Corrective Exercise - Part 2: The Lumbo-Pelvic Hip Girdle

In the first article of this two part series, you learned how to assess the structures of the foot, ankle and knee. Their interrelatedness to the rest of the lower kinetic chain was explained and some examples of corrective exercises to help address the most common imbalances were given. In this article, you will learn how to assess the lumbo-pelvic hip girdle. You will also learn how the alignment of the structures in the lumbo-pelvic hip girdle affects other parts in the lower kinetic chain. Finally, you will be given some exercises that can be used during regular fitness programs to help correct problems, eliminate pain and improve function.

About the Lumbo-Pelvic Hip Girdle

The lumbo-pelvic hip girdle is the area where the lower spine, pelvis and top of the legs come together. The lumbo-pelvic hip girdle has two very important articulations: the sacro-iliac joint and the acetabulum. The sacro-iliac joint is where the sacrum (base of your spine, just above your tailbone) meets the back of your pelvis (ilium). The acetabulum is a cup shaped depression in the pelvis where the end of the femur sits to form the hip socket (see Figure 1). There are many ligaments that help hold the bones of the pelvis, spine and femur in place during the complex, multi-dimensional movements that are possible in the lumbo-pelvic hip region.

The two most common deviations found in the lumbo-pelvic hip girdle are an anterior pelvic tilt and excessive lumbar lordosis. An anterior pelvic tilt refers to an excessive forward rotation (downward tilt) of the pelvis in relation to the back of the pelvis. When viewed from the side, the pelvis is rotated anteriorly (forward) around the acetabulum. It is normal to have a slight (approximately 10 degrees) anterior pelvic tilt.

Excessive lumbar lordosis refers to an excessive curvature in the arch of the lower back. The lumbar spine naturally curves inward to form a concavity. However, an excessive lordotic curve can cause pain and dysfunction.

Note: An anterior pelvic tilt is almost always accompanied by excessive lumbar lordosis and visa versa.

Assessing the Lumbo-Pelvic Hip Girdle

In order to assess the lumbo-pelvic hip girdle, you must be able to see the area clearly. Inform clients prior to their visit that they should wear shorts or form fitting workout pants. Females should wear a sports bra or form fitting t-shirt. Males should remove their shirt, lift their shirt above their waistline or be asked to tuck their shirt into their shorts. The assessment process includes a verbal, visual and hands-on evaluation. Always write down or make note of your assessment findings.

Verbal Assessment

Conduct a verbal assessment first to gain insight from clients into their interpretation of the pain and function of the body parts you are assessing. Ask the following questions:

1. "Do you ever experience pain in your hips, buttocks, lower back or groin?" This will help you identify a probable cause.
2. "Have you ever been diagnosed with arthritis of the hips or spine?" This will help you understand the integrity of the joints of the lumbo-pelvic hip girdle.
3. "What is your occupation or job and level of physical activity?" This will help you understand any additional stress on the joint.
4. "What aggravates the condition, and what makes it feel better? Does the pain coincide with other pains in the body?" This will help you and your client understand the cause of the pain.

Visual and Hands On Assessments

Excessive Anterior Pelvic Tilt

Look at your client’s pelvis from the side. If the back of the pelvis appears to be much higher than the front, this indicates an excessive anterior tilt (see Figure 2). The way the waistband sits on your client's hips can also help you to assess the position of the pelvis (i.e., high at back, low at front). A posterior pelvic tilt would be indicated by the front of the pelvis appearing higher than the back. However, a posterior pelvic tilt is not common. 

Excessive Lumbar Lordosis

To check for excessive lumbar curvature, ask your client to stand against a wall with the heels, buttocks, shoulders and head touching the wall. Slide your hand, palm down, behind the lower back. Evaluate the space between the lumbar spine and the wall. You should only be able to slide your fingers under the lower back (see Figure 3). If you can slide your entire hand under your client’s back, then they have excessive lumbar lordosis. If your client has an excessive curvature of the lumbar spine, this will help confirm your finding from the previous assessment that he also has an anterior pelvic tilt

Note: If your client has excessive body fat or muscle on the buttocks, his lumbar spine will appear further away from the wall.

