The Hip Flexors and Anterior Pelvic Tilt

I’m very hip-centric. I understand the importance of a well functioning pair of hips. This is one of those topics that I could spend days and days studying and discussing. Alas, I realize that most readers have no such interest, but I can not stress enoough how important the hip joint is to human performance. It can be the difference between living a life free of pain or one ruled by pain. In this post I’m simply going to outline what the hip flexors are and one very common condition associated with tight hip flexors.

The hip flexor muscles are located in the front of your leg, above the thigh muscles, and they act to bring your leg up towards your trunk. Hip flexion occurs whenever you take a step while running or walking up a flight of stairs. The hip flexors are relatively small muscles yet are extremely important because of what can happen when they aren’t functioning normally.

The most important hip flexor muscles are the psoas, the iliacus, the TFL, and the rectus femoris. Three of these muscles, the illiacus, TFL, and rectus femoris originate on the pelvis while the psoas originates on the lower spine. In addition, the rectus femoris is one of the quadriceps muscles and attaches below the knee so that it also performs knee extension. The other hip flexors all attach onto the upper leg in one fashion or another.

In the image below you can see the TFL, iliacus, and psoas major. The rectus femoris is not shown.

hip flexor muscles

The psoas, illiacus, and TFL are three hugely important muscles that can cause a lot of grief.

In a normally functioning body, no one would pay much attention to any of the hip flexor muscles because they have limited trainability.  It’s surprising to learn that these overlooked muscles can wreak havoc on the human body when they are short or stiff. Few people are even aware that they exist but ignorance of their existence and the role they play can cause huge problems.

The most common problem I see in regards to hip flexors is when they cause anterior (to the front) pelvic tilt. If hip flexor muscles are short or tight, they exert a downward pull on your pelvis resulting in the pelvis being tilted down in front. This downward pull and resulting excessive tilt can lead to numerous issues that result in pain and discomfort. Knee, lower back, and neck pain can all at times be attributed to anterior pelvic tilt with lower back pain the most prevalent. When the pelvis is pulled down in front, the curve in your lower back is increased. This is a recipe for lower back pain.

anterior pelvic tilt

Anterior Pelvic Tilt causes excessive curve in the lower back.

Hip flexor muscles often become tight due to lack of movement. Think of someone who sits in a chair all day. Their hip flexors are constantly in a flexed, and thereby shortened, position. A consistently flexed position puts the muscles in a chronically shortened state. Over time, the muscles “warp” and stay shortened. The shortened muscles then begin to exert the downward pull on the pelvis when you are standing. Hip flexor muscles can also get tight through activity. Constant activity and contraction of any muscle will lead the muscle to get tight. The more exercise you get and the more hip flexion performed, the more likely the hip flexors will end up being tight. It’s a damned if you do, damned if you don’t scenario.

Thankfully the remedy is the same for both scenarios. A shortened or tight muscle needs to be returned to its natural state. This can be done through foam rolling, dynamic warmups, and static stretching. I had anterior pelvic tilt due to my old IT career where I sat for 8-10 hours a day. I had chronic pain for years in my feet and various episodes of neck/upper back spasms, lower back pain, and hip pain. Once I started doing dynamic warmups, which served to return my hip flexors to a more normal length and reestablished hip range of motion, the pain diminished almost completely. I got back into a more natural alignment. It gave me a new lease on life, and I haven’t looked back since.

PS: For an overview of the hip joint check out this post.

Comments

    • Administrator says

      I’ll be working on them shortly. In the meantime, read the page on Dynamic Warmups. These are amazingly effective exercises to restore hip function.

  1. ivan says

    thanks, thanks, thanks … took more than 12 years with extreme low back pain and pelvic anterior and none of the doctors told me the reason for this pain.
    I am a driver by profession and a lead of 10-12 hours sitting and now I understand your narrative the source of pain (hip flexor) desencadenaros my back … Greetings from Spain, Basque country.

    website where you see some exercises for the Rehabilitation of the hip flexors ???

