Practical Science on Movement and Pain

Does Anterior Pelvic Tilt Cause Low Back Pain?

Question: What is anterior pelvic tilt?

Answer: It means the front end of the pelvis tips forward and the back end hikes up.

Question: Will that make my gut look bigger?

Answer: Yes.

Question: Is that why my low back hurts?

Answer: Let’s check the internet…

What Google Says

An internet search for anterior pelvic tilt and low back pain returns 54,000 articles, almost all of which claim that anterior pelvic tilt causes low back pain.

The articles usually argue one of more of the following points – that anterior tilt is a postural distortion; which is caused by caused by excessive sitting; which tightens the hip flexors; which pull the front of the pelvis down; which creates an excessive lumbar lordosis; which causes strain and pain.

The cure for pain is usually presented as involving one or more of the following elements: stretching the hip flexors, strengthening the glutes and abs, or making a conscious effort to suck in the gut or otherwise modify the pelvic angle in standing.

There are many different variations on this prescription of course, but you can find some version of it almost anywhere you look in the world of manual therapy and corrective exercise. But is there any evidence to support it? And does it really matter so long as it makes our guts look smaller?

The sad thing is that there is a a lot of evidence bearing on the pelvic tilt theory of low back pain, and it is easy to find. And as you may have guessed by the tone of the post so far, the evidence provides little support for the theory.

What Pubmed Says

If it is indeed true that excessive anterior pelvic tilt is a risk factor for back pain, then you would expect that studies would find a clear association between anterior pelvic tilt and/or lumbar lordosis and back pain. However, as described below, this is simply not what we see. It appears that most of the studies looking at these issues have found little or no correlation between these factors. Here is a brief sampling of some of the results.

Studies looking for correlations between low back pain and pelvic tilt or related spinal curves have found:

  • no difference in lumbar curvature between people with and without low back pain;1
  • no difference in lumbar lordosis between people of different ages or in people with and without pain;2
  • no difference in thoracic kyphosis, lumbar lordosis and sacral inclination between people with acute low back pain and chronic low back pain;3
  • low back pain is not associated with the degree of lumbar lordosis or pelvic tilt;4
  • 2008 systematic review of 56 studies finds no strong evidence of an association between measurements of spinal curves and pain.5

To be fair, I found a couple studies that found some correlations between spinal curve measurements and pain.6 But the weight of the evidence appears to be that if any correlation exists, it is weak. And, even if a weak correlation exists between pelvic tilt and back pain, this does not prove that the pelvic tilt is causing the pain. It is just as plausible that pain causes the tilt, and in fact there are studies to show that pain causes postural changes that are presumably protective in nature.7 And, even if anterior pelvic tilt does predispose you to back pain, it is yet another leap to conclude that it can be corrected. And yet another to prove that correction will reduce back pain.

So what can we conclude from this?

First, that trying to correct anterior pelvic tilt may be an unproductive way to treat back pain. Second, we shouldn’t take back pain advice (including mine!) without looking for references. And third, if you want to sell a fitness/wellness concept, make sure it makes people’s guts look smaller.

If you want this see this myth die, spread the word.

And if you want to read more on related topics, check out one of the related articles below:

Back Pain Myths

Does Excessive Sitting Shorten the Hip Flexors?

Five Misconceptions About Posture

Endnotes

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44 Responses to Does Anterior Pelvic Tilt Cause Low Back Pain?

  1. Dale Favier says:

    I sometimes teach people posture for sitting meditation, and one the things I commonly have to tell people is to let their guts hang out in front of them. If they try to suck it up and sit “straight” they’ll be miserable within five minutes.

    Almost everyone, it seems, has been told that the lordotic curve of the back is postural original sin.

  2. Here is something…http://www.nationalscholastic.org/trackmedic/article/736/

    I had “low back” pain within days of starting a job where I sit a lot. Interestingly, it hurts during squats (especially front) and some ab exercises, but not deadlifts. Sometimes, by the middle/end of workouts it is completely gone (it has not made a disappearance for a long time though). My speed has decreased also upon starting the job (+.5 sec on my 60m!), and two of my friends have commented that my stride looks “way different” and “choppy.” I suspect it may also have to do with vitamin D, as I was outside a lot beforehand (but my vitamin D levels are adequate, so I’m not sure).

