Lower back pain (LBP) is a widespread, painful medical condition that has been plaguing society for many years. Present conservative rehabilitation focus is on lumbo-pelvic hip stability exercises in individual planes. However, a functional integrative rehabilitative approach addressing lumbo-pelvic misalignment in the sagittal (anteriorly tilted pelvis) and frontal (Trendelenburg gait) planes has not been presented. The aforementioned patho-biomechanical conditions and their management are often discussed estranged from each other rather than functionally integrated. This paper serves as a short communication which discusses the lumbo-pelvic anatomy, identifies the anatomical and biomechanical associations between the anteriorly tilted pelvic and Trendelenburg gait. Through an analysis of relevant literature, recommendations were made on the improvement of flexibility of the hip flexors, taut iliofemoral and pubofemoral ligaments to resolve the primary abnormal force-couple, with improved flexibility of the erector spinae and quadratus lumborum to resolve the secondary abnormal force-couple. In addition, improved flexibility of the hip flexors should coincide with closed-kinetic chain concentric strengthening of the ipsi-lateral hip abductors and contralateral external obliques. Patient education is also needed for self-re-alignment of the lower extremity to a neutral position and neutral foot stance. Biokineticists/exercise therapists should also review the patient’s gait biomechanics to determine whether sartorius synergistic dominance is in play. In conclusion, the association between an anteriorly tilted pelvis and Trendelenburg gait, is in regard to taut anterior acetabulofemoral ligaments and femoral retroversion torsion angle that is both preceded and followed by the biomechanical influence of various anatomical structures. These anatomical and biomechanical factors must be evaluated by the biokineticists/exercise therapists before prescribing a rehabilitative programme to ensure successful rehabilitation of lumbo-pelvic hip complex.
Lower back pain (LBP) is a common, painful and costly medical condition adversely impacting society, which can be traced backed to Imhotep (2800 BC) [
Exercise therapy students often ask the question: what is the association between an anteriorly tilted pelvis and Trendelenburg gait? Most prescribed literature used in the teaching of exercise therapy discusses the aforementioned conditions separately, creating the mind-set that these lumbo-pelvic hip conditions are estranged from each other [
Subsequently comprehension and management of anteriorly tilted pelvis and Trendelenburg gait becomes a challenge to both the student and novice exercise therapist. The objective of this paper is to review the anatomical and biomechanical association between the anteriorly tilted pelvis and Trendelenburg gait in the sagittal plane and frontal plane respectively. The evidence of this clinical commentary will enhance the understanding of the LBP and its multi-planar contributors. Derived from this aforementioned knowledge, exercise therapists will be empowered to formulate a rehabilitative strategy to stabilize the lumbo-pelvic hip complex in a functional multi-planar dimension.
The typical practices for systematic reviews, PRIMSA and its PICOS checklist for participants, interventions, comparisons, outcomes, and study designs were charted. The participants were records describing the relationship between Trendelenburg gait and anterior pelvic tilt; the intervention was not necessarily a therapeutic intervention but is interpreted as an exposure. The outcomes of interest were the relationship between Trendelenburg gait and anterior pelvic tilt. The exclusion criteria were 1) recording pertaining individually to Trendelenburg gait, 2) studies pertaining individually to anterior pelvic tilt.
A literature search was conducted utilizing peer-reviewed and professional journal publications, using the CROSSREF meta-database. CROSSREF includes the following databases: Pubmed, Medline, Science Direct, Ebscohost, Biomed, CINAHL, and Sabinet. The key search words were: relationship between Trendelenburg gait and anterior pelvic tilt. The screening eligibility of papers was performed in the following three steps: 1) title screen, 2) abstract screen, and 3) full-text screen. However, there were no results found describing the relationship between Trendelenburg gait and anterior pelvic tilt. Therefore, this short commentary theoretically describes the anatomical and kinesiological relationship between Trendelenburg gait and anterior pelvic tilt.
The lumbo-pelvic hip complex is a coupling unit that transfers, absorbs, dissipates and amplifies force from the upper kinetic chain to the lower extremities and vice versa [
this ball and socket joint are to provide a wide base of support for the lower extremities, abundant multi-planar range of motion and the kinetic link between the upper and lower extremities [
The muscles of interest in the sagittal plane include hip flexors and hip extensors. Hip flexors include iliopsoas (iliacus and psoas major), rectus femoris, sartorius and tensor fascia latae (TFL) (assisting hip flexion), while the antagonistic hip extensors are the gluteus maximus, biceps femoris (long head), semimembranosus, semitendinosus and adductor magnus (long head) (
femoris) and internal rotators (gluteus medius (anterior fibres) and minimus and TFL) [
An anteriorly tilted pelvis is caused by hip flexor contractures, which by definition is a limitation to passive hip extension triggered by a lack of extensibility of the anterior acetabulofemoral ligaments and muscles [
The secondary abnormal force-couple of the short-arc pelvis-on-femur flexion is the lengthening and weakening of the rectus abdominus, internal and external obliques due to the contracture of the erector spinae (spinalis, longissimus and iliocostalis lumborum muscles and quadratus lumborum), as a consequence of the subsequent lumbar lordosis (
and ligaments will not be discussed.
These abnormal force-couples of the short-arc pelvis-on-femur flexion in the sagittal plane radically influence the force closure of the lumbo-pelvic hip complex specifically due to the counter-nutation of the SIJ, which leads to muscular asymmetries in the frontal plane [
It is recommended that exercise therapists should stretch the hip flexors and taut iliofemoral and pubofemoral ligaments to resolve the primary abnormal force-couple. This would reverse the anterior tilt of the ilium and the counter-nutated position of the SIJ. In addition, the erector spinae and quadratus lumborum should also be stretched to address the secondary abnormal force couple.