  2. George says

    Great article and diagram. I just had bilateral hip surgery and was reading about hip flexors. I can’t really work hard yet but I want to be sure to get the flexors back to reasonable condition as soon as possible after 60 years of trying to work with bad hips. Right now I am doing aqua therapy. It is cool to look down and see my feet pointing straight ahead. I had hip resurfacing from Dr DeSmet in Ghent Belgium. Very happy so far. Thanks again.

  3. Geoff says

    Hi Neal,

    First of all, great article! I am a golfer and am interested in ensuring my hips are balanced correctly on the anterior-posterior axis (the one you focus on in the above article). Can you comment on the desirable position of the hips in a golf swing, how it is achieved, and what it would feel like?

    Thanks!

    Geoff

    • Administrator says

      Hello Geoff,
      Though I’m not a golfer myself, I have a couple thoughts on the golf swing regarding the hips and upper back.

      First, if you eliminate anterior pelvic tilt in daily life, then your hips should line up naturally in the golf swing. If they are in a more neutral position when you are standing around, this would indicate that the musculature surrounding the pelvis is pretty much in order. I’m not sure how a golf pro would teach the swing, but in regards to hips, fix APT and everything should work itself out on its own.

      In or around 2005, when I had bottomed out physically (foot pain, back pain, etc…) I tried to hit golf balls at the range. It was a miserable experience. I had no power. It was embarrassing. It was similar to what I noticed a few years earlier when I played softball during the summers. Although I looked strong, I had no power. The problem was that I did body building type training (after sitting at a desk all day), splitting my workouts up into different muscle groups, instead of training it as the inter-connected system that it is.

      The golf swing puts creates a huge amount of torque at the knee at lower back, which is why many golfers end up with bad lower backs and bad knees at some point. If you hit golf balls every day for years, the wear and tear adds up. Thus, to ensure maximum bodily health and power, I’d recommend:

      1. Work on your hip range of motion. Any tightness or limited range of motion at the hips can stress out your lower back. Plus limited ROM cuts down on power production.
      2. Make sure your legs and glutes are strong. This is where power is produced in the lower body.
      3. Make sure your core is strong so that the power produced in your legs is efficiently transferred to the upper body.
      4. Make sure your upper back (thoracic spine) has good range of motion (if your posture isn’t perfect, you’ll need to work on it). In the golf swing, you want range of motion in the hips and thoracic spine, not in the lower back. Make sure you have adequate range of motion and strength in your upper back. This will keep your shoulders healthy and protect your lower back.

      Hope this helps
      Thanks for the question.

      Neal

  4. Geoff says

    Thanks Neal! I really appreciate your response and will be incorporating your advice into my routine.

  5. Sonya says

    Thanks for a wonderful article and links to the exercises. I have a inverted pelvis and have suffered pain for a few years now. I started on these exercises last night and felt so much better the next day. I plan to incorporate them into my daily routine now. Many thanks.

  6. Dominic says

    Thanks for the post Neal.

    What I found confusing, possibly counter-intuitive, is the position of the pelvis during sitting versus the common problem outlined above of the anterior pelvic tilt.

    When we are sitting, and usually badly in the slouched position (back rounded), surely the pelvis is tilted posteriorly? Is this correct? It certainly feels easier to get into a slouch than with hips tilted forwards.

    So is what you are saying above that long periods of sitting in the posterior tilt position ends up in a shortening of the hip flexors, thus producing an ANTERIOR pelvic tilt when standing?

    This issues isn’t made easier by others switching the posterior and anterior words around as in here: http://www.floota.com/desk_jockey.html – see their diagram compared to yours. Yours seems intutively right (tilted anteriorly must mean with front of pelvis pointing downwards).