    • Todd Hargrove says:

      Thanks for the link John. After a quick browse, I see lots of claims there, many of which sound suspicious. And there is no specific reference to a study that found an association between hip flexor tightness and pain. There are some cites to general resources at the end, but no links, and no indication they would involve a study proving the title of the article.

      Sorry to hear about the back pain. Back pain is rather mysterious, and clearly multifactorial – there is is good evidence that it can be affected by emotions, social context, and …. not liking your job. You may be interested in several articles on this site which address pain science – click on the pain tab in the menu to find them.

  3. […] Is that why my low back hurts? Answer: Let’s check the internet…  Read More » Be Sociable, […]

  4. The problem with myths is that they usually have some basis in reality. But as anyone knows who has worked on young women, their pelvis’ tilt so far forward that they run the risk of tripping on their belly button jewelry. Very few of these ladies have low back pain issues. However, put a few years on these girls … maybe 30 or more … and now we have a different set of issues. That tilting pelvis may or may not have something to do with the pain. I understand where you are coming from. But like my mother always told me, “don’t throw the baby out with the bath water”.

    • Todd Hargrove says:

      Ross,

      I’m not going to completely throw posture away. I am open to the idea that there may be some ways of having correctably bad posture that is somehow not being measured in these studies. But anterior tilt as a stand alone variable can be thrown out as far as I am concerned. If you are right that it will only make a difference over time, then the studies would have accounted for this and found a correlation.

  5. Ryan Flowers says:

    Since when is the lumbar lordosis “postural original sin”? Primary and secondary curvatures of the spine are products of normal development. I don’t hear of that very much, frankly.

    And we should be careful about lumping all pain into the biopsychosocial model…. many people love their jobs, but hate their chairs. Pain research, all of it combined, tells us that it is not an all-or-nothing scenario. We still have much to learn… .

    Pain is contextual. That’s about all we really ‘know’.

    • Todd Hargrove says:

      Ryan,

      I think the whole rationale for the theory that anterior pelvic tilt is bad is that it encourages excessive lordosis. I have certainly heard this claim quite a bit. Of course the idea that it is original sin is just a joke.

      I’m not sure what your point is in saying that we shouldn’t “lump all pain into the bps model” or that pain isn’t an “all or nothing scenario.” I didn’t make any of those claims and I don’t really understand what they are supposed to be claiming.

  6. Ryan Flowers says:

    While I’m not a fan of this positional labeling, ‘pelvic tilts cause pain’, I would argue that long term deviation that promotes inefficient soft tissue functioning could be a factor that studies are not able to easily quantify. So I don’t believe that studies are always going to be able to assess the ‘timing’ given all of the other potential variables involved. I would love to see a means for a clear analysis, but it appears thus far that there are some limitations on what can be tested, given the nature of pain. Clinical presentation and effects suggest a different picture. I guess time will tell.

  7. Todd Hargrove says:

    Ryan,

    The people in the studies are of varying ages and include middle aged people. Since posture is a habit that tends to be stable over time, I would presume that whatever degree of pelvic tilt that was measured in the studies had been there for many years. If anterior pelvic tilt only causes a problem after years of use, then I would expect the studies would have picked up on that. But they didn’t. I agree that may be some some aspects of efficient posture that were not measured, but I doubt that these aspects include the degree of anterior tilt or lordosis.

  8. Ryan Flowers says:

    Is posture really stable over time? I do not observe that to be the case. It has shown in clinical practice to often be progressively deteriorating over time.

    Again, I’m not a fan blaming pain on an anterior tilt of the pelvis as a general marker, because there is nothing inherently wrong with an anterior tilt, unless it is disrupting normal movement patterns and joint kinematics. As to why pain presents in some and not others with such aberrant deviations is largely unknown.. I don’t know why this is. But clinical experience has shown many of us that pain changes when various relationships are addressed, when other more conventional ideas about the ‘source’ of their pain have failed to achieve the desirable effects. Getting results keeps me open to questioning what is actually going on. It doesn’t mean I take a hard stance one way or the other, or that I believe movement or otherwise isn’t effective (that’s certainly not what I’m saying). But I remain open, despite the limited scientific inquiry into the issue. How can one not when you see positive effects from such a model of intervention? I don’t see how clinical evidence of change in condition has become a mute point of discussion or relevance. Or why some folks choose to simply be negative about what we don’t understand, and offer no alternative for discussion, other than it’s in the head? Why do people suddenly acquire pain in the low back or hip if it’s really just coming from the brain’s perception? Why not the knee for that person? A lot of questions still present for me, and I’m fine with the uncertainty and make no claim as to why.

