a static posture, such as standing, we might most commonly look at it, but very importantly also in dynamic tasks and what's happening with the pelvis in dynamic tasks because of the big impact it can have on joint loads and muscle loads. And so if we think of your pelvis here, when you go into anterior pelvic tilt, It's basically bringing the front of your pelvis, if you like, closer to your femurs. And so in clinic, generally that goes hand in hand with an increase in a lumbar lordosis. But we always need to make sure that we have a feel of the ASIS and the PSIS at the front and back of the pelvis to actually see where the pelvis is sitting. Because sometimes you can have people who actually just have a big glute max, who look like they're in a lot of anterior pelvic tilt, but actually they're not. So make sure you actually have a feel of the pelvis and see where that is. So we've got anterior pelvic tilt where the pelvis is tipping forward. We have posterior pelvic tilt where the pelvis is tipping backwards. And that usually goes hand in hand with a reduced lumbar lordosis. And often that also goes with what we call a sway type posture, if you like, where the pelvis is anteriorly translated. relative to your base of support, so relative to your feet. And that usually ends up with the trunk posteriorly translated. So we've sort of got the trunk back and the pelvis forward relative to the feet. And in the coronal plane, then we also have lateral tilt. And I think we're all pretty used to looking at that during things like single leg stance or walking. So single leg tasks are where we're looking for how much does a pelvic drop or occasionally how much does it hitch? And if it hitches, often it's associated with a bit of trunk lean as well. So they're the main things that we're looking at in clinic in both static postures, but dynamic posture is very important as well. So we look at people in squats and things like that. What is their pelvis doing? That can be incredibly important.
SPEAKER_00:And I think that's really important you mentioned there in terms of that, not just looking at this as a static posture, but also dynamically. And does it change as well with certain movements? I'm assuming you mean when someone has a static tilt, that might change when they start moving?
SPEAKER_02:Usually just exaggerates, I suppose. For example, for someone with a sway type posture who might have posterior pelvic tilt, flattened lumbar spine. Well, it depends on what they're doing. So if they're walking, for example, they tend to keep that same sort of posture. But if you get them to sit down, well, they'll still be in posterior pelvic tilt, but they'll go into a lot more lumbar flexion. But when they do a squat, for example, again, they'll tend to use reduced lordosis and more posterior pelvic tilt. So that is one of the reasons why it's good to look at that static posture because it actually gives you a fairly good indication of how they will move. But of course, you can't just assume one is going to lead directly to the other. You need to have a look. With the anterior pelvic tilt, the more lordotic postures, again, when we see patients going into a squat, they usually stay in that position until they get to a point where they've got no more hip flexion. So for example, if you go into a deep squat, then eventually most people will end up in a posterior pelvic tilt if they're squatting right to the floor. But we might see someone whose pelvic tilt looks fairly normal in a static posture, but when they do a squat, their technique might be that they really exaggerate that anterior pelvic tilt and that lordosis. And so that's why it's really important not just look at static postures, but to look at what's happening with the pelvis and the hip joint position when you're moving into dynamic tasks.
SPEAKER_01:This podcast is sponsored by Cliniko.
SPEAKER_00:Brilliant. So getting into this now, we're looking now at the implications. So what are the implications, Alison, of pelvic tilts on load and structure within our patients?
SPEAKER_02:So let's go through anterior tilt and posterior tilt. If we think about posterior tilt, so this is where the pelvis moves relatively backwards. So if you're standing and your femurs are vertical, then it's like your tail is dropping down. What happens then up here at the hip joint is that when you post your pelvic tilt, the acetabulum moves relatively backwards and so we have relative uncovering or reduced covering of the most anterior aspect of the femoral head and at the back of the hip joint, we'll have increased coverage of the back of the femoral head and so that reduces bony support for the front of the hip joint. It also means that there's less weight bearing surface to actually absorb loads at the front of that hip joint when we're in weight bearing. And so that increases load around the edge of the acetabulum. And so we call that increased edge loading and the things that are sitting at the edge Well, of course, we have the cartilage that comes right out to the edge. But importantly, we also have the acetabular labrum, that fibrous piece of cartilage that hangs off the edge of the acetabulum like a fringe. And so in posterior pelvic tilt, we have a lot more weight-bearing load going through the labrum. So if someone has pathology through that anterior surfaces, it might be something that increases a load to that area. And for some people, that might translate to pain or aggravation of their existing pain. The other thing that happens in posterior pelvic tilt is that we will also get changes in muscle loads and loads of the soft tissue at the front of the hip joint. And so we'll get increased contributions to Loads in gait, for example, as that paper showed us from Ismael and Cara Lewis, their lovely modelling study showed us that when you're in posterior pelvic tilt, you get much more load on the tissues at the front of the hip joint and we get increased contribution of the anterior hip muscles and reduced contribution of the posterior hip muscles. And so we get a lot more load on the iliopsoas tendon, for example. And if someone's had a total hip replacement and then they're sort of in that position, that will also increase load on the prosthesis, but the iliopsoas tendon as it wraps around the front of the hip joint. And so you can get increased impingement of that iliopsoas tendon against that underlying prosthesis. So there's lots of implications for posterior pelvic tilt, and this will be even more important for someone who has acetabular dysplasia. So if you have a shallow joint or reduced weight bearing surface already, and then you remove part of that weight bearing surface by going into posterior pelvic tilt, then that's going to leave