The tilt of the Leaning Tower of Pisa comes from its foundational base, not the building itself. In a like manner, if the pelvis is tilted, then the spine will end up being tilted. In this episode of The ABMP Podcast, Kristin and Darren speak with Dr. Joe Muscolino about the three different types of pelvic tilt, how forward head posture translates to the pelvis, and treatment approaches that can be used during and after the session.
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0:01:03.2 Darren Buford: I'm Darren Buford.
0:01:04.3 Kristin Coverly: And I'm Kristin Coverly.
0:01:05.8 DB: And welcome to the ABMP podcast, a podcast where we speak with the massage and body work profession. Our guest today is Dr. Joe Muscolino. Dr. Muscolino has been a manual and movement therapy educator for more than 35 years. He has created several online streaming subscription platforms for manual therapy continuing education, including learn muscles continuing education with more than 3000 video lessons and more than 300 hours of NCBTMB credit. He has also created muscle anatomy masterclass, bone and joint anatomy masterclass, visceral anatomy masterclass and kinesiology masterclass. And he is the author of multiple textbooks with Elsevier and has authored more than 90 articles. For more information about Dr. Joe's content, visit learnmuscles.com. Hello, Joe, and hello, Kristin.
0:01:55.1 Dr. Joe Muscolino: Hey there, such a pleasure to be here, Darren, Kristin, Colin in the background. Thank you ABMP for inviting me.
0:02:02.2 KC: Thank you so much for coming back. This is your three-peat, it's your third visit to the ABMP podcast, and we're so happy to have you back with us. Thanks for being here.
0:02:09.5 DM: Okay. Well, it's a pleasure and an honor.
0:02:11.5 DB: Joe, let's dive in. Listeners, we're gonna reference the most recent cover feature in the May/June, 2022 issue of Massage and Bodywork Magazine. Joe's feature is called pelvic tilt and spinal compensation. Joe, can... You used a fantastic analogy to set up the article at the beginning with regards to a statue on a pedestal to symbolize the relationship we're talking about here. Can you reference that for the listeners here, potentially for those who haven't read the piece and to remind those who have read the piece?
0:02:41.8 DM: Sure. So image two in the article, right on page 36, we have a picture... Two pictures of a statue. And in one case, the statue is standing on a pedestal and the pedestal is level. So we see that the person's body, and it's an anterior front view, we see that the person's body is going straight up vertically, and it's symmetrical. If you were to measure iliac crest heights, left and right sides, they'd be the same. Top of the shoulder girdles, they'd be the same. But right next to it is another picture of a statue, anterior front view again, and now the pedestal is crooked. One side is higher than the other. And we see that if there is no compensation with the body of the statue, if the statue were to stay exactly the same statue, then we see that it's tilted, it's leaning to one side, and then in fact, image three shows the Leaning Tower of Pisa. And the statement is made that the problem with the Leaning Tower of Pisa, if you go up onto it, you're going to see maybe plaster cracking on the third floor. Well, the problem's not in the third floor, the problem is the foundation. It's the basis upon which the Leaning Tower of Pisa stands. It is the pedestal of it, it's the foundation.
0:04:03.7 DM: And this is all an analogy to go over to the idea that the spine sits on the pelvis. Now, more specifically, we would say that the cervical thoracic lumbar spine all the way down to L5 sits on the sacrum. Now, technically the sacrum is part of the spine as is the coccyx, but if we were to say, okay, we're going to look at the pelvis, the pelvic girdle as being the two pelvic bones, the two hip bones, innominate bones, a lot of names for the same thing and the sacrum and coccyx, then we can make a line and say, "Okay, look at the line across the top of the sacrum. That is the top of the pedestal upon which L5 sits and all of the lumbar spine, all of the thoracic, all of the cervical spine, the entire body above." So if the line of the sacrum, if the base of the sacrum, which is the landmark at the top of the sacrum, the sacrum is a triangular shape bone, and it is an upside down triangle, so the apex is at the bottom, the base is at the top. If we look at the base of the sacrum, we can look at it in the frontal plane, left to right. We can look at it in the sagittal plane, front to back, and we can look at it in the transverse plane, whether it is rotated, twisted to one side, right side or rotated to the left side.