    • Todd Hargrove says:

      In regard to the change in posture over age, the first study I linked has a relevant quote:

      “Our study aimed to investigate whether lordosis changes with age and is reduced in those with low back pain. Although our results confirm known observations that lumbar lordosis is more prominent in women (P < 0.01) and those with a higher body mass index (P < 0.04), we were unable to demonstrate any significant variation in lordosis with age.”

      I agree that we don’t know everything, that pain is multifactorial complex and non-linear, and that we should keep an open mind. But we should also follow the evidence that is available, and abandon theories that are clearly not supported by the evidence. For me, the evidence makes clear that the degree of anterior pelvic tilt and related spinal curvatures is not a likely cause of back pain.

      As to your question about why someone gets pain in the hip or back and not the knee if pain is in the brain, here is my answer – because the brain thinks, based on the sensory info from the body and many other factors, that the subject needs a pain action signal to protect the knee, and not the hip or low back.

  9. Jeewon Kim says:

    Here’s a whole method based on the anterior tilt of the pelvis, what Esther Gokhale calls an “anteverted pelvis.” egwellness.com Here’s a summary of it on Mark’s Daily Apple. Any thoughts?

    I’ve been trying her method, sitting, standing, lying, walking, and even running, and have found it to be a dramatic improvement. For me, anterior tilt + a long extended spine has improved mobility along the whole spine, hips, and shoulders.

    Love your site Todd. I’ve been slowly reading through your articles for a couple of weeks now and doing your Feldenkrais exercises, which are a revelation.

    JK

    • Jeewon Kim says:

      Link to Mark’s Daily AppleMark’s Daily Apple

    • Todd Hargrove says:

      Hi Jeewon,

      Thanks for pointing that out. I’m glad you are getting good results from Gokhale’s approach. I have her book and have read it (but not carefully.) Perhaps someday I will do a detailed post with my thoughts but until then here are my initial impressions. First, I like the evolutionary angle a lot and I think that is good place to look for guidance about what type of posture or body organization is best. I also agree with her that a little anterior tilt of the pelvis has gotten a bad rap and this is a fine way to stand. But I am very skeptical about any approach to reducing back pain that is based on correcting posture, for the reasons stated in the above post and the ones I linked below it. For example, if an anterior tilted pelvis were preferable, we would expect that the studies I cited above would show that people with posterior tilting pelvises had more pain, but that is not what we saw.

      Further, I think that postural advice often suffers from an overabundance of cues that require too much conscious effort to maintain. But it seems like most of her consumers are satisfied so perhaps that is not a problem. My own experience was that I felt a little stiff and inhibited trying to hold good posture so it was not for me. But to make a real judgment of course we would need outcome studies and I don’t think those are available. Thanks again for the comment and I’m glad you like the Feldenkrais lessons!

      • Nick says:

        Todd, I read Gokhale’s book and I found myself in more pain trying to follow all the guidelines about changing my posture. I, too, was more stiff and my hips began to hurt more when I tried to walk the way she recommended. I understand that I could have been doing everything she suggested wrong, but I no longer heed her teaching.

        Meanwhile, I do still suffer from pain which is related to poor sitting posture on long plane flights and office work. Additionally, after I play golf I find it very difficult to stand up straight when I get out of my car upon returning home. Sometimes it seems to affect my whole body and then is gone the next day. I do think a great deal of this pain is related to my hips and trigger points, but I can’t really figure it out. I’ve read Paul Ingrahm’s work and found it helpful.

        Regards

        • Todd Hargrove says:

          Nick,

          Thanks for relating your experience with Gokhale and Ingraham. Good luck with the hips. Blatant self promotion alert – I will coming out with a product this summer called Better Movement for the Hips. Look for it!

