<h2>Does Your Client Really Have Tight Hip Flexors? Or An Anterior Tilt Of The Pelvis?</h2>
&nbsp;

<span style="font-weight: 400;">We may hear client's saying they have been told they have an </span><i><span style="font-weight: 400;">anterior pelvic tilt</span></i><span style="font-weight: 400;"> &amp; </span><i><span style="font-weight: 400;">tight hip flexors &amp;</span></i><span style="font-weight: 400;"> it’s usually followed by something along the lines of… </span><i><span style="font-weight: 400;">“I spend a lot of time sitting at a desk, so I’ve been told my hip flexors are weak and tight. I need to stretch them, strengthen them.”</span></i><span style="font-weight: 400;"> </span>

&nbsp;

<span style="font-weight: 400;">Perhaps you feel that one of your clients has tight hip flexors because they report them <em>feeling</em> tight when they extend their hip. Yet no matter how much they stretch them, nothing changes...maybe they have been told they have an anterior tilt because their ASIS are lower than their PSIS..?</span>

&nbsp;

<span style="font-weight: 400;">Things to consider....</span>
<ol>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Who decides the ideal pelvic posture considering we are all built differently?</span></li>
 	<li style="font-weight: 400;"><span style="font-weight: 400;">Rarely have I seen a short psoas muscle during the Thomas Test.</span></li>
</ol>
<span style="font-weight: 400;">While I am not suggesting there is no such thing as a perfect pelvic position or that no one has ever had a short hip flexor, I do believe there are other things we should consider before making these assumptions. </span>

&nbsp;

<span style="font-weight: 400;">How can we broaden our understanding of the things that influence our exercise prescription for those who feel they may have an anterior tilt to their pelvis or possibly tight hip flexors? What else could be happening?</span>

&nbsp;
<h3><b>What Is An Anterior Tilt?</b></h3>
&nbsp;

<span style="font-weight: 400;">First of all, if our clients are symptomatic, or experience pain, then this alone can be a red flag and may require a referral to rule out any clinical risk.</span>

&nbsp;

<span style="font-weight: 400;">However if they are pain-free and </span><span style="font-weight: 400;">have no symptoms it important to let them know they are perfectly normal and having an tilt at the pelvis may well be nothing at al to worry about. W</span><span style="font-weight: 400;">e all have the ability to anteriorly tilt our pelvis and this in itself isn't a diagnosis but could be an observation made by a practitioner who wants to help.</span>

Lordosis is also perfectly normal and occurs during an anterior tilting of the pelvis too, some people have a more exaggerated curve and others have less.

<span style="font-weight: 400;">We all have the ability to a tilt posteriorly too and present with a flatter lumbar spine.</span>

<span style="font-weight: 400;">Since we all have different genetics so it doenst make sense that we should all look the same does it?</span>

&nbsp;
<h2><span style="font-weight: 400;">So what is meant when a practitioner suggests you have an anterior tilt?</span></h2>
&nbsp;

<span style="font-weight: 400;">If you stand up and stick your bottom out or arch your back you will be in an anterior tilt. The 'diagnosis' of an anterior tilt will likely follow someone complaining of symptoms like back pain for example. If they present with excessive lordosis or an exaggerated lumbar curve and the ASIS appearing lower then the PSIS the practitioner may deduce that something is tight, causing this to become the default posture, maybe tension in tissues that tip the pelvic bowl down at the front, like psoas.  </span>

We base our understanding of anatomy on learning <strong><em>anatomical neutral </em></strong>which has been defined in this instance as the ASIS &amp; PSIS being at the same height. The problem is there are other things to consider like being born with a different shaped pelvis to a typical pelvis. We are as different on the inside as we are on the outside.

<span style="font-weight: 400;">The problem is if we assume the anterior tilted posture to be wrong and try to 'correct' it when its actually typical or normal for them. </span>

&nbsp;

<span style="font-weight: 400;">A posture by definition is simply a position of the body, there is not good or bad one, just the one we hold for too long, without variation. Consider a solider in 'good' posture, hes going to ache after a day on duty! Alternatively consider demonstrating a 'bad' posture, you probably wouldnt mind because you know it does hold risk when done for a brief amount of time. However sitting a desk day in day out, then in a car, then on the sofa could be inducing adaptions and compensations that result in symptoms over time.</span>

