The Pelvis: Hidden Puppeteer of Posture and Pain

Pelvis and posture: The pelvis is the most underestimated anatomical structure in the genesis of musculoskeletal pain. Clinical experience demonstrates how the pelvis is implicated, directly or indirectly, in most cases of chronic and recurrent back pain, hip pain, knee pain and even neck pain.

The pelvis represents the body’s center of gravity and the connection point between the trunk and lower limbs. Any alteration in its position affects the entire kinetic chain, generating ascending compensations (toward the spine) and descending compensations (toward the legs).

Functional Anatomy of the Pelvis

Functional anatomy of the pelvis examines how pelvic bones, joints, and muscles work together in the lower trunk to support posture, movement, and load transfer throughout the body. The pelvis is formed by:

• Two hip bones (ilium, ischium, pubis)
• Sacrum: connects the vertebral column to the pelvis
• Coccyx

Fundamental joints:

• Sacroiliac joints: semi-mobile, crucial for load absorption
• Pubic symphysis: provides stability to the pelvic ring
• Coxo-femoral joints (hips): functionally inseparable from the pelvis

The Pelvic Musculature

Anterior: iliopsoas (hip flexor), rectus femoris, abdominals
Posterior: gluteals (maximus, medius, minimus), hamstrings, erector spinae
Lateral: tensor fasciae latae, piriformis
Pelvic floor: visceral support and stabilization

Main Postural Alterations of the Pelvis

Anteversion (Anterior Tilt)

The most common alteration. The pelvis rotates forward causing:

• Lumbar hyperlordosis
• Compensatory thoracic hyperkyphosis
• Forward head posture
• Overload of the lumbar facet joints

Shortened muscles: iliopsoas, erector spinae, rectus femoris
Weak muscles: gluteals, abdominals, hamstrings

This configuration (lower crossed syndrome by Janda) is extremely common in sedentary people.

Retroversion (Posterior Tilt)

The pelvis rotates backward with:

• Flattening of the lumbar lordosis
• Increased load on the discs (risk of protrusions and hernias)
• Common in elderly people and “slumped” sitting posture

Lateral Tilt

One side of the pelvis higher than the other, caused by:

• Leg length discrepancy
• Gluteus medius weakness
• Scoliosis

Predisposes to trochanteric bursitis on the lower side.

Pelvic Rotation

One pelvic half anteriorized relative to the other. Causes:

• Hip asymmetry
• Possible sciatica from asymmetric compression

How the Pelvis Influences Distant Pain

Ascending Compensations (upward)

• Lumbar: low back pain from hyperlordosis or hypolordosis
• Thoracic: thoracic pain from compensatory hyperkyphosis
• Cervical: neck pain from forward head posture

Descending Compensations (downward)

• Hip: joint overload, trochanteric bursitis
• Knee: knee pain from asymmetric loading
• Foot: plantar fasciitis from altered kinetic chain

Pelvic Assessment

• Palpation of iliac crests: identify asymmetries
• Thomas test: iliopsoas shortening
• Trendelenburg test: gluteus medius weakness
• Sacroiliac mobility tests: Gaenslen, FABER
• Leg length measurement: from ASIS to medial malleolus

Exercises to Correct Pelvic Dysfunctions

For Anteversion (the most common)

Exercise 1: Iliopsoas Stretch in Lunge

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Kneeling on the mat, bring the right foot forward in a lunge position, with the right knee at 90 degrees. The left knee stays on the ground, supported on a cushion if necessary.

Step-by-step execution:

1. Step 1: Contract the glutes and bring the pelvis into slight retroversion (flatten the lumbar area), keeping the torso upright
2. Step 2: Slowly shift body weight forward, increasing flexion of the front knee, until feeling a stretch in the front of the posterior hip (iliopsoas area)
3. Step 3: Hold the position for 30 seconds, breathing slowly. Return to starting position and repeat on the same side, then switch

Sets and repetitions: 3-5 repetitions per side — 2-3 times daily (especially after prolonged sitting periods)

Common mistakes to avoid:

• Arching the lumbar area during the lunge, canceling the stretching effect on the iliopsoas
• Projecting the front knee beyond the toes
• Not contracting the glutes, losing the pelvic retroversion that is essential for this stretch

How to know you’re doing it correctly:
You feel a specific stretch in the front of the hip of the back leg, in the area between the groin and thigh. The lumbar area remains flat, without accentuation of lordosis. With consistent practice, hip mobility improves significantly.

Exercise 2: Bridge (Glute Bridge)

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Supine on the mat, knees bent, feet on the ground hip-width apart, arms extended along the sides with palms facing down.