  10. Ryan Flowers says:

    Thanks Todd. The architecture of the vertabrae will dictate this limited excursion. I see this as structural stability, not postural. What I was referring to in terms of ‘postural’ stability that you mentioned was the whole of the structure… The combined pattern of the spine (which is dynamically changing/moving), such as increase of kyphotic curvature in the thoracic, vertebral wedging that occurs as a result and further commits the pattern… . Genu valgus… Scoliotic progressions… None of this is absolute, always the case, but frequently observed as time passes… . Perhaps this has more to do with physics and the resiliency of a person’s system than anything else. I don’t know, but I observe this.

    So if we may agree that the knee is sending a notable signal to the brain to warn it, would that not suggest an inquiry is needed into what may be going on in relation to the knee? Verse trying to turn the signal off/down at the cns level? Thus further exemplifying the important role of peripheral receptors and perhaps the potential for treatment of the local and/or distal regions to alter said input? What is the potential cost for the patient in neglecting the peripheral elements when present? This is where I have many questions as well, in terms of both pain and function. And the only way to understand this more is to push for more research in a wider spectrum. We’ve already nearly exhausted the approach of “work where it hurts”… PT was/is based largely on this treatment concept… Treat the painful area. I would suggest and like to see a more in depth look at how these regions relate to the whole and how this effects treatment strategy, function and pain alike. I haven’t seen much research to date on this, so it’s hard for me to accept that it is not a relevant perspective, just overlooked. And given that I, and many others, observe this relationship everyday and have no way to explain why it occurs, it appears to be important to clarify. We also really need to do more than work off of research alone… Clinical observations most often precede scientific study.

    I think this type of comparison (pelvic tilt and pain) is an oversimplification and misrepresentation of what certain practitioners are doing with “structural” work, namely Rolfing/S.I.. We don’t equate pelvic tilt with pain. We aim to improve function and relationship, which often then effects the pain being experienced (this is also not an absolute, as pain resolution or dampening will often have to precede functional directives). We also are primarily engaged with the CNS to provide new sensory input, new schemas, heightened awareness and the subsequent potential for more comfortable, natural and efficient motor output.

    This ‘newer’ biopsychosocial’ model in pain science is not a new approach, but a newly supported approach. Various methods have been recognizing and educating the ‘patient’ for some time now, empowering change from what ‘they’ can do, not by some mechanical means of what we ‘supposedly’ do to them. I enjoy having discussions, but only when both sides are clear about where the other is coming from. There are too many misunderstandings and misrepresentations out there, such as this pelvic tilt and pain comparison.

    Thanks again Todd.

    • Mark Hollis says:

      Ryan,

      From what i understand when reading this blog there is less of a misunderstanding and misrepresentation of the comparitive relationship between pelvic tilt and pain because studies have been done to find out what parameters the relationship falls into (causative, correlative, coincidental, none) with the majority of studies indicating that it is not causative.

      So doesn’t the blog support your view of trying to decrease misunderstanding and misrepresentation by saying that to date it is understood that anterior pelvic tilt does not in general represent a causative contribution to pain? It doesn’t say that all practitioners think this but it definitely indicates that some do (and someone has to have thought this as a possibility for the studies and research to have been initiated). There are a lot of beliefs out there that upon greater research don’t hold up but it doesn’t stop them from being perpetuated.

      I have clients who come in and i get them to anteriorly pelvic tilt and they report their back pain initiates/increases but the reason they came to see me is because normally they can anteriorly pelvic tilt without it causing pain so I can’t say their previous summated history of anterior pelvic tilt was the causative feature of their current pain/movement dysfunction nor can i say that their current anterior pelvic tilt is the causative feature of their current pain/movement dysfunction. Yes it will have some sort of relationship to it, as every thing in the universe that exists does somehow appear to relate to everything else at some level, the question is what sort of relationship is it and what sort of relationship isn’t it?

  11. Mark Hollis says:

    Hey Todd,

    You may have missed a word out in the paragraph after footnote 6. ‘But the weight of the evidence appears to be that if any correlation exists, it is weak. And, even if a weak correlation exists between pelvic tilt and back pain, this does prove that the pelvic tilt is causing the pain. It is just as plausible that pain causes the tilt, and in fact there are studies to show that pain causes postural changes that are presumably protective in nature’ should it read ‘…back pain, this does [NOT] prove that pelivc tilt is causing the pain?

    Great blog btw, thanks for the effort you put in and the clarity, presentation, and thought of your work.