0:05:32.9 DM: And that is the base that the statue must begin on. And if that pedestal, that sacral base, is not perfectly level, symmetrical, in frontal plane, sagittal plane, or transverse plane, then we would have, in effect, some type of a "Leaning Tower of Pisa," but we don't want to have a Leaning Tower of Pisa. Because if we have a leaning tower of Pisa and just think about frontal plane, one side of the pelvis, one iliac crest, let's say, is low on the right side, the sacral base is going to be unlevel, so that its left side iliac crest, pelvic bone is high on the left, the sacrum is higher on the left than the right, L5 sits on that crooked pedestal sacral base, and L5 is going to be... The lumbar spine has to skew and lean toward the lower right side.
0:06:37.8 DM: If we had a "perfectly straight spine," Oh, people think, "I have a straight spine. Straight spine is good, right? I don't want to curve in the frontal plane." By definition, a curve in the frontal plane would be a scoliotic curve, a scoliosis. And that scoliotic curve, even though it might be deemed as being, "Oh my goodness, scoliotic curve, that's not good," well, I'm happier with a scoliotic curve, assuming it's not tremendously large in it's... How the angle of the curve you measure, I'm happier with a scoliotic curve at my eyes and ears level than I am with a straight spine, and I'm crooked over to the side, like the Leaning Tower of Pisa.
0:07:20.9 KC: Dr. Joe, in the article, you described three different types of pelvic tilt, when one iliac crest is lower than the other, an anterior posterior pelvic tilt and rotational distortion, and the muscles, another factors that might be involved in creating each of those different types of tilt. How do you think most practitioners become aware of a client's pelvic tilt? Do you think it's through a visual assessment or a more in depth postural assessment?
0:07:49.2 DM: So first, to define our terms, we have three planes, three cardinal planes, sagittal, frontal, transverse and movement of the pelvis in the sagittal plane. Well, the word pelvis comes from the Latin word, and it means basin. So if you picture the pelvis as a basin of water, if I tilt my pelvis forward, such that the water spills forward, then that's an anterior tilt. If I tilt my pelvis back such that the water spills backward, posterior tilt, sagittal plane, anterior posterior tilt. Frontal plane, you can say it's lateral tilt, side tilt, right lateral tilt, left lateral tilt. Some books instead would say depression on one side, elevation on the other side. Some books call the side that goes up hiking the hip. There's many different terms depending on what the particular reader or listener is familiar with. But if we use the term tilt, right lateral tilt, left lateral tilt, it's where the water spills. Transverse plane movements, a transverse plane is a horizontal plane, so it doesn't technically tilt it simply rotates, it spins.
0:08:56.5 DM: Right rotation, left rotation. Okay, so now the idea here is that if we have an anterior tilt in the sagittal plane, then the pelvis is tilted forward. Then what we have to have is some type of "tilting back," some type of curve going back to bring our center of weight over our pelvis. Because in the end, we always want to have a balanced posture. So we need to have the center of weight of our trunk over our pelvis. We want to have the center of weight of our head over our trunk. We want the center of weight of our pelvis to be over our feet when we haven't... We're not talking about feet here, and some people might say, "He's saying the foundation of the body, we have to talk about the feet." And I do not disagree there.
0:09:48.9 DM: We can talk about kinetic chains that involve the feet for this, but right now I'm only talking about the pelvis. So, we wanna look for these tilts. The way I believe it can and should be done is right after you finish your physical exam, the first thing I do with every new patient is I do a postural exam. I have them perhaps facing away from me. And if I have them facing away from me, then I'm looking at frontal plain distortion patterns. If I look at the right iliac crest and the left iliac crest, are they level or not? The right shoulder girdle, the left shoulder girdle, are they level or not? And by the way, when you're looking at shoulder girdle, you have to make sure you're not thrown off by a lot of musculature. If they're right hand dominant, they might have a lot of built up right lateral reflection, upper trap, lateral scapulae, etcetera, musculature, you have to feel for the bone of the acromion process.