    • Administrator says

      Hello Dominic,
      I wouldn’t get caught up in the position of the pelvis while sitting. The reason I say this is because what makes your pelvis tilt down is tightness of the hip flexors. Try this: stand up straight on two feet. Now, lift one knee up towards your chest while the other foot stays on the ground. Your hip flexors are the muscles moving your knee towards your chest. In order to do this, they have to shorten. It wouldn’t matter whether your pelvis is tilted or neutral, it’ll still be your hip flexors pulling your knee up towards your chest. The action of the hip flexors is independent of your pelvic position.

      Put this into a sitting context. Even if you sit with perfect posture (which probably doesn’t exist), your hip flexors will still be in a shortened position. The only difference between the standing position with one knee up, and the seated position, is that you had to actively put your hip flexors in the shortened position. When you sit, they are passively put into a shortened position. Either way, they are shortened and a chronically shortened muscle will end up tight and can actually shorten physiologically (to describe this process would take a post of its own).

      Now when you stand up, the tight and/ or shortened hip flexors will exert a downward pull on the front of the pelvis, causing anterior pelvic tilt. Bottom line: if the hip flexors are flexed, as they are when you are sitting, they are in a shortened position irrespective of how the pelvis is positioned.

      Hope that helps clear up the confusion.

      PS. make sure you are viewing the pictures correctly. Back in the day I used to view spine/pelvis diagrams backwards because the curve of the lumbar spine changes with the position of the pelvis. This used to make me interpret the pictures incorrectly.

  7. Dominic says

    Neal, thanks for excellent clarifying reply. It makes sense now – hip flexors are engaged whatever the position of the pelvis. Thanks.

    BTW, you’re right, I had misread the diagrams, apologies to all for the confusion!

    Now for those dynamics warm-ups….

  8. says

    Ah…the rectus femorus…the tightest of my quads. I didn’t know it originated in the pelvis, though I should have. The pelvis is so central to everything, like a train station hub and if there is a problem on one of the tracks, it affects all other incoming and outgoing trains.

  9. Linda P says

    I can’t believe I found this amazing site. I have been having debilitating spasms in my mid-back (QL is suspect) and I was seriously thinking something was tilted somewhere. This made so much sense. When the spasms stop I will follow the protocols you suggest. Thank you so much for sharing.

  10. Brandon Heller says

    Hi,
    Thank you for your article. What type of doctor can diagnose pelvic tilt? I’m 25 and have two bulging discs from bad form from squats and deads. I am almost certain that my lower back pain stems from extremely tight hamstrings or shortening in my hip flexors. I’ve recently learned hamstrings can wreak havoc on the lower back when tight. And I’m naturally tight, considering I’ve had chronic exertional compartment syndrome throughout my highschool and collegiate sports career. However, I’ve had bi-lateral fasciotemies that have done wonders, but I still have tightness either in my posterior calve muscles, or it stems from hips/hamstrings. I want to get on with my life… its been extremely dibilitating, especially coming from a life of sports. I’m scared to play basketball, or even go up hills, because I know the next day I’m in for a world of pain.

  11. Karah says

    I myself have been going to a physical therapist for a week now because of this issue. I have extreme pain due to pelvic rotation and after the exercises I have had pain. The pain. I was wondering if having pain after exercising the pelvis such as; pelvic tilt and etc. If not please let me know and what should I do concerning this issue?

    • Administrator says

      Hello Karah, I suppose it’s possible. What type of pain are you having? Lower back? Have you asked the physical therapist about it?

      Neal

  12. Maurissa says

    Hi Neal, I just came across your blog tonight and am learning so much about the anterior pelvic tilt, which I have fallen victim because of my tight hip flexors. Question about sleeping and sitting. Any specific recos for the best positions? Should I use pillows or towels for added support? Thanks so much for your insight!