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  13. Cayte says:

    One objective measure of “good posture” would be to minimize postural sway. Sway is an indication of the need for corrective motion to avoid toppling over.

    In my opinion a measure such as pelvic tilt should not be tested in isolation because each change requires compensation to maintain stability. According to the Gokhal method it requires a slight forward tllt of the torso. The study did not include data on overall balance.

    Besides back pain the risk of falls should be reduced in optimal posture.

  14. Cayte says:

    Since my post I dug up this tidbit from Pubmed. PMID:
    21762484

  15. Ryan Flowers says:

    This just needs some clarification as it is very misleading. Sorry for the length of this, but I think you’ll find it important.

    The goal of the first study cited states: “Our study aimed to investigate whether lordosis changes with age and is reduced in those with low back pain.” And concludes “Therefore, a ‘reduced lumbar lordosis’ should be regarded as a very weak clinical sign.” This study examines any correlation between a REDUCTION in lordosis and back pain, which they found to be more prevalent in men, but not statistically significant. However this study did not examine excessive lorsdosis and being positioned supine for an MRI is not sufficiently accurate to determine degree of lordosis as the spine will potentially flatten in this position. In any case, this study examines lumbar curvature, not pelvic tilt. Individuals must be standing to assess the functional position of a lordosis.

    Citation number two is the same study, but more accurately referred to the point being made, yet still flawed in its design/methodology and number of people examined… way too small to get an accurate assessment. Standing X-Ray would have been more accurate determinate of position.

    The third point refers to a study (citation #3) that IS done properly to assess lumbar and sacral inclination and angles. It did find “A statistically significant difference was found between the 2 groups in terms of age, gender, and lumbar stability.” It’s conclusion was “… a statistically significant difference was found for lumbar stability. Further extensive studies are needed to examine lumbar stability and its relationship between angles of lumbosacral region. The BIG FLAW in this study making it inconclusive to the argument at hand is this study does not compare the two groups, one with acute low back pain and the other with chronic low back pain, with a control group with no low back pain! But it is stated above that there is one??? Misleading.

    The fourth point and citation offer these results. “Among all the factors tested, endurance of the back extensor muscles had the highest association with LBP Other factors such as the length of the back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal muscles also had a significant association with LBP.” The conclusion notes, “It appears that muscle endurance and weakness are associated with LBP and that structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles are not associated with the occurrence of LBP.” Supporting your point here, but not considering the reason for the lack of endurance in related tissues to low back function. It does not offer a conclusion as to whether inefficient postural strategies could be playing a role in the lack of endurance noted. My jury is interested and still awaiting more testimony.

    The fifth study noted relating spinal curvature in the sagittal plane and pain concludes the following. “Evidence from epidemiological studies does not support an association between sagittal spinal curves and health including spinal pain. Further research of better methodological quality may affect this conclusion, and causal effects cannot be determined in a systematic review.” Author of the study note, “The included studies were generally of low methodological quality.” There were 4 health outcomes of moderate association including “daily function” as one.

    The studies next cited (http://www.ncbi.nlm.nih.gov/pubmed/21870097 & http://www.ncbi.nlm.nih.gov/pubmed/18758367) in defense of the influence of position and pain were much larger than the other studies mentioned (907 & 766 respectively, vs 56). The previous studies supporting his argument by measuring lumbar and sacral angles, contained no control group as well and this one did, and found a very different conclusion. “Sagittal spino-pelvic alignment was different between patients with chronic LBP and controls. In particular, there was a greater proportion of chronic LBP patients with low SS, low LL and small PI, suggesting the relationship between this specific pattern and the presence of chronic LBP.” The second of these (766 subjects) show results stating “Those adolescents classified as having non-neutral postures when compared with those classified as having a neutral posture demonstrated higher odds for all measures of back pain, with 7 of 15 analyses being statistically significant.” And concluding “More neutral thoraco-lumbo-pelvic postures are associated with less back pain.” Todd stated about these two much larger studies (and more accurate frankly) “But the weight of the evidence appears to be that if any correlation exists, it is weak.” That’s not what an objective reader would gather from them, by comparison to the ones he prefers to support. Read them yourselves, it’s pretty clear that there is enough evidence to keep this issue alive and well for more investigation.