0:10:43.3 DM: And then I can have them... And you could have done that from the front, but I think it's easier from the back. So I think it's just simply done in a postural exam. The hardest are the transverse plane rotations, because really, if you want to see them well, if you see there was a pattern before, the pattern was always, you're looking at the plane of distortion perpendicularly. To see the transverse plane, you need to get on a ladder and look down from up above, and that's not the most logistically feasible, so I try to normally do it from the front and I look to see where their umbilicus belly button might be pointing, where their ASIS-es are pointing, where their acromion processes are pointing, whether or not the hands are lying evenly by the side of their lower extremities, or one hand is out away, are they rotated with their head and neck a bit? That type of thing.
0:11:35.0 KC: And I think it's really important for listeners to know that assessment can be just those simple steps. Oftentimes, I think listeners are intimidated. Practitioners are intimidated by the idea of an assessment, but what you just walked through there and told us about, very doable. And a question for you, sometimes with the rotational and the transverse plane, I'll even notice that when the client lays on the table. I can see that one hip is higher than the other, the pelvis is rotated a little bit. So sometimes that's almost easier to see when they're supine or prone. Do you agree?
0:12:07.5 DM: Especially supine, because it's easier for the body to rotate around. You might even see one shoulder girdle is up. Now is that the shoulder girdle that's protracted or is that the thoracic spine let's say, that's rotating up. So, there sometimes can be more than one reason to see a certain landmark that's asymmetrical.
0:12:28.0 DB: Let's take a short break to hear a word from our sponsors.
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0:13:08.0 DB: Now let's get back to the podcast. Dr. Joe, which type of pelvic tilt is the most common in your clients?
0:13:16.7 DM: This is an interesting... This is a great question, Darren, because I have a kinesiology book that's in its third edition, I'm in the midst of doing a fourth edition. And when I put in the postural distortion chapter by I think the second edition, I talked all about what's called lower crossed syndrome, which is a term that was coined by a physiologist outta the Czech Republic, Vladimir Janda and lower crossed syndrome looks at the lower part of our... Well, if there's a lower crossed syndrome, there would have to be an upper crossed syndrome. So lower crossed is pelvic girdle, upper crossed is shoulder girdle. And he talks about how you can do an X across, which is an X. And there's two arms to the X, and you can look at four groups of muscles, in the sagittal plane, which is what he's looking at there, where he coined and described, you have the muscles in the front of the abdomen to pelvis, anterior abdominal wall muscles, rectus abdominis, external, internal abdominal obliques. In the back of the trunk to pelvis, you have the paraspinal extensor muscles erector spinae, transversospinalis.
0:14:27.1 DM: In the front of the hip joint, going from thigh, thighs to pelvis you have the hip flexors, and in the back, you have the hip extensors, glutes and hamstrings. And he basically says that there's a typical pattern wherein one arm of the cross, which would catch the hip flexors and then picture it angling the low back extensors, they tend to be overly facilitated by the nervous system, which means they are locked short at baseline tone. They're tight at baseline tone. The other arm that would in effect be the opposite would be the anterior abdominal wall, let's say rectus abdominis is the example, and the glutes, hamstrings, and they would be overly inhibited by the nervous system. And therefore, at baseline tone, they're not contracting as much. Well, the hip flexors and the low back extensors are anterior tilters of the pelvis and the anterior abdominal wall and glutes, hamstrings are posterior tilters of the pelvis. If you have these four major groups in the sagittal plane that can move the pelvis into anterior posterior tilt, and you have two of the four groups that are anterior tilters, that tend to be locked short, you're going to be pulled into anterior tilt excessively.
0:15:47.8 DM: And then the other groups, the two groups that are supposed to oppose it, anterior abdominal wall, and let's forget hamstrings for a moment, and glutes, well, they're posterior tilters, and they're not contracting as much. So therefore, they're weak and you cannot stop that anterior tilt force, so you end up being pulled into excessive anterior tilt because your anterior tilters are too tight and your posterior tilters are relatively too "weak" at baseline tone. And if most people say where am I tight? Oh, my little back is tight. Oh, my hips... The front of my hips are tight. Where am I flabby and weak? Oh my God, my abdomen in front and my glutes in back. And you can even see it in lay terms, if you talk to anyone and said, tell me your muscle groups that are too tight or too weak, and weak and tight are not really the best pairs of terms. It's now kind of overly facilitated, overly inhibited, locked short, locked long. The net result in the end though is except for the hamstring group, for posterior tilters, we generally are way too weak at baseline tone, which means overly inhibited with posterior tilt and way too strong/tight at baseline tone for anterior tilters.