    • Administrator says

      Hello Maurissa,
      Besides trying to sit as little as possible, I don’t have any real positional recommendations, as sitting with your hips flexed is somewhat unavoidable. In terms of sleeping, I guess sleeping on your back would be best, and perhaps with a pillow under your knees (tight hip flexors can cause strain on the lower back when laying supine). I’m a terrible sleeper and end up tossing and turning. I always end up on my side with hips flexed. I think foam rolling and stretching can help most people if you do them a few times per week.
      Thanks for the comment!

      Neal

  13. Saleena says

    This article was very helpful! I’ve dealt with back pain for about 8 years and I’m 16 now. They first diagnosed it as scoliosis until recently when I had x-rays done and said my hips were tilted forward. They couldn’t even explain to me why I was having back spasms to where I could not get off the ground or wherever I was at for at least ten to fifteen minutes. I feel like I’m quite young though to be dealing with this kinda of thing? But I was mainly wondering if you knew any way to stop back spasms or atleast sooth them when they do happen. Because most times when they do occur it’s when I’m in school and I’m not quite sure how to deal with it without attracting too much attention to myself. Thanks.

    • Administrator says

      Thanks, Matt. Nice catch. No matter how many times I edit my posts before posting, it’s hard to catch everything.

  14. Stephan says

    Hi, great article. Just one correction I wanted to make: paragraph 3, sentence 3: “In addition, the rectus femoris is one of the quadriceps muscles and attaches below the knee so that it also performs knee flexion.” Rec Fem performs knee EXTENSION, not flexion.
    Do you have more specific articles or advice on exercises for low back pain due to lumbar disc tears? Thanks again.
    Stephan, Physical Therapist

    • Administrator says

      Thanks, Stephan. It’s been corrected.
      In regards to lumbar disk tears, are the tears accompanied by herniations?

      Neal

  15. Rush says

    Hi Neal,

    Apprieciate the lengths you have gone through to educate others. Few questions:

    – For muscles which are tight and of poor muscle tissue quality, do you suggest foam rolling first or dynamic stretches

    – Where are the links to the recommended APT dynamic stretches

    – When performing glute activation workouts like the glute bridge, should people be wary that it also seems to work the lumbar erectors? When I perform the glute bridge my hams and lumbar erectors also get in on the action, I am able to focus somewhat on my glutes but never seem to be able to fully awaken them

    Thanks,
    Rush

    • Administrator says

      Hey Rush,
      I would do the following: some traditional cardio warmup for 5-10 minutes, could be riding a bike, brisk walking, etc… just to get body temp up, blood flowing, and joints lubricated. Then i would foam roll to relax the muscles. Then I would do the dynamic stretches. Some people have a hard time going straight into dynamic warmups.

      If you look at one of my responses to a comment in the same comment thread, on Sept 12, 2010 I listed a couple videos to watch. I’d also add quadruped hip circles to the exercises that I use for hip range of motion.

      Optimally you want to only feel it mostly in your glutes, but many people feel it in their hamstrings also. You could try playing around with your foot position: keep them flat or do it with your toes up and only heals on the ground, see which one works better. You could also try placing a towel between your knees.

      Your lower back shouldn’t be helping out. Perhaps you have limited ROM at the hips going into hip extension, and your lower back is going into extension as a compensation. Once your hip flexors are looser, you may notice that your lower back stops trying to contribute.

      Thanks for the comment!
      Neal

  16. Rush says

    Hi Neal – Thanks for the feedback, okay understood.

    I currently foam roll only my quads and hip flexors as this seems logical.

    Will have a play around with the glute bridge and see what works and doesnt as you also stated.

    For glutes currently the only activation I get is from leg kick backs (head down to eliminate the lower back) and kicking upwards to the ceiling. Its not ideal as it takes a fair few reps to get a burn. Squating does nothing for my glutes, its all quads followed by lower back and abs.

    I understand your recovery took time, but did you just keep working on glutes/abs/stretching of the hip flexors in rotation to see results?