Teaching Neutral Position of the Pelvis

While your client is standing against the wall, instruct him to tilt his pelvis posteriorly, engaging the abdominals to assist with the movement. You should feel the space between the wall and his lumbar spine decrease.

Now, ask your client to step away from the wall. Instruct your client to place the palms of each hand on the bony protuberance on the front of each hip (ASIS). His index fingers should touch and be parallel to the ground. Ask the client to look down at his hands and coach him to posteriorly tilt his pelvis until he can see both the index and the second fingers of both hands (see Figure 4). This is a neutral position for the pelvis.

When your client has achieved a neutral pelvic position, coach him into a neutral foot and ankle position (see “Teaching Neutral Foot and Ankle Position” in Part 1 of this series). This should cause his knees to correctly align over the center of the foot. This is a neutral position for the entire lower body. Now, coach your client to keep his spine erect without overarching the lower back. It may be difficult for your client to maintain these postures, but it is very important to help him attain a kinesthetic awareness of these positions so he can replicate the movement when asked during training sessions. 

Relationship Between the Lumbo-Pelvic Hip Girdle and the Knees, Ankles and Feet

The first article in this series explained how foot and ankle pronation causes the knee to move medially (i.e., toward the center line of the body). This displacement at the knee causes the tibia and femur to rotate inward, which directly affects the alignment and movement capabilities of the lumbo-pelvic hip girdle.

The inward rotation of the femur affects the way the head of the femur sits into the hip socket (acetabulum). To accommodate the movement of the femur in the acetabulum, the pelvis must rotate forward, which causes the lordotic curve of the lumbar spine to increase. If an excessive anterior pelvic tilt and excessive lumbar lordosis persists, it will impair movements required for daily activities and/or exercise. For example, lumbar spine flexion will become restricted due to the restriction of the muscles, tendons and fascia of the lower back. Moreover, range of movement into hip/leg flexion may also be inhibited as the pelvis loses its ability to posteriorly rotate. These imbalances can make simple tasks like bending over or lifting the leg to tie one's shoe laces very difficult.

Exercise Recommendations

Walking, running and all forms of cardiovascular exercise that work the large muscles of the lower kinetic chain involve hip/leg flexion and extension. However, an excessive anterior tilt and excessive lumbar lordosis will affect the body’s ability to effectively rotate the pelvis posteriorly, which is necessary to correctly move the legs forward in front of the body. This type of musculoskeletal imbalance will result in compensation patterns that may lead to problems like lumbar disc degeneration, sacro-iliac joint dysfunction and hip bursitis. Additionally, imbalances in the lumbo-pelvic hip girdle will lead to a disruption of movement in the knees, ankles and feet. Therefore, it is imperative to strengthen the structures of the lower leg as well as the hips.

Here are three possible exercises to help your clients correct the structural deviations discussed herein.

1. Calf Stretch on BOSU (see Figures 5-6) - The lack of dorsal flexion and overpronation that are common in most clients is usually the result of the muscles of the lower leg not being able to move through all three planes of motion. To increase flexibility of the muscles that cross the ankle joint and foot, all the muscles of the lower leg must be stretched in the sagittal, frontal and transverse plane. Instruct your client to stand on a BOSU ball and use the wall to aid with balance. Ask your client to place one foot behind him on the ball and push his heel down into the BOSU ball. Teach your client to oversupinate by rotating his standing leg out. In doing this, he should feel a stretch on the outside of the calf (poreneal muscle group). Then coach your client to overpronate. Now he will feel a stretch on the muscles on the inside of the calf (medial part of the gastrocnemius and posterior tibialis). If it is practical, have your client perform this stretch in bare feet so that the foot and ankle complex can move freely. Figure 5 Figure 6

   It might seem counterintuitive to stretch your client into overpronation. However, if he is a chronic over pronator, many of the soft tissues that aid in slowing the foot down into pronation will probably lack flexibility and eccentric control into an over pronated position. Therefore, by controlling pronation through the stretch, you can help rejuvenate the soft tissues, strengthen the muscles and mobilize the ankle joint so that forces can be shared throughout the foot and ankle complex. Hold each position for one to two seconds. Repeat three times each position and for each leg.   