    The two studies Todd is presenting as evidence to its relationship were larger, had a control and reached a very different conclusion than the studies he presents prior to attempt to demonstrate a lack of correlation or relationship. This is the kind of misrepresentation I’m talking about. If we read the studies ourselves we see that they are not the strong evidence that is being purported and it appears that we too often see poorly understood matters being decisively dismissed with weak or inconclusive evidence… Thus ones bias driving them to dismiss a speculation with another speculation. Which is worse, not fully understanding the matter at hand as it presents, or creating even more complex misunderstandings and inaccurate conclusions based on selective and poor review of the literature. I’m all for evidence based practice, but I’m not supportive of debunking anything for the sake of debunking alone, or to serve my own personal/professional bias in view.

    Furthermore, it is stated above that pelvic inclination cannot be changed, yet here is study performed demonstrating this to be untrue. http://pedroprado.com.br/cgi-bin/cont_ipr.cgi?cmd=show1artigo&ling=eng&id=374&txt_srch=pelvic%20inclination
    And another here, http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=3420170&log$=activity
    Also demonstrating the more physiologically significant effects of this on parasympathetic tone. Much more work is warranted to better understand all of this, yet if it were up to some it would get pushed aside for more convenient and overly-simplistic explanations.

    And of course we have evidence that pain influences functional measures, but that reality and argument doesn’t dismiss what is being argued here. That is a separate matter (functionally inter-related of course). Distinguishing what is the ‘effect’ of pain on movement and positioning and what is the ‘cause’ is a much more difficult and complex question to answer. Removing the variables out of bias thought/reasoning, rather than evidence-based disassociation, is not helpful in better understanding matters. Why are we trying to debunk certain clinical observations (supported by the studies above) to start a ‘new’ myth?

    • Todd Hargrove says:

      Ryan,

      Thank you for reading the studies in detail. Here are my responses.

      In the first study you object that the researchers were looking for a correlation between reduced lumbar lordosis and low back pain as opposed to increased lumbar lordosis and low back pain. Even if that was their intent, their findings of no statistically significant correlation between low back pain and the degree of lumbar lordosis also stands for the proposition that excess lumbar lordosis is not correlated with low back pain.

      As to your claim that the methods for determining the degree of lumbar lordosis were poor, I cannot comment because I do not know anything about measuring posture and was deferring to the expertise of the scientists in the study.

      In regard to your claim that the study examines lumbar curvature not pelvic tilt, I will point out once again that as far as I know the theory for why pelvic tilt leads to back pain is that it creates an excess lumbar curvature. Therefore, any study which finds that excess lumbar curvature is not correlated with back pain is, in my view, evidence against the proposition that excess anterior pelvic tilt causes low back pain.

      In regard to the 2nd study, you claim that the number of participants in the study was too small to form any accurate statistical conclusions. The study involved 56 people. I’m not an expert in statistics but I assume that your concerns with the low sample size were addressed in the peer review process, and that many people with far more statistical knowledge than either of us have already concluded that the sample size was large enough to warrant publication.

      In regard to the 3rd study you are correct in pointing out that I made a mistake in stating that this study involve a control group without back pain. Thank you for pointing that out and I apologize for the error. The study instead determines whether there were any differences in postural measurements between people who have chronic and acute low back pain. However, I still think the study is relevant. Acute low back pain is not the same thing as chronic low back pain, and as you point out the researchers were able to measure significant differences between the two groups in regard to stability. However there were no differences in the postural measurements, which suggests that posture plays no role in the differing stability or pain characteristics of the two groups.

      As to the two studies that did find a correlation between postural measurements and low back pain, I agree that these are interesting and relevant and should be considered. That is why I referred to them. And I appreciate the ones you cited above, those should be considered as well. However, I still think it’s fair for me to state that the weight of the evidence on the existence of a correlation between anterior pelvic tilt and back pain is that if it exists, it is weak. This is because the 5th study that I cited was a systematic review that considered 54 original studies on the subject. And it found “no strong evidence for any association between sagittal spinal curves and any health outcomes including spinal pain.” Regardless of whether many of the studies were of poor methodological quality, it seems to me that after 56 groups of scientists looked for a correlation between anterior pelvic tilt and low back pain, and were unable to produce any evidence that such a correlation exists as of 2008, then it is fair to conclude that the weight of the evidence militates against the existence of such an association. This is particularly striking in light of the context of my article, which is that people have devoted a huge amount of time and effort to the idea that pelvic tilt is a cause of LBP. Clearly this time and effort has been out of proportion to the state of the evidence, and that is my main point.