    Cheers,
    Rush

    • Administrator says

      I’ve always gotten a lot of glute activation from exercises like step-ups and lunge variations. You can also try hip thrusts http://www.youtube.com/watch?v=hCm-70-9_XE
      Deadlift variations should hit your glutes, as well. Proper technique is essential, though.
      I’d recommend foam rolling your entire lower body: calves, quads, hamstrings, IT bands, hip flexors, and glutes.

      What really helped me was the dynamic warmups. I didn’t do much foam rolling in the beginning because no one was doing it back then, although the more I studied, the more I started to foam roll.

      From my experience, and experience from training people, it does take a couple weeks to a month to start noticing a big difference. People tend to feel a difference right away, but it takes time for the body to really take to these exercises. If you are tight, there is the idea that not only do your muscles have to undergo changes, but your CNS has to permit bigger ranges of motion.

  17. Rush says

    Hi Neal,

    This is all self diagnosed; I feel through trial and error that my hyperlordosis and inactive glutes cause struggle firing and building upon my glutes.
    Either my lower back is too curved so the exercises are difficult to correctly perform, my hamstrings will also fire OR my quads carry a large portion of the load. Squats and lunges I feel in my quads, very little to no glutes.
    A side squat however does fire my glute very well, but puts pressure on my knee eventually causing great pain. I understand this is down to muscle imbalance and most likely bad form due to my posture, but I am unable to avoid it through different attempts.

    Will experiment with the link provided, but can see the same problems with hamstrings activation.
    I have to really take care due to my disc bulge too; still don’t feel quite 100% yet. I mentioned before my lower back muscles also activated during a floor hip thrust, I mostly eliminated them by slightly neutralising my pelvis.

    The Spiderman’s and hip flexor stretches feel great as well as hip rotations. However the box squat again doesn’t do much for my glute activati0n I’m afraid.

    I’ve actually noticed now that I cannot stand for long without my lumbar erectors becoming overloaded and very tired, no matter how straight I hold my posture. It even feels as if the top area of my glutes hurt! And this is after about 2 weeks of performing:

    – supine groin stretch (20 mins each side)
    – static back
    – hip flexor and quad stretch (focusing on reducing the hyperlordosis before the stretch to maximise affect)
    – attempted glute activation
    – planks and side planks

    I will not give up as I can’t accept my current condition, but sometimes your body talks to you as they say. And I do not feel anything I am doing is helping.
    Also you mention deadlifts, I would not dream of doing them with a recovering lower back disc bulge in case of re-injury.
    Perhaps my CNS prefers the APT? 😉

    Thanks,
    Rush

    • Administrator says

      Another possibility for glute activation is the “pull-through”
      http://www.youtube.com/watch?v=A32WSOB-6Gw

      I also use unweighted side lunges in warmups as a way to get glute stimulation in a different plane of motion.

      Also, single leg Romanian deadlifts. While hard to do correctly if you are unfamiliar with them, this exercise is great for hamstring/glute work. Plus you probably won’t feel anything in your back. As always, just start light and work your way up.

      You may want to get checked out by a PT. It’s hard to speculate about what might be occurring.

  18. Nettie says

    Neal
    I had back surgery then 6 months later I had total hip replacement surgery after the hip surgery my pelvis tilted and now my leg is now about 1 1/2 longer than the other ,do you know what may have happened? My Dr. said he didn’t know what happened and didn’t know what to do about it, I’m in pain almost all the time.

  19. Nettie says

    I have pelvis tilt that has caused my leg to be pushed down and is 1& 1/2 longer than the other ,I had back surgery then 6 months later I had total hip replacment , Dr. don’t know what happened and dosn’t know to do about it, I’m in pain most of the time.?????

  20. jane says

    I don’t notice any pelvic tilt, per se, however, upon rising from a sitting position, I have excruciating pain in my front hip flexor. In the past, I have been faithful on the elliptical, however, the last year and a half, (with especially the last 9 months), I have been in a job that has kept me sitting long hours at a time. The pain is horrible upon standing and by the third of fourth step, has subsided. Will all of your suggestions in your original post help correct this situation? I think you said it was good to continue with elliptical training. Also, I know everyone’s body is different, but what is a reasonable amount of time to give for improvement given an aggressive recovery program?
    Thanks for your help.