Step-by-step execution:

1. Step 1: Contract the abdominals and glutes, flattening the lumbar area against the mat
2. Step 2: Lift the pelvis toward the ceiling by pushing with the heels, until forming a straight line from shoulders to knees. Actively squeeze the glutes at the top
3. Step 3: Hold the position for 2-3 seconds at the top, then lower the pelvis slowly, vertebra by vertebra, until returning to the mat

Sets and repetitions: 3 sets x 15 repetitions — 30-second pause between sets

Common mistakes to avoid:

• Hyperextending the lumbar area at the top, lifting the pelvis beyond the straight line shoulder-knees
• Pushing mainly with the lumbar area instead of the glutes
• Spreading the knees during the lift, losing alignment

How to know you’re doing it correctly:
The work is felt mainly in the glutes, not in the lumbar area. The glute contraction is clearly perceived throughout the movement. No pain or discomfort is felt in the back.

Exercise 3: Dead Bug

Difficulty: Intermediate | Equipment: Mat | Duration: 6 minutes

Starting position:
Supine on the mat, arms extended toward the ceiling perpendicular to the body, knees bent at 90 degrees with hips flexed at 90 degrees (“tabletop” position). The lumbar area is completely adherent to the mat.

Step-by-step execution:

1. Step 1: Contract the abdominals to flatten the lumbar area against the mat. This is the fundamental position to maintain throughout the exercise
2. Step 2: While exhaling, slowly extend the right arm overhead and simultaneously the left leg toward the floor, without ever touching the ground. The back must remain completely flat
3. Step 3: While inhaling, return arm and leg to starting position. Repeat with left arm and right leg. Alternate sides

Sets and repetitions: 3 sets x 10 repetitions per side — 30-second pause between sets

Common mistakes to avoid:

• Allowing the lumbar area to lift from the mat during extension: if this happens, reduce the range of motion
• Performing the movement too quickly, losing core control
• Holding your breath: exhale during extension, inhale during return

How to know you’re doing it correctly:
The lumbar area stays glued to the mat throughout. You feel deep work in the abdominal muscles, without any back pain. The movement is slow, controlled, and coordinated with breathing.

Exercise 4: Front Plank with Retroversion

Difficulty: Intermediate | Equipment: Mat | Duration: 4 minutes

Starting position:
Prone on the mat, lift onto elbows (positioned under shoulders) and toes. The body forms a straight line from head to heels.

Step-by-step execution:

1. Step 1: Actively contract the abdominals and glutes to bring the pelvis into slight retroversion (rotate it slightly backward), eliminating any lumbar arching
2. Step 2: Hold the position for 20-60 seconds (based on level), breathing regularly. Active pelvic retroversion during the plank is the key element to re-educate pelvic position
3. Step 3: At the end, lower slowly to the ground, rest, then repeat

Sets and repetitions: 3 sets x 20-60 seconds — 30-45 second pause between sets

Common mistakes to avoid:

• Letting the pelvis drop downward, creating lumbar hyperlordosis that nullifies the exercise and overloads the back
• Lifting the pelvis too high upward, forming an inverted “V”
• Looking forward instead of toward the floor, causing cervical tension

How to know you’re doing it correctly:
You feel intense work in the abdomen and glutes. The lumbar area has no discomfort. The body forms a straight line observable laterally. Active pelvic retroversion is maintained consciously throughout.

For Retroversion

Exercise 5: Hamstring Stretch

Difficulty: Easy | Equipment: Mat, towel or elastic band | Duration: 4 minutes

Starting position:
Supine on the mat, both legs extended. Wrap a towel or elastic band under the sole of the right foot, holding the ends with both hands.

Step-by-step execution:

1. Step 1: Keeping the left leg extended on the ground, slowly lift the right leg toward the ceiling, keeping it as straight as possible, gently pulling the towel
2. Step 2: Continue lifting until feeling a stretch in the back of the thigh (without pain). It’s not necessary to reach vertical: the correct position is where you feel tension without pain
3. Step 3: Hold the position for 30 seconds, breathing slowly. Then lower the leg with control and repeat on the other side

Sets and repetitions: 3 repetitions per leg — 10-second pause between repetitions

Common mistakes to avoid:

• Lifting the head and shoulders from the mat during the stretch
• Bending the knee of the leg being stretched to reach a higher position
• Pulling the towel with excessive force, turning a gentle stretch into a forced movement

How to know you’re doing it correctly:
You feel a gradual and tolerable stretch in the back of the thigh. The lumbar area and head remain in contact with the mat. The leg on the ground remains extended without lifting.