      I am willing to consider the idea that posture is somehow involved in back pain and that people who use better postural habits are less likely to have pain than people who do not. It is a commonsense idea which I find very appealing. However I can’t deny that there is quite a bit of evidence which suggests that the correlation is much less than most people assume that is why I wrote the article.

      I don’t appreciate your implications that my article was misleading. Unlike most articles on the subject, it makes an honest effort to deal with the actual evidence as opposed to simply making unsubstantiated claims. Of course different people will read the evidence differently, and that is fine. I welcome the different interpretations, but not any suggestion that mine was done in bad faith.

  16. Ryan says:

    This paper offers an excellent unbias review of the current lit on back pain and posture. This paper also dovetails with Todd’s other article on hip flexors. Any conclusions at this point are premature, at best.

    http://cirrie.buffalo.edu/encyclopedia/en/article/190/

    This summarizes how I feel about this type of comparison, as I mentioned in earlier comments. This is why ‘my’ jury is still hearing testimony….. .
    “Furthermore it could be suggested that attempts to link certain postures with a history of spinal pain is a generalised rather than a specific way to address this question, as posture and pain are not being directly studied at the same time.”

  17. Mike says:

    Hi Todd,

    Above you say: ‘Acute low back pain is not the same thing as chronic low back pain…’

    I know there are differences in experience of the pain(but all chronic pain starts as acute pain)but does the difference preclude “the” same underlying cause, in this case for arguments sake poor posture.

    In general the definition of when acute pain becomes chronic is arbitrary. Why make pain of the two types so fundamentally different and then draw such big conclusions? Including conclusions which I have come across such as acute pain is a warning something is biologically wrong but chronic pain serves no such biological purpose.

    If “the cause” of acute pain persists leading to ongoing pain then chronic pain is still a warning something is still wrong and we should find out what(even if it isn’t your curves).

    • Todd Hargrove says:

      Mike,

      Agreed that acute and chronic pain do not have a very bright line in between them, but my conclusions aren’t really based on that distinction. The conclusions are based on the fact that over many studies a correlation between pain and postural measurement does not appear clearly.

  18. john power says:

    If upon examination a client demonstrates certain movements, postures or spinal positions increase and decrease symptoms. And if the movement that happens to increase symptoms is lumbar extension and is decreased by a neutral or flexed spine then it is reasonable to assume that lumbar extension is part of a specific movement pattern that places stress or sensitizes particular spinal structures leading to an experience of pain. Lumbar extension is a couple movement with pelvic anterior tilt and is not dependent on hip flexor tightness. This is a simple evaluation procedure looking at mechanical pain and movement impairments. If the pain is persistent regardless of postural loading or spinal movement then one could reasonably assume that anterior tilt is not a causative factor.

  19. john power says:

    This reasoning is part of the McKenzie process but it is a simple example of using a provocative procedure to test for mechanical pain versus inflammatory or disease. Shirley Sahrmann uses the term Movement Impairment Syndrome to describe pain and dysfunction based on a collection of criteria – poor flexibility, lack of strength, coordination (neuromuscular) as well as anatomical features that may predispose one to mechanical pain etc. It is a pretty thorough, insightful process that uses movement reeducation as a treatment process. All body centered therapists, trainers and movement specialists do need to have an understanding of the possibility of pain from biopsychosocial processes especially in the chronic pain patients.

  20. nicnack says:

    Dear Devil’s Advocate –

    I’ve read through every blog on your website. I must tell you that you would make a decent lawyer. Your ability to scrutinize conventional wisdom is keen and to challenge any lack of statistical data is useful..

    As a professional in the industry of health and wellness, I wonder if you feel confident in telling your audience that:
    – sitting may not really shorten your hip flexors, or
    – that poor posture may not really cause pain or
    – that an anterior pelvic tilt perhaps does not result in back pain..

    I would have to turn it back to you and question your proof and hope that before posting this information that you can offer some concrete conclusions as to why people should consider this information and not become even more confused about how to approach their health and anatomical issues?