  21. Jacqui says

    Cooee. I run ultra distance and I suffer at times with hip flexor/sacrollaic issues. Today, Im off the running as the knee is starting to rumble and the foot is constantly tight with tendonitus. It all came on about three weeks ago and Ive curtailed training but it’s still plagueing me. Im definately a wonky legged runner, always have been since childhood but Ive never been out for this long. Any advice would be great as Ive read your article above and it’s more informative that any specialists Ive seen over the years.

    • Administrator says

      Hi Jacqui,
      I don’t have any additional advice except that many people aren’t meant to run long distances. For most people, the wear and tear catches up to them. As long as you are taking care of your body in terms of lifting weights, proper stretching and foam rolling, the only other option seems to be cutting down the mileage, especially as long as symptoms persist.

      good luck
      Neal

  22. Sam says

    Hi, I’m guessing cycling causes tight hip flexors as you are moving your knee up and down repeatedly I suffer from lower back pain I have flexible hamstrings, quads, slightly tight glutes and I’m not really sure on my hipflexors I do feel good after I stretch them My back pain feels like its burning for a while then it will start to hurt when cycling. Sitting down my back hurts more not so much with the burning feel I do have a lower disc bulge cant remember what one it is, and some degeneration in the lower spine I’m 19 aswell and work on the core alot given by a sports therapy

    • Administrator says

      Hi Sam,
      Pretty much anything can cause tight hip flexors: sitting too much, exercising too much (especially in a limited range of motion). Also, your lower back might not respond well to sitting on the bike, because your lower back will tend to be flexed forward. Sometimes ridding yourself of pain, or simply managing pain, comes down to behavior change–not doing things that hurt. It seems too simplistic, but often that is the solution.
      However, if you continue to cycle, make sure your hip flexors are stretched and your glutes and upper back are strong.

      Good luck,
      Neal

  23. Lori says

    I was hit by a moving car at age 14, in 1976. I was sent to a hospital with a mild concussion, and then nothing was ever thought about it. There was a large purple bruise on my right buttock, and it slowly went away.
    For years, about twenty three years, there was no pain. I was told by a chiropractor at age 27 that my hips were rotating to the left. I wanted to help my problem, but th e treatment was beginning to hurt a little.
    I became suddenly disabled in 2002, when my left hip began to go out , and I began to sleep on the floor, hoping to manage it. After that, all kinds of things began to happen, in all different areas.
    In 2006, I bent over to tie a gabrgae bag up, and became struck with severe exquisite pain in my lower spine which I could not relieve with any movement, had to collapse to the floor, and after two days finally submitted to being brought by police to an emergency room. That hospital did not handle it well, I asked for morphine.
    I never really learned much about my pelvic area. Now I am 50 years old, have to manage pain daily. The pain is getting worse.

  24. Lori says

    I was hit by a moving car at age 14, in 1976. I was sent to a hospital with a mild concussion, and then nothing was ever thought about it. There was a large purple bruise on my right buttock, and it slowly went away.
    For years, about twenty three years, there was no pain. I was told by a chiropractor at age 27 that my hips were rotating to the left. I wanted to help my problem, but th e treatment was beginning to hurt a little.
    I became suddenly disabled in 2002, when my left hip began to go out , and I began to sleep on the floor, hoping to manage it. After that, all kinds of things began to happen, in all different areas.
    In 2006, I bent over to tie a garbage bag up, and became struck with severe exquisite pain in my lower spine which I could not relieve with any movement, had to collapse to the floor, and after two days finally submitted to being brought by police to an emergency room. That hospital did not handle it well, I asked for morphine.
    I never really learned much about my pelvic area. Now I am 50 years old, have to manage pain daily. The pain is getting worse.

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