0:17:04.0 DM: And we end up with too much anterior tilt and that is Vladimir Janda's lower crossed syndrome. And then the consequences, if the pelvis is excessively anteriorly tilted, then you have to have a hyperlordotic lumbar curve to bring you back over your pelvis, which very often precipitates. Since the upper lumbar spine is overly leaning back at the top of the lumbar region, you end up with a hyperkyphotic thoracic spine, and that means the superior top of the base of the T1 vertebra is now tilted too much. And then the cervical spine projects out anteriorly with a hypolordotic lower cervical spine, the head's way forward, And then the person goes into hyperextension lordosis of the head upon the atlanto-occipital joint. And then when the thoracic spine goes forward into too much kyphotic curve, the shoulder girdles round forward into too much protraction, and then the humerus, the humeri overly immediately internally rotate.
0:18:16.1 DM: And those are all the sequelae of simply having, for example, tight hip flexors, tight low back extensors, weak anterior abdominal wall, weak glutes. Ironically, by the third edition of my Kinesiology book, which I hadn't covered in the second, I had to change it around. I kept that there, but I talk about a posture that might be called sway back or a falling backward with the pelvis. And that is too much posterior tilt of the pelvis. And largely the reason for that is the excessive amount of time we spend on digital devices down in front of our body, whether they're going to be smartphones, cell phones, what's the term outside of the United States? Oh, a mobile phones or tablets, iPads, etcetera or even laptops down there. We tend to wanna go down to it.
0:19:21.0 DM: And what people tend to do is they tend to drop their pelvis back and round their entire spine to get down to that. And I am seeing that way more than I'm seeing the Lower Crossed Syndrome excessive anterior tilt. So now, if the pelvis goes back posteriorly in the sagittal plane, well, what happens is, you don't want as much lumbar lordosis curve of extension, because that would pull you back even more posterior. So the lumbar spine becomes hypolordotic, not enough curve, so to speak. It might even become somewhat strained. And actually, it could become kyphotic. If that pelvis is tilted enough posteriorly, now your center of weight is way behind you, and the lordortics curve of the lumbar spine is lost. And it becomes kyphotic to bring you forward. And all of this is simply a plain old mechanical compensation for the pedestal being off.
0:20:28.7 KC: And I think that's interesting, because most of us associate forward head posture with digital devices. But we forget that that translates all the way down to the pelvis. It affects the full body.
0:20:40.5 DM: I certainly have some pictures of some individuals. I take pictures when I travel around. And I always blur out the face when I show them at workshops or whatever. I have some pictures of someone who's standing straight up, and all they're doing is absolutely kinda destroying their cervical spine to head posture to go down. But most people do not isolate it right there, because I think that excessive asymmetric force right there, they would notice sooner than later. And by the way, this brings us back to a previous article I had written for ABMP about forward head posture. So I invite our listeners to go back and read that, because I think there have been some pendulum swings that went too far in incorrect interpretations of a specific study that kind of made a statement like forward head posture doesn't matter toward pain. And I wholly disagree. It doesn't mean it causes pain today, but it is an asymmetrical load on your body. And the odds are it's going to cause pain at some point. So I like to make the statement. I think Shakespeare originally said this, "Look thee to the pelvis." It was just edited out of one of his plays. [laughter] But my point is if you want to see spinal posture, you have to look at the pedestal that it stands on. You have to look at the pelvis.
0:22:06.3 DM: Now, just for everyone else, sure, the pelvis could be thrown off because of a overpronated arch structure in the foot at the subtalar joint. I'm not disagreeing. My article was simply trying to limit it to, "Let's look at pelvic obliquity." And if we look at pelvic posture, then we have to say, bones are passive elements, except for someone born with a tremendous genetic anomaly in their bones, which does occur, but is extremely rare, a bone simply goes wherever forces bring the bone. And primary forces are myofascial forces. So I'll simplify and say, muscle forces. And that means if we were looking at the sagittal plane, we look at the anterior tilters of the pelvis and the posterior tilters of the pelvis. And we simply compare their pulling force at baseline tone. And that will give us our posture of the pelvis at baseline tone. If we want to look at the posture in the frontal plane, we will look at the muscle groups that can change the posture of the pelvis in the frontal plane. The pelvis can change its posture relative to a FAI, a femur at a hip joint or both thighs, both femurs at the hip joints or relative to L5 at the lumbosacral joint. The pelvis is more mobile at the hip joint. So I look there primarily first. But I certainly then look at the lumbosacral joint.