Trendelenburg gait is characterized by hip abductor weakness that is unable to play a key role in the swing phase of walking and running [
Kendall et al. reports that muscles have dynamic interrelationships that expand across different planes of motion whose functional role change from primary agonists to synergists [
lower extremity is in an open-kinetic chain movement, which necessitates the synergistic concentric contraction of the contra-lateral external oblique muscle to move its distal attachment towards it proximal site, in order to keep the entire hip in equilibrium [
Another biomechanical intrinsic factor that comes into play is the synergy of the TFL and sartorius to act as hip abductors, which creates the issue of synergistic dominance [
It would be valuable to stretch the hip flexors and concentrically strengthen the ipsi-lateral hip abductors and contralateral external obliques with closed-kinetic chain exercises, further adjusting the hip’s retroversion torsional angle by teaching the patient to re-align their lower extremity to a neutral position and neutral foot stance. Biokineticists/exercise therapists should also review the patient’s gait biomechanics to determine whether sartorius synergistic dominance is in play.
The following rehabilitative exercises are mere recommendations to increase stability of the lumbo-pelvic hip complex in all three planes (frontal, sagittal and transverse). It is advised that patient should first consult with a medical practitioner to confirm hip pathology and then consult a physiotherapist for myofascial release, before the biokineticist/exercise therapist begins a rehabilitative programme. The rehabilitative programme (
Stretching Exercises | |||
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Muscles | Traditional exercise | Recommendations | New exercise |
Hip flexors (rectus femoris and iliopsoas) | The modified stretch needs to increase the ROM of the hip flexors. One can also add external rotation to stretch taut iliofemoral and pubofemoral ligaments. | ||
Hip adductors, internal rotators and taut iliofemoral and pubofemoral ligaments | The modified stretch needs to increase the ROM of the hip flexors. One can also add external rotation to stretch taut ligaments. | This stretch increases elastic ROM of the iliofemoral and pubofemoral ligaments. If the hip is extended will also stretch the hip flexors. This stretch counters a Trendelenburg gait and an anteriorly tilted pelvis. | |
Lower back stretch (lumbar erector spinae and quadratus lumborum) | The modified stretch needs to increase ROM in the sagittal and transverse planes. |
Strengthening Exercises | |||
---|---|---|---|
Muscles | Traditional uni-planar exercises | Recommendations | Multi-planar exercises |
Mostly rectus abdominus, external obliques internal obliques transverse abdominus | There is only movement in the sagittal plane. These muscles are multi-planar movers. Therefore, use a Swiss ball crunch that stabilizes the lumbo-pelvis in all planes. | ||
Contra-lateral external obliques and ipsi-lateral obliques | There is movement in the transverse plane in an open-kinetic chain movement. There is no frontal plane movement. Therefore, use a Swiss ball crunch that stabilizes the lumbo-pelvis in all planes. | ||
Hip abductors (gluteus medius and minimus) | This exercise needs to strengthen hip abductors in a closed-kinetic chain movement to directly rehabilitate Trendelenburg gait. | ||
Hip abductors (gluteus medius and minimus) | This exercise needs to strengthen hip abductors in a closed-kinetic chain movement to directly rehabilitate Trendelenburg gait. |
Hip extensors (Gluteus maximus) | This exercise needs to strengthen hip abductors in a closed-kinetic chain movement to directly rehabilitate Trendelenburg gait. | ||
---|---|---|---|
Modified plank | Bi-planar movements, in the sagittal and transverse planes are needed. The exercise only enforces frontal plane stabilization. The multi-planar movement activates lumbo-pelvic force closure and stability. It counters both an anteriorly tilted pelvis and a Trendelenburg gait. | ||
Multi-directional 3D-lunge | Bi-planar movements, in the sagittal and transverse planes are needed. The exercise only enforces frontal plane stabilization. The multi-planar movement activates lumbo-pelvic force closure and stability. It counters both an anteriorly tilted pelvis and a Trendelenburg gait. |
nature that should be maintained for 15 seconds, three repetitions each. All strengthening exercises focus on local muscle activation and should be completed as 20 repetitions of three sets. This rehabilitative programme should be completed every alternate day for three weeks. Thereafter, patients should be re-evaluated by a biokineticists/exercise therapist to determine quantitative progress.
The association between an anteriorly tilted pelvis and Trendelenburg gait, is in regard to taut anterior acetabulofemoral ligaments and femoral retroversion torsion angle. Slackened iliolumbar ligaments fail to synergistically support the ipsi-lateral hip abductors to hold the contra-lateral hip in equilibrium in the frontal plane, resulting in Trendelenburg gait. The iliolumbar ligaments became slackened due to the anteriorly tilted pelvic in the sagittal plane. Weakened, lengthened contra-lateral external obliques dynamically fail to synergistically support the ipsi-lateral hip abductors to hold the contra-lateral hip in equilibrium, producing Trendelenburg gait. These contra-lateral external obliques have become weakened and lengthened due to an anteriorly tilted pelvis. These anatomical and biomechanical factors must be evaluated by the biokineticists/exercise therapists before prescribing a rehabilitative programme to ensure successful rehabilitation of lumbo-pelvic hip complex.
The authors declare no conflicts of interest regarding the publication of this paper.
Paul, Y., Swanepoel, M., Ellapen, T.J., Barnard, M., Hammill, H.V., Müller, R.W. and Williams, J. (2018) What Is the Association between an Anteriorly Tilted Pelvis and Trendelenburg Gait? Open Journal of Orthopedics, 8, 464-475. https://doi.org/10.4236/ojo.2018.812048