Exercise 6: Prone Lumbar Extensions (Cobra)

Difficulty: Easy | Equipment: Mat | Duration: 5 minutes

Starting position:
Prone on the mat, hands placed on the ground next to shoulders, elbows bent, forehead on the ground. Legs extended and slightly apart.

Step-by-step execution:

1. Step 1: Pressing with hands on the ground, slowly lift the chest from the floor by extending the arms. The pelvis and hips remain in contact with the mat
2. Step 2: Lift until feeling a comfortable extension of the lumbar area, without pain. It’s not necessary to fully extend the arms
3. Step 3: Hold the position for 15-20 seconds, breathing normally, then lower slowly returning to starting position

Sets and repetitions: 8-10 repetitions — 5-10 second pause between repetitions

Common mistakes to avoid:

• Lifting the pelvis from the mat, nullifying the lumbar extension effect
• Excessively contracting the glutes during the lift
• Forcing extension beyond the comfort point, generating acute pain

How to know you’re doing it correctly:
You feel a slight extension in the lumbar area without any pain. The movement is fluid and controlled. With practice, the extension range increases gradually. Lumbar lordosis is progressively restored.

For Lateral Tilt and Stability

Exercise 7: Clamshell with Elastic

Difficulty: Easy | Equipment: Mat, resistance loop | Duration: 5 minutes

Starting position:
Lying on the right side, head resting on arm or pillow. Knees bent at about 45 degrees, feet together. Place the resistance loop just above the knees.

Step-by-step execution:

1. Step 1: Lightly contract the abdomen to stabilize the pelvis and trunk. The feet remain together throughout the exercise
2. Step 2: Slowly open the upper knee (left) toward the ceiling, rotating from the hip, against the resistance of the elastic. Keep the pelvis stable, without rotating the trunk backward
3. Step 3: Hold the open position for 1-2 seconds, then close slowly. Complete all repetitions on one side before switching flanks

Sets and repetitions: 3 sets x 15 repetitions per side — 20-second pause between sets

Common mistakes to avoid:

• Rotating the pelvis backward during opening, compensating with the trunk instead of working with the gluteus medius
• Opening the knee too quickly, using momentum instead of muscle strength
• Separating the feet during opening, a sign that the pelvis is rotating

How to know you’re doing it correctly:
You feel work in the lateral and posterior part of the glute (gluteus medius and minimus), not in the lumbar area. The pelvis remains perfectly still throughout the movement. The opening is controlled and symmetrical on both sides.

Exercise 8: Side Plank (Lateral Plank)

Difficulty: Intermediate | Equipment: Mat | Duration: 4 minutes

Starting position:
Lying on the right side, right elbow positioned directly under the shoulder, forearm on the ground. Legs extended and stacked, feet one above the other.

Step-by-step execution:

1. Step 1: Contract abdominals and glutes, then lift the pelvis from the ground until forming a straight line from head to feet. The upper arm can remain along the side or be extended toward the ceiling
2. Step 2: Hold the position for 15-30 seconds, breathing regularly. Check that the pelvis doesn’t drop downward and isn’t lifted too high
3. Step 3: Lower the pelvis slowly to the ground, rest, then repeat. Complete all sets on one side before switching

Sets and repetitions: 3 sets x 15-30 seconds per side — 20-30 second pause between sets

Common mistakes to avoid:

• Letting the pelvis drop downward, losing alignment and overloading the shoulder
• Rotating the torso forward or backward, exiting the lateral plane
• Holding your breath during the hold

How to know you’re doing it correctly:
You feel intense work in the oblique abdominals and gluteus medius of the supporting side. The body forms a straight line visible laterally. The supporting shoulder has no pain. The hold is stable without excessive tremors.

Exercise 9: Monster Walk with Elastic

Difficulty: Intermediate | Equipment: Resistance loop | Duration: 5 minutes

Starting position:
Standing, resistance loop positioned around the ankles. Feet shoulder-width apart (the elastic should already be slightly tensioned). Knees slightly bent in half-squat position, torso slightly inclined forward, gaze forward.

Step-by-step execution:

1. Step 1: Maintaining the half-squat position, take a lateral step with the right foot, widening the base of support against the resistance of the elastic
2. Step 2: Bring the left foot closer without ever completely releasing the tension of the elastic, then take a new lateral step with the right. Continue for 15 steps in the same direction
3. Step 3: Reverse direction and repeat for 15 steps to the left. Maintain the half-squat position throughout

Sets and repetitions: 3 sets x 15 steps per direction — 30-second pause between sets

Common mistakes to avoid:

• Straightening the knees during walking, losing glute activation
• Dragging the foot that approaches, completely releasing the tension
• Tilting the torso laterally during the step, compensating with the trunk

How to know you’re doing it correctly:
You feel intense work in the lateral part of the glutes (gluteus medius) of both legs. The pelvis remains stable and horizontal throughout the walk. The elastic tension is constant, without moments of complete release.