0:23:34.8 DM: So I'm looking at the muscles that go on the pelvis down more distally to the lower extremities and muscles that go from the pelvis, higher up, so superiorly onto the trunk. So if we're looking in the frontal plane, we would say, "Well, what can move the pelvis in the frontal plane?" Well, abductors of the thigh at the hip joint, adductors of the thigh at the hip joint. Then what can do it up in the trunk? Lateral flexors. And if we look at the pelvis posture from movement too at the hip joints, we would say, "Well, what can rotate internally medially or externally laterally rotate a thigh femur at the hip joint could instead play back on the pelvis. And what could rotate the pelvis from the trunk area would be the muscles that rotate the trunk. So I'd like to springboard into something right here. I very often like to ask a trick question in the class. And it was one of my class, and after I asked it, I said, "By the way, guys, this is a trick question. So you better think carefully before you answer." [chuckle] I'll say something like, "What's the transverse plane function of the external abdominal oblique?" And people jump up and say, "It's a contralateral rotator." And I go, "No, it's an ipsilateral rotator." And they look at me like I'm from another planet. I'll say it ipsilaterally rotates the pelvis at the lumbosacral joints.
0:24:57.0 DM: Yes, it's a contralateral rotator of the trunk at the lumbosacral and spinal joints. But if your superior attachment is stable fixed, then it will pull the pelvis into rotation to the same side. And that brings me to my really big picture point where I wanna say, and this is especially true with the hip joint to look at and have an analogy. This is not just geekiness, nerdiness.
0:25:24.4 DM: And that is that a muscle is a pulling machine, it is nothing more than a pulling machine. Never make it any more complicated than that. When a muscle contracts, let's say the nervous system tells it to contract, the motor neuron, a lower alpha motor neuron goes and tells the muscle or a bunch of neurons tell the muscle to contract, the muscle creates a pulling force toward its center, it pulls equally on both attachments, it doesn't pull more on what might be called the insertion than the origin or distal attachment and proximal attachment, it pulls equally on both. Which attachment will move? Well, assuming that the contraction force is greater than the resistance to moving, that would usually be the weight of the body part that has to move, plus whatever other body parts have to go along for the ride.
0:26:12.9 DM: So let's take something like a hip flexor in front, take the TFL, Tensor Fasciae Latae, as an example. If it's going to flex the thigh at the hip joint in the sagittal plane, it's going to have to move the weight of the thigh, plus the weight of the body parts that have to go along for the ride, which would be the leg and the foot. There's a certain resistance to that. Well, it's also pulling on the pelvis and pulling the pelvic bone down toward the femur. You could say it's pulling the anterior femur up toward the anterior pelvic bone, but it's also pulling the anterior pelvic bone down toward the anterior femur. Well, there's not a lot of resistance to the pelvic bone and truly tilting... In fact, you don't even have to pull the whole trunk and arms, and that can have hands and forearms along with it. You can just kind of collapse the pelvis forward. Well, both attachments are very mobile, but people very often in school learn the insertion pulls toward the origin, the insertion pulls toward the origin.
0:27:14.1 DM: And that, of course, gives me my great soapbox speech. I dislike tremendously origin insertion terminology. First of all, it means a student has to learn something more than the name of the muscle, where the two attachments are, you have to know and learn which one is origin, which insertion, and learning its actions, and it gives an incorrect view in your mind that the insertion always moves. Some people say, "No, no, it doesn't always move, but the insertion usually moves." Well, you know the gait cycle when you're walking? 60% of the time, your foot is on the ground, unless you're on olive oil, a banana peel, or slick ice, your foot is on a stable surface, and that means that the distal end of your kinematic chain of your lower extremity is stable and fixed. That means it's more likely your proximal attachment will move towards your distal 60% of the time, more than half of the time, and that can be called origin toward insertion, that can be called reverse action. It's still a concentric shortening contraction, but it is the proximal attachment moving toward distal. People don't see that because they get the idea in their mind from origin insertion, that it's the distal attachment that moves.