&nbsp;
<ul>
 	<li><span style="font-weight: 400;">How do we measure degrees of pelvic tilts? </span></li>
 	<li><span style="font-weight: 400;">How is the the benchmark defined and by whom? </span></li>
 	<li><span style="font-weight: 400;">How accurate is it? </span></li>
 	<li><span style="font-weight: 400;">What evidence is there for postural assessment? </span></li>
 	<li><span style="font-weight: 400;">Is postural assessment too subjective due to genetic differences?</span></li>
</ul>
<h2></h2>
<h2><b>What &amp; Where Are The Hip Flexors? </b></h2>
&nbsp;

<span style="font-weight: 400;">Some have described the psoas' role as more of a local and global stabiliser that assist in hip flexion as part of a conjoined hip movement.</span>

&nbsp;

<span style="font-weight: 400;">A yoga teacher once suggested that “…</span><i><span style="font-weight: 400;">they (hip flexors) aren't WEAK they are exhausted!”</span></i>

&nbsp;

<span style="font-weight: 400;">Travell and Simon named it the</span><i><span style="font-weight: 400;"> ‘hidden prankster’</span></i>

&nbsp;

<span style="font-weight: 400;">Hip Flexors are basically..... muscles that flex the hip. </span>

<span style="font-weight: 400;">To contribute to this movement they must attach above and below the hip joint, which is where the pelvis and femur bones meet.</span>

&nbsp;

<strong>Primary Flexors of the Hip </strong>

<span style="font-weight: 400;">Psoas Major L1-4 transverse spinous processes to meet with iliacus to become the iliopsoas that ends up on the lesser trochanter of the femur.</span>

Psoas Minor - only found in around 40-60% of us! Attaching to the lateral aspects of the 12th thoracic &amp;1st lumbar vertebrae from there it blends with the iliopsoas fascia.

<strong>Other Hip Flexors </strong>

<span style="font-weight: 400;">Rectus Femoris - AIIS to Patella </span>

<span style="font-weight: 400;">Tensa Facia Latae - ASIS to ITB</span>

<span style="font-weight: 400;">Sartorius - (Longest muscle in the body!) ASIS to medial knee.</span>

<span style="font-weight: 400;">Adductor longus, brevis, magnus - superior pubis to medial femur </span>

<span style="font-weight: 400;">Gracilis - ishiopubic ramus to tibia</span>

<span style="font-weight: 400;">Pectineus - pubic bone to femur</span>

&nbsp;

<span style="font-weight: 400;">The actual muscles can be analysed and defined by their attachments and fibre directions but when considering how to help our clients better all we really need to understand is the movements they influence or inhibit.</span>

&nbsp;
<h2><b>How Do We Assess The Hip Flexors?</b><span style="font-weight: 400;"> </span></h2>
&nbsp;

<span style="font-weight: 400;">Or what may be a more helpful way of thinking about it, particularly for those who aren't so confident about their anatomy recall, is how to assess Hip Flex<em><strong>ION</strong></em>?</span>

&nbsp;

<span style="font-weight: 400;">The most well-known way of testing if the hip flexors are inhibited is to use what is most commonly known as the Thomas Test.</span>

&nbsp;
<h2><b>The Thomas Test (Thomas, 1878)</b></h2>
&nbsp;

<span style="font-weight: 400;">The Thomas Test was named after Dr.Hugh Owen Thomas, and is now used to assess hip extensibility. So it requires being able to lie your client supine off the end of a massage table, supported from the back of the hip and up their spine. </span>

&nbsp;

<span style="font-weight: 400;">They then lower one leg down to hang freely and you measure if the hip has the capacity to allow the leg to drop down ‘enough’. The knee is required to be below the hip to pass the test. </span>

<span style="font-weight: 400;">This is where the ability to measure should be…..</span><i><span style="font-weight: 400;">should</span></i><span style="font-weight: 400;"> be…</span>

<span style="font-weight: 400;">However this method of the test is being challenged since some programmes teach for the top hip to be flexed to 45 degrees, other interpretations suggest the knee should be pulled into the chest however a key component is of course the pelvic position. Should the knee be pulled into the chest too much the pelvis would tip back into a posterior tilt, thus lifting the hanging leg due to the femur pressing the illium back. So not as a result of tissue tension but due to bone on bone making this a void result or hip flexor extensibility. </span>

<span style="font-weight: 400;">Likewise if the hanging leg weighs the pelvis forward into an anterior tilt, the test will also be void due to the pelvic position lowing the knee in comparison to the hip.</span>

&nbsp;

<span style="font-weight: 400;">Also, the landmarks for measuring the degree of drop from hip to knee are often vague. The hip is a pretty large area and the knee, while smaller, also has a relatively large area to choose from as a landmark for a measurement.</span>

&nbsp;