2. One Leg Stand (see Figure 7) - Instruct your client to stand on one leg. (Use a balance aid, if needed.) Coach him to rotate the tibia and femur out by rolling the foot out and raising the arch. He should also feel the gluteal muscles contracting and pulling both the lower and upper leg outwards. Ensure the hips are extended and the spine is erect. This will help align the leg in the hip joint. Coach your client to have his foot straight and his weight centered. The skills your client learned from the “Big Toe Pushdowns” exercise (in Part 1 of this series) will help him to remain balanced and stable.
   
   Figure 7
3. Single Leg Squat with Reach (see Figures 8-9) - Have your client stand on one leg and then instruct him to bend at the hips and squat as he reaches forward and away from the body. His leg will rotate inward and his foot will pronate. Teach your client to control the inward motion of the foot and leg by trying to slow down this motion with the muscles of the butt and foot. The knee should move toward the midline of the body and the foot should pronate. However, the key to performing this exercise correctly is having your client use his butt and foot muscles to control this motion. If the muscles of the foot and butt are not slowing down this motion, then the joints will take the stress. Teach this movement so that the muscles do the work and control joint motion effectively.

Figure 8

Figure 9

Conclusion

Structural assessments and corrective exercises can be integrated into any fitness program. Simply conduct your regular exercise programs and incorporate strategies that address any musculoskeletal imbalances you identify during the assessment process. Additionally, developing a thorough understanding of the individual structures of the body will help you to understand more complex information on movement and whole body mechanics.

The topic of the third and final article of this series will be the thoracic spine, shoulder girdle, neck and head. You will learn how to assess these areas of the body, how they relate to other structures and some sample corrective exercises you can incorporate into your personal training programs.

References:

1. Abelson, Dr. Brain and Abelson, Kamali. Release Your Pain. Calgary: Rowan Tree Books, 2003.
2. Golding, Lawrence A. and Golding, Scott M. Fitness Professionals’ Guide to Musculoskeletal Anatomy and Human Movement. Monterey, CA: Healthy Learning, 2003.
3. Gray, Henry. Gray’s Anatomy. New York: Barnes & Noble Books, 1995.
4. Petty, Nicola and Moore, Ann, P. Neuromusculoskeletal Examination and Assessment: A Handbook for Therapists. Edinburgh: Churchill Livingstone, 2002.
5. Price, Justin. “A Step-by Step Guide to the Fundamentals of Structural Assessment”. Lenny McGill Productions, 2006.
6. Price, Justin. “A Step-by Step Guide to the Fundamentals of Corrective Exercise”. Lenny McGill Productions, 2006.
7. Price, Justin. “Integrating Corrective Exercise and Personal Training. Part 1: The Foot and Ankle”. Personal Training on the Net. Article Archives, 2008.
8. Schamberger, Wolf. The Malalignment Syndrome: Implications for Medicine and Sport. Edinburgh: Churchill Livingstone, 2002.
9. Shafarman, Steven. Awareness Heals: The Feldenkrais Method for Dynamic Health. Massachusetts: Perseus Books, 1997.
10. Taylor, Paul M. and Taylor, Diane K. (Eds.). Conquering Athletic Injuries. Champaign, IL: Leisure Press, 1988.
11. Whiting, William C. and Zernicke, Ronald F. Biomechanics of Musculoskeletal Injury. Champaign, IL: Human Kinetics, 1998.