0:28:35.1 DM: Now, let's go back to our postural exam, we're looking at someone standing. When someone is standing, 100% of the time, they are going to have their feet stable, closed chain on the ground, and it's going to be easier for the pelvis to move toward the femur and the femur to move toward the pelvis. And in fact, if that person comes to you, you've done your history, now they stand in front of you, then you're looking at them from the front, let's say, and they're standing there and their right foot is up in the air, 10 inches up in the air in front of them, inflection, their thigh at the hip joint is up inflection, and you look at them and say, "Wow, I think your hip flexors are tight on the right." And they go, "You are so intuitive. How do you see this?" They're not going to stand that way, they need to have their feet on the ground, they're going to get reverse closed chain pulling of origin toward insertion, of the proximal attachment toward the distal, of the pelvis toward the thigh. And that is what's going to happen for people's posture whenever they're standing, and we stand a lot. You're going to see if someone who's tight in flexors, excessive anterior tilt to the pelvis, all hip flexors of the thigh, hip joint are anterior tilters of the pelvis at the hip joint, all hip extensors are posture tilters of the pelvis at the hip joint.
0:30:04.1 DM: All ABductors of the thigh, the hip joint are lateral tilters to the same side, depressors to the same side, and therefore elevation on the other side of the pelvis at the hip joint. All ABductors, and this is a harder one to see, but if you stand up and kind of picture pulling your pubic bone down toward your femur on that side, you'll see that your iliac crest goes up on that side. ADductors that are tight will cause same-side elevation of the pelvis at the hip. All lateral rotators of the thigh at the hip joint, like piriformis, are contralateral rotators of the pelvis at the hip joint. All ipsilateral rotators of the pelvis at the hip joint would be the medial rotators. And by the way, you can see that right away, lie someone down on their stomach, bend their hip knee joint to 90 degrees and try to do a stretch for piriformis, and you'll see their pelvis start to rotate to the opposite side, 'cause the tension is being played out there, so you need to stabilize it.
0:31:07.5 DM: The point of this is we need to stop looking at muscles across the hip joint as flexors, extensors, abductors, adductors etcetera. We need to say, "Oh, we have anterior tilters in front, posterior tilters in back, lateral tilters on the abductor outside, and lateral tilters to the other side on the inside of the adductor compartment." In other words, the pressors on the same side for abductors and elevators in the same side, and all lateral rotators would be contralateral rotators to the pelvis and epsilon. We need to think reverse action. And if we can do that, we can see how the posture of the pelvis goes off. And if someone comes in and they have a hyperlordotic lumbar spine, I'm going to immediately say, "Well, look at the pelvis. It's excessive actually tilted, of course it has to be hyperlordotic lumbar spine, it has to be, for the righting reflex." And I'm going to think, "Let me check out all 12 hip flexors, anterior tilters. Let me check out all hip extensors to see if they might need queuing to be activated, and I'll go up to the trunk and look at the muscles for the pelvis or the trunk, that's my soapbox here.
0:32:21.8 KC: Wow, Dr. Joe, you have given us so much to think about as practitioners today, to really look at our clients in a different way and to understand that what's happening in the pelvis affects the full body, and also to really look at doing that assessment, really learning what's happening with the pelvis and then adjusting our treatment plan based on that. So much good information. Any last thoughts to just summarize the topic for our listeners?
0:32:51.1 DM: Just one last one, and that is that I believe so much in myofascial muscular forces. And when someone says, "Oh, that's skeletal, we can't do that." No, the skeleton is made up of passive elements bones. Bones can't move themselves, they must be moved by something, maybe gravity, or wind, or wrestling with someone, but most of the time, they're moved by musculature. If you see an asymmetric posture of a bone, just take a step back and think about the muscles that could create it and the muscles that would try to oppose it, and then assess them for their balance with their tone at baseline tone.
0:33:28.0 DB: I wanna thank our guest today, Dr. Joe Muscolino. For more information, visit learnmuscles.com. Thanks, Dr. Joe, and thanks, Kristen.
0:33:36.6 DM: Thank you so much.
0:33:37.0 KC: That was wonderful, thanks so much.