    These particular posts seem a bit empty or lacking in any real factual point other than.. there’s no real proof of these common approaches. sure, I don’t believe anything is ever 100% and that we each need to listen to our body and make informed choices, but if you are going to share anything useful then I would love to hear some real data that supports these notions as well as some constructive guidance as to what to do as an alternative?

    • Todd Hargrove says:

      Hi Nicnac,

      You read every post? That is hard to believe, because if you did you would notice that most of them are not skeptical or critical in nature. Many offer my ideas about what would be good practice. I probably do just as much building up as tearing down.

      Yes I would be comfortable telling my audience exactly what you just stated, especially since you used language like “may” and “perhaps.” And in fact that is exactly what several of my posts do.

      You are free to question my “proofs”, but the fact is that I rarely claim to have proved anything. And that is because I haven’t, and hardly anyone else has either on most issues that are the subject of any debate at all. Usually my language has appropriate disclaimers, limitations, and admissions that what I am saying is just speculation.

      And yes that is because I used to be lawyer.

      • nicnack says:

        yes every post! you are clearly an educated person in your field and like I said in my comment, it was those ‘particular posts’ that I was referring to. I guess there may not be statistical research about everything, so maybe some things are more about common sense and results. Anyways, thanks for the response

  21. Todd Hargrove says:

    Ah you did limit your comment to “particular posts.” I didn’t notice that. You are rather lawyerly yourself:)

  22. Rami says:

    Thank for your interesting post and blog which I recently discovered.
    May I ask what do you think about Foundation Training?

  23. Nancy says:

    What do you think about foundation training? I have just been diagnosed with quote unquote pelvic tilt after having had abdominal and severe lower back pain for over two weeks. I can’t stand or sit without screaming and pushing on things to get up or down.

    • Todd Hargrove says:

      Hi Nancy,

      I am very sorry to hear about the back pain. My guess is that it probably doesn’t have much to do with pelvic tilt but who knows?

      I am not very familiar with Foundation – it looks like a reasonable approach to improving posture and movement – like many other approaches. Best of luck. And make sure to see a doc to rule out serious issues.

  24. bjones says:

    Interestingly, there is some scientific evidence that INCREASING anterior inclination 10-15% DECREASES back pain, at least during bicycling. To save you time, it means adjusting the front of the bike seat to be lower and the rear higher.

    Journal Article:
    “Effect of changing the saddle angle on the
    incidence of low back pain in recreational
    bicyclists” (1999) (British Journal of Sports Medicine)
    http://bjsportmed.com/content/33/6/398.full.pdf

  25. Now I’m not a researcher by trade but as a chiropractor and deep tissue sports massage therapist also trained in acupuncture, I can tell you that roughly 50+ % of the people with back pain have a rotated or torqued pelvis which is causing pressure and or locking sensation one or both of the SI joints. In the vast majority of these cases the side of anterior pelvis has a shortened psoas muscle / hip flexor when measured to the other. Most of those cases I would say the the longer side is also shortened , just not as much. As say this because I measure and release, measure and release. A bilateral hip flexor release allows the SI joints to adjust very easy and smoothly, opposed to have to really jump on the stiffened joint to get it to move and release. The second amnd third most common presentations I see is the anterior and L5 vertebrea, or rotation of the last 3 vertebrea, most commonly to the right. Next is an anterior rotation of primarily the sacral base on the top right that is very tender to pressure “yeah that’s the spot”. Lastly and rarely I find a rotation of the sacral apex. I know this is perhaps beyond the scope of most professional articles, but there really are more variables in real life situations that need to be but into the equation. The main thread with all of these presentations is that the bones and joints of the low back and or pelvis have also been twisted and torqued, putting pressure in one or more joints and causing a locking or reduction is ease of movement. Hope this helps. Craig Eymann DC

    • markus says:

      Craig, I wonder if your findings might also be a case of back pain actually causing the distortion. a causal relationship is important. Why would the body distort itself? what is the reason? and more so how come chiro can correct it.

      im certainly not arguing the chiro can work as I myself suffered a terrible bout of chronic lbp several years ago that was corrected through just a few adjustments to my si joint area, but im very skeptical that chiro by itself is a solution and feel there is more at play here.

      im not a doctor but one thing I do know is that muscles move bones. and muscle tension is set through neurological pathways.

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