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| Lumbar hyperlordosis and pelvic anterior tilt Ref: https://www.medicalnewstoday.com/ |
Postural observation in patients with low back pain is one of my gold standard physical evaluation protocols which is investigated by physiotherapist visual and postural grid charts. Most of them showed faulty lumbar spine and pelvic alignment.
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| Postural grid chart (Ref: https://www.pinterest.com/) |
Many cases have presented low back pain with hyper lumbar lordosis or hyper pelvic anterior tilt which is one of poor posture that can develop low back musculoskeletal disorders. When a combination of faulty alignment and muscle tightness is present, both position and constant although it may vary in intensity with change of position. Stresses which would not be excessive under ordinary circumstances may give rise to pain. An apparently inconsequential act may cause an acute onset of pain.
However, some cases have chronic back pain from this posture, as well. It is true that some individuals with lordosis complain of low back pain while others with a more severe lordosis may not complain of any pain. A lordosis may be habitual, but if the muscles of the back are flexible enough that position can be changed from time to time, symptoms may not develop. However, a back so tight that the lordosis position is fixed tends to be a painful back in any position of the body.
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| Lumbar hyperlordotic makes soft tissue and joint compression (Ref: https://osteopathy.colganosteo.com/hyperlordosis/) |
"There is undue compression posteriorly on the vertebrae and the articulating facets, and there is undue tension on the anterior longitudinal ligament in the lumbar area."
The lumbar hyperlordosis or the hyper pelvic anterior tilt is in result of muscle imbalances that associated with an anterior tilt may include all or part of the following: weak anterior abdominal muscles, weak hip extensor muscles, tight hip flexor muscles (chiefly iliopsoas), and tight low back muscles.
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| Muscle imbalance in lumbar hyperlordosis and pelvic anterior tilt (Ref: https://www.semanticscholar.org/paper/Effects-of-a-massage-therapy-program-on-functional-Wong/59d1cdb704700562cd73e420cfb73ead2eda8e67) |
We will discuss only muscle tightness induced hyper lumbar lordosis in this article. Referring to above, the tightness of low back extensor muscles and hip flexor muscles cause shortened distance of anterior hip and posterior lower torso. Hip flexors consist of iliopsoas, rectus femoris, and tensor fascia latae (TFL) where the most important muscle is iliopsoas.
However, sometimes I found an association of origin of rectus femoris and hip adductor tightness with iliopsoas tightness. I have always seen TFL tightness in flat back posture more than hyper lordosis posture.
The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO.
Basic 6 stretching to correct anterior pelvic tilt. (Please stop stretching and consult a physiotherapist or doctor if you feel worse pain and/or numbness.)
Exercise #1: Supine double knees to chest
Exercise #2: Child pose
Exercise #4: Standard half kneeling stretch where the target muscle is on the rear leg. The pose needs to keep back straight with a shift pelvic in front that no need to arch the back.
Exercise #5: Chair stand posterior pelvic tilt
Exercise #6: Half kneeling with toe touch stretch: the target leg is on the knee with set ankle at neutral with toe tips touching the floor. Lean back and pelvic posterior tilt slightly without arching the lower back. We need the hip joint to be neutral or extension.
If you would like to have more stretching exercise information please follow the link include;
(1) Back muscle: https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-7-basic-lower-back.html
(2) Hip flexors: https://yimphysionearme.blogspot.com/2022/05/physiotherapy-with-6-tips-to-stretch.html
(3) Proximal quadriceps: https://yimphysionearme.blogspot.com/2022/07/tips-of-proximal-quadriceps-stretch-for.html
Pelvic tilt is defined as the angle between the horizontal and a plane passing through the posterior superior iliac spines and anterior superior iliac spine. Lumbar lordosis is defined as the curve assumed by the lumbar spine, where the lumbar spine forms an anterior convexity. The degree of lumbar lordosis is variable among individuals and is the result of the lumbar vertebrae, especially L5.
Anterior pelvic tilt, the low back arch forward into a position of lordosis. The vertebral spine has regional curves on the sagittal plane designed to absorb impact, reduce its longitudinal stiffness, and intensify muscular function.
There are no normative lumbar lordosis angles. Values of sagittal curves measurements on the spine present great variability in normal individuals. One study compared the measurement of lumbar lordosis, as well as of its components (vertebral bodies and intervertebral discs) showed a high variation in studied subjects. The result illustrated the lumbosacral curvature measurements (L1S1) ranged from –33.0° to –89.0° (average –60.9° ± 10.65). The values for lumbolumbar curvature (L1L5) ranged from –15.0° to –78.0° (average –45.1° ± 10.8).
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| Lumbar lordosis curve measurements (Ref: https://www.scielo.br/j/aob/a/PnpKbZMb7P7cPDrTTcmcH3L/?format=pdf&lang=en) |
Janda has written about standing posture with lumbar hyperlordosis that we can see in Military - type posture which is common in soldiers and kyphosis - lordosis posture which is seen in my clinic often, especially in swimmers.