even less weight bearing area to actually absorb those loads. So it can have a really big impact for particular people. So that's posterior pelvic tilt. For anterior pelvic tilt, When we go into an anterior position, the acetabulum then will roll further forward over the head of the femur. So relatively, we get anterior overcoverage and posterior undercoverage. And so we're more likely at the front of this hip joint then to get impingement at the front of the hip. not so much during tasks like walking, but if we're going into a squat position or any position where we're in a flexed hip position, then because the front of the acetabulum is further over the head of the femur, we'll get impingement earlier in range. Now, impingement is not necessarily a dangerous or problematic thing, but if you already have femoris tabular impingement syndrome and you've got a very grumpy labrum and then you're doing your squats or sitting at your desk in hypervigilant postures with extreme anterior pelvic tilt and this rigid sitting position, then that might be causing some of that or contributing to some of that irritable pain that you're getting at the front of the hip. We also have to consider what happens at the back of the hip. So if you're standing and you're leaning forward with extreme anterior pelvic tilt, that will reduce your posterior coverage or your posterior stability at the back of your hip joint. For most people, we've usually got a fair bit of bone at the back of your hip, so it's not going to be as big an issue. But if you have acetabular dysplasia where you have reduced coverage at the back of that hip joint, leaning forward or squatting in extremes of anterior pelvic tilt may actually leave your hip joint relatively undercovered by bone. And so then we get more loads at the posterior labrum and the posterior muscles at the back of the hip joint. So our deep rotators have to take a lot more load. So we change both joint load and soft tissue load depending on where that position is.
SPEAKER_00:Wonderful. Wow. There's an awful lot of information packed into that, Alison. And for clinicians using this as a takeaway point, would you say that this is something that clinicians might be able to use as a load modification in their treatment with patients?
SPEAKER_02:Exactly. And that's probably the best way to use this information. It's not to be used in terms of seeing a particular position and trying to make people worried or fearful about their position. Oh my goodness, your pelvis is in a terrible position. It's not about that. It's just looking at load and symptoms and seeing if we can alter those loads with simple cues. So with the paper that was published by Ismael and Lewis that we talked about on the posts on social media, they did a modelling study talking about changing from 10 degrees posterior tilt to 10 degrees anterior tilt. But of course, we're not going to try to change someone's pelvic tilt in clinic by 20 degrees. That's a massive change that was just highlighting the impact of change in pelvic position. But in clinic, we'd be trying to just use simple cues to try to reduce that. So as you said, load modification, a great example for that would be someone with FAIS going into a deep squat and doing that in a really anteriorly pelvic tilted position. So with a large lordosis and getting that pinchy pain at the front of their hip joint, often just simply asking them to drop their tailbone or to lift their pubic bone a little bit more and hold that position as they go into the squat. can immediately improve the range of motion they have without pain or reduce their pain at the end of that range. And that can be a really empowering thing for a patient. So that doesn't usually make them fearful. It makes them very grateful. Oh my goodness, I can do something to change my pain. So we're looking for some sort of change. If we can make that immediately, then that's great. Same sort of thing with posterior pelvic tilt, with walking and that pain, it ends dance phase. Often just simply walking Thinking tall will often reduce the amount of anterior translation and posterior tilt, and that can often make immediate changes to some people. So different cues, of course, work for different people, but we're not going to be asking people to stand with your tail out and hold that there. That's going to create a lot of inefficient muscle patterns and often causes more problems that we don't want to create. So keep it simple and try it during if it's a mechanical pain, which is where this sort of intervention is most effective. Try it with someone and see if you can make some changes with simple modifications.
SPEAKER_00:Wonderful. And I'm sure many listeners are doing exactly what I'm doing right now and following along, moving and cueing myself into different hip positions. But I think as you've highlighted there, Alison, so perfectly, it's how we frame it to the patients and it's how you use it in your practice alongside, as you say, that discussion and that education, which is so very, very important. Alison, that has been a real whistle-stop tour of a quite a complex area, but I think you've covered it really well, giving our listeners something that they can take away today and put into their practice straight away. So I thank you very much for that and thank you for your time today. How can our listeners find out a little bit more about you and some of the work you do?
SPEAKER_02:Probably the easiest place to find me would be on my website, drallisongramaldi.com and on my social platforms as well. So I'm on most of the socials there if you just search my name. On my website, you can find different courses on trying to help people with different hip conditions and And in Hip Academy, actually, because of the interest in this topic, our next Hip Academy meeting topic will actually be on the power of pelvic tilt and what we can do in clinic to help people with modifying pelvic position and exercises that we can do to supplement that as well. So if anyone's got a particular interest in pelvic tilt and what they can do, they can visit me at my website and have a look at Hip Academy.
SPEAKER_00:Lovely. And we'll put all of that information down into the show notes, Alison. And for our listeners who want to find out even more about HIP, I would recommend heading over to some of our research reviews where you've wonderfully reviewed some research and literature as well around the HIP and other areas too. Again, Alison, I'd like to thank you so much for coming on the podcast. Well, we definitely need to get you back on to talk more about the HIP. So thank you very much, Alison.
SPEAKER_02:Thanks very much, James. It's been great to be on.
SPEAKER_00:Thank you.
UNKNOWN:Thank you.