<span style="font-weight: 400;">The MOST important things about a measurement is having as much objectivity as possible so the test can be reproduced accurately. A benchmark with standardisation that considers the variations in the body but also uses the bony prominences of the anatomy so we can all assess individuals in the same way.</span>

&nbsp;
<h2><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4991856/" target="_blank" rel="noopener noreferrer"><b>The Modified Thomas Test</b></a></h2>
&nbsp;

<span style="font-weight: 400;">Almost exactly the same but by ‘fixing’ the pelvis into a neutral position and using specific bony landmarks to measure the drop we can find some degree of accuracy for comparison.</span>

&nbsp;

<span style="font-weight: 400;">So while your client is supine you take hold their top leg, then take hold the ASIS with your thumb as your hand grips around the back of the pelvis/ilium. Now while firmly holding onto their thigh, rock the leg into flexion and back while feeling the pelvis tilt back and forth. Once you feel the posterior tipping point bring the thigh to the position just ahead of the tip, ask the client to carefully hold the knee in this position. Now quickly move to the hanging leg side, crouch down to measure the angle from the centre of the greater trochanter to the lateral condyle of the knee. You could even photograph it with their permission.</span>

&nbsp;

<span style="font-weight: 400;">Repeat the other side. </span>

&nbsp;

<span style="font-weight: 400;">This is not just a range test but also a symmetry test so we can compare one side to the other. </span>

<img class="aligncenter size-large wp-image-18634" src="https://biomechanicseducation.com/wp-content/uploads/2019/11/Modified-Thomas-Test-Biomechanics-Education-1-1024x683.jpeg" alt="" width="1024" height="683" />
<h3><b>What’s A Good Measurement?</b></h3>
<span style="font-weight: 400;"> </span>

<span style="font-weight: 400;">Great question!!</span>

<span style="font-weight: 400;">Well to take into account natural differences between us if the lateral condyle is between parallel (to the greater trochanter) and 30 degrees lower than the greater trochanter that leg technically passes in terms of range. However the legs should drop by the same amount each side for symmetry, so this must be noted too.</span>

&nbsp;

<span style="font-weight: 400;">What we often see is decent range on both sides but an asymmetry so the question is are hip flexor/s really ‘tight’?</span>

&nbsp;

<span style="font-weight: 400;">Well if tight means short then no but what causes the asymmetry?</span>

&nbsp;

<span style="font-weight: 400;">What’s the issue? Can muscles like hip flexors be dysfunctional but long or lax or length tensioned?</span>

or maybe they have hypertonicity?

&nbsp;
<h2><b>Master Of Compensation</b></h2>
&nbsp;

<span style="font-weight: 400;">We have discussed regularly how the body is amazing at compensating. So imagine for a moment what your wonderful integrated system might be thinking when your client sits a LOT…..</span>

&nbsp;

<span style="font-weight: 400;">“….</span><i><span style="font-weight: 400;">Ok so we aren't using these hip flexors, they are simply wasting energy while not in use for such long periods, let’s save energy and down regulate them…”</span></i>

&nbsp;

<span style="font-weight: 400;">What happens when we stretch them? Nothing...why not? They are technically ‘tight’ or possibly they are not even short....ok so what do we do?</span>

<span style="font-weight: 400;">Lets ‘stimulate’ them safely with a low grade muscle energy technique (MET) instead!</span>

&nbsp;

<span style="font-weight: 400;">Hip flexion <a href="https://www.biomechanicseducation.com/1333-2/" target="_blank" rel="noopener">isometrically resisted at 20% muscular effort held for 20 seconds x 4 reps x 4 sets </a></span>

<span style="font-weight: 400;">Follow this with some funky hip extensor strength exercises - kettlebell swings, deadlifts, squats OR simply alternate a set of MET’s on either hip then a set of swings, squats - repeat 4 times.</span>

<span style="font-weight: 400;">This takes advantage of the law of reciprocal inhibition in your programming and makes for a very cool training session for the client! </span>

&nbsp;

<span style="font-weight: 400;">So now you have the test necessary to assess what’s going on with your clients’ hip flexors and if they are in need of attention you know what to do. </span>

&nbsp;

<hr />

<h2 style="text-align: center;">Ready To Help Your Clients Move Better &amp; More Freely?</h2>
rachel@biomechanicseducation.com

<a href="https://biomechanicseducation.clickfunnels.com/biomechanics-coach-l4-low-back25799549"><img class="aligncenter wp-image-10836 size-large" src="https://biomechanicseducation.com/wp-content/uploads/2019/01/Always-Always-Start-With-Why-1024x512.png" alt="" width="1024" height="512" /></a>