The Military - type posture was named following the traditional discipline standing of soldiers. The standing order to the straight torso with open chest and shoulder is a component of hyperextension/ hyperlordosis of lumbar spine and pelvic anterior tilt. This chain of movement can develop tightness of low back and hip flexor muscles.
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| The military - type posture (Ref: https://www.pinterest.com/) |
Kyphosis - lordosis posture was indicated by over - kyphosis of thoracic spine and over - lordosis lumbar spine that we can see a big S curve from lateral view. Lumbar spine is hyperextension/ lordosis, and pelvic anterior tilt, and flexion of hip joint. Muscles tightness of lower part including hip flexors. In part of the low back extensors are strong and may or may not develop shortness.
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| The Kyphosis - lordosis posture (Ref: https://www.pinterest.com/) |
Tight one - joint hip flexors (chiefly iliopsoas) is a crucial factor because it causes an anterior tilt of pelvis in standing. The low back goes into a lordosis as the subject stands erect. Occasionally, a subject inclines forward from the hips, avoiding an erect position that would result in a marked lordosis.
The severity of the lordosis depends directly on the extent of tightness in the hip flexors. Stress on the low back in the lordotic position is often relieved by giving in to the tight hip flexors. In standing, this is accomplished by bending the knee slightly.
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| Tightness of iliopsoas (Ref: https://blog.voltathletics.com/home/2015/3/25/psoas-talk-with-christye) |
In sitting, the hips are flexed and hip flexors are slack. Some people can sit for long periods of time without pain or discomfort but have pain when standing for brief periods. One should examine for hip flexor shortness in such cases.
Lying on the back or on the side with hips and knees flexed relaxes the pull of the tight hip flexors on the low back.
When knees are bent to relieve discomfort in the back, an effort should be made not to bend them more than necessary. After the hip flexors are stretched through appropriate stretching exercises, it is not necessary to flex the hips and knees in order to be comfortable when lying on the back.
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| Tightness of hip flexors can pull spine into lordosis in supine (Ref: https://learnmuscles.com/blog/) |
In the supine lying position with hips flexed enough to allow the back to flatten, the patient is more comfortable on a firm mattress than on a soft one. On a soft mattress, the pelvis sinks down and tilts anteriorly, causing a lordotic position of the low back.
Prone lying is not tolerated because the tight hip flexors hold the back in a lordotic position. However, the prone position can be made comfortable by placing a firm pillow directly under the abdomen to help flatten the low back and allow slight flexion of the hips.
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| (Ref: https://commons.wikimedia.org/) |
Rectus femoris and TFL are the two - joint hip flexors that the degree of tightness usually does not cause lordosis in standing.
The reason is that the muscles are not elongated over the knee joint when the knee is straight. (tightness would have to be severe to be tight over both joints). And when the quadriceps muscles are overworked, the muscle becomes tight and inelastic. When the rectus femoris is tight, it will pull the hip bone and continue to turn the whole pelvis moves downward or forward. This position is said to be the anterior tilt of the pelvis. Muscle tightness may be linked to postural disturbance. Both can contribute to multiple musculoskeletal conditions. By the way, the tightness of quadriceps are accompanied by weak hamstrings. That’s why the onset of low back pain was also associated with quadriceps muscle tightness.
Therefore, sometimes this tightness is very marked, and stretching should be done in a manner that does not put stress on the patella during knee flexion. For that reason, it is recommended that the knee be placed in flexion, so the patella can ride over the knee joint before starting further stretching. Proceed to stretch hip flexors by pulling up and in with the lower abdominal muscles to posteriorly tilt the pelvis and extend the hip joint.
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| Force direction of rectus femoris and back extensor in pelvic anterior tilt (Ref: https://mskneurology.com/) |
Tight low back muscles cause an anterior tilt of the pelvis and hold the low back in a position of lordosis. Due to the low back extensions pull upward on the pelvis posteriorly. While these muscles cross over joints of the vertebral column, they do not cross over another joint at which the muscles can give in to the tightness. Regardless of what position the body assumes, the low back will remain in a degree of extension that corresponds to the degree of tightness of these muscles. If forward bending, the low back remains in an anterior curve and does not straighten.
In cases in which tightness of the low back muscle is the primary factor, pain may be chronic but often has an acute onset. Pain is increased by, and tends to have its onset in, movement rather than standing or sitting positions. The problem tends to be more common among men than women.
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| Combination of muscle impairment in pelvic anterior tilt (Ref: https://file.scirp.org/) |
To correct pelvic and lumbar lordosis posture needs not only flexibility as above but also strength in the involved muscle. Abdominal musculature is a major contributor to excessive anterior pelvic tilt and an increased lumbar lordosis. And the hamstring pulls the pelvic downward posteriorly. Any one of the above may be the primary factor but the tight low back and weak hip extensor muscles are least likely to be the primary cause.
Reference:
https://novyimir.net/gallery/nmrj2606%20f.pdf
https://www.scielo.br/j/aob/a/PnpKbZMb7P7cPDrTTcmcH3L/?format=pdf&lang=en
Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.
1993.
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