Exercise 10: Lateral Step-Down

Difficulty: Intermediate | Equipment: Step or platform (15-20 cm) | Duration: 6 minutes

Starting position:
Standing on a step or platform with both feet, near the lateral edge. Hands on hips to monitor pelvic position. Upright posture.

Step-by-step execution:

1. Step 1: Shift weight onto the right leg (supporting) and slowly slide the left foot beyond the step edge. Bend the right knee controlling the descent
2. Step 2: Lower the left foot toward the floor slowly and controlled, brushing the ground with the heel without loading weight. Throughout the descent, maintain the pelvis perfectly horizontal (hands on hips shouldn’t tilt)
3. Step 3: Return to starting position by extending the right knee. Complete all repetitions on one side before switching

Sets and repetitions: 3 sets x 10 repetitions per side — 30-second pause between sets

Common mistakes to avoid:

• Letting the pelvis drop on the side of the descending leg (positive Trendelenburg sign), indicative of gluteus medius weakness
• Bending the supporting knee inward (dynamic valgus)
• Descending too quickly, losing movement control

How to know you’re doing it correctly:
The pelvis remains horizontal throughout the movement (verifiable with hands on hips). The knee of the supporting leg remains aligned with the toes. The descent is slow and controlled, without drops or jerks.

Recovery Times

Prevention

• Ergonomics: chair with lumbar support, feet on the ground
• Active breaks: every 30-45 minutes
• Daily iliopsoas stretching: especially if sedentary
• Strengthening glutes and core: 2-3 times per week
• Don’t cross legs: promotes pelvic rotation
• Pilates and yoga: excellent for pelvic rebalancing

Frequently Asked Questions (FAQ)

Frequently Asked Questions

How is pelvic anteversion typically identified?

Pelvic anteversion, or anterior tilt, is generally identified through a professional assessment conducted by a physical therapist or other qualified healthcare provider. This evaluation involves observing posture, assessing range of motion, and palpating specific anatomical landmarks. Accurate identification is crucial for developing an effective corrective strategy.

What is the importance of the pelvis in cases of neck pain?

The pelvis serves as the body’s center of gravity and a critical link between the trunk and lower limbs. Alterations in its position can create ascending compensations throughout the kinetic chain, extending to the spine and potentially influencing the cervical region. Addressing pelvic dysfunction can therefore be an important consideration in the comprehensive management of neck pain.

Can prolonged sitting negatively affect pelvic posture?

Yes, prolonged periods of sitting, especially with poor ergonomic setup, can contribute to muscle imbalances surrounding the pelvis. Over time, these imbalances may lead to postural alterations such as anteversion or retroversion. Maintaining varied postures and incorporating regular movement breaks are important for pelvic health.

Do orthotics directly correct pelvic problems?

Orthotics are primarily designed to address biomechanical issues in the feet and lower limbs, influencing the body’s alignment from the ground up. While they can indirectly affect ascending compensations and contribute to overall postural support, direct correction of primary pelvic dysfunctions usually requires more targeted interventions. A comprehensive assessment by a physical therapist can determine the most appropriate course of action.

For a broader overview of related conditions, see our complete guide to back pain.

Scientific References

1. Janda V. Muscles and motor control in low back pain. Churchill Livingstone; 1987.
2. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. Mosby; 2002.
3. Lee DG. The Pelvic Girdle. 4th ed. Elsevier; 2011.
4. Kendall FP, et al. Muscles: Testing and Function, with Posture and Pain. 5th ed. LWW; 2005.
5. Powers CM. The influence of abnormal hip mechanics on knee injury. J Orthop Sports Phys Ther. 2010;40(2):42-51.
6. Vleeming A, et al. The sacroiliac joint: an overview. J Anat. 2012;221(6):537-567.
7. Neumann DA. Kinesiology of the hip. J Orthop Sports Phys Ther. 2010;40(2):82-94.
8. Sueki DG, et al. A regional interdependence model. J Man Manip Ther. 2013;21(2):90-102.
9. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine. Spine. 1996;21(22):2640-2650.
10. Comerford MJ, Mottram SL. Functional stability re-training. Man Ther. 2001;6(1):3-14.

Dr. Cosimo Pilotto — physical therapist | MyPhysioHelp.it

Related articles:

• Kinetic Chain
• Low Back Pain and Iliopsoas
• Trochanteric Bursitis
• Sciatica
• Adult Scoliosis
• Piriformis Syndrome
• Cervicalgia
• Knee Pain
• Plantar Fasciitis