May 12th, 2017

​The Gold Standard for Checking for Anterior Pelvic Tilt

If I had to choose one test for checking anterior pelvic tilt, it would be the Sidelying Extension Adduction (SEA) test.  I use it for all incoming clients because anterior pelvic tilt is a global alignment problem, and this test can detect it in under two minutes.  This test is also more reliable and precise than the Thomas Test.   It is the gold standard in my book.

(A variation of this test is offered by the Postural Restoration Institute. It’s a great test. I however position my clients at 45 degrees and I check for the first sign of passive tension.) 
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Here’s how to do the test:    

1. Get the client or patient sidelying with hips pointed 45 degrees downwardly.   
2. With one hand, press into the top of the pelvis making sure the top of the pelvis is stacked right on top of the bottom pelvis. The pelvis will likely want to move, so keep a constant pressure.  
3. With your other hand, grab under the knee and make sure the person is relaxed enough that if you dropped the knee, it would suddenly drop.
4. First, abduct the leg about 15-20 degrees. 
5. Very slowly, bring the leg back maintaining the abducted state. When you feel the slightest pull forward, this is your stopping point.  Look down and observe.
6. If your leg is in line with the rest of the body and the low back has not moved, the pelvis is neutral.  It’s also neutral if it goes past zero degrees.
7. However, there is anterior pelvic tilt (APT) present if the hip does not make it to zero degrees (meaning you feel any bit of tension before you get to zero degrees).  There is also anterior pelvic tilt present if you observe that the hip gets to zero degrees, but there is low back extension present. 
8. The leg should drop down to at least horizontal and maintain it’s position.  If however, hip moves forward, anterior pelvic tilt is present.

This test is ideal for checking for anterior pelvic tilt because it succeeds where other tests fail. The SEA test is a stiffness test, not a length test.  One of the problems with the traditional Thomas Test is that the Thomas Test measures only the length of the hip flexors.  What the Thomas Test doesn’t do is measure the stiffness between the muscles which produce anterior pelvic tilt (hip flexors and erector spinae) and the muscles which produce posterior pelvic tilt (abdominals, hamstrings, and glutes). 

Why is this important?  Anterior pelvic tilt is not caused by short hip flexors or erector spinae muscles.  It is caused by greater stiffness of the hip flexors and erector spinae muscles over the hamstrings, abdominals, and glutes.  What’s the difference between stiffness and shortness?
Think of a slingshot. For those with excessive anterior pelvic tilt, the hip flexors and erector spinae muscles are like a thick rubber band which actually can stretch very far. If you launch a rock with this band, it’s going to go a long way.    

This is why it doesn’t matter if the hip flexors or erector spinae are very flexible, the SEA test will detect the stiffness by checking for tension, not length.  I encourage you to test this out for yourself with your most hypermobile client. What you’ll find often is that you can bring their leg back very far.  However, if you pay attention to where you actually begin to feel any hint of tension, you’ll often find these individuals have excessive anterior pelvic tilt because their leg does not make it back to neutral alignment.

If you perform a Thomas Test and find the hip flexors are short, they are guaranteed to have a positive SEA test (meaning they do have anterior pelvic tilt).  Why is this?  Whenever the hip flexors are short, their stiffness is so great that even with the weight of the leg and gravity assisting, it is not enough to bring the hip into a neutral position of zero degrees of hip extension. This is easily seen if you do the SEA test with someone who has short hip flexors from the Thomas Test.  

Why can’t you simply do a Thomas Test to determine if a person has anterior pelvic tilt?  The problem is that you can get a false negative result (meaning the person could appear to have normal length of their hip flexors, but in reality, they still have greater stiffness of the hip flexors over the muscles which produce posterior pelvic tilt (PPT).

The reason why you can get a false negative is because gravity and leg weight can cause the leg to appear to be of adequate length, but in reality, it’s not. The power of the SEA test is that it takes gravity and leg weight out of the equation and strictly measures the tension between the hip flexors and erector spinae and the abdominals, hamstrings, and glutes.   

Another reason why the SEA test rocks is that it checks for compensatory movement with the low back.  Even if you can get the hip to neutral during the SEA test, if you see extension in the low back, anterior pelvic tilt is present.  The passive tension of the hip flexors is greater than the abdominals, glutes, and hamstrings.

What happens if you find a positive result for the SEA test?  You need to do a length test for the hip flexors and erector spinae. You should measure the hip flexors with the Thomas Test.  You can measure the erector spinae using the prone rock test (as found in the SFMA).

If either the hip flexors or erector spinae are short, you should lengthen them.  How you lengthen them is of importance which we’ll cover later. However, even if you don’t find the hip flexors or erector spinae are short, there is still greater stiffness in the hip flexors and erector spinae.  This definitely calls for strength training the abdominals, glutes, and hamstrings.

If for whatever reason you’re in solitary confinement reading this article and no prison guard is going to perform the SEA test on you, you can do it by yourself.  The key is simply allowing your leg to go back in the same way as the regular SEA test. You must however, relax your whole body and even your leg when it is lifting up (as much as possible).  Bring your leg back very slowly and at the slightest hint of tension, that is your stopping point.  Once you find this point, you should look down and if you can see your leg. If you can see it, you probably have anterior pelvic tilt. 

If you can’t see your leg, you probably don’t have anterior pelvic tilt.  However, if you felt your back extend at all, then anterior pelvic tilt is present.  Again, DO NOT tense up your abdominals or your hips, just let your leg go back very lightly, and see how far it goes.

While the sidelying extension adduction test does a great job measuring stiffness between the muscles which produce APT and PPT, there are some things which the SEA test doesn’t measure. This includes potential anterior pelvic tilt that could present in your alignment, movement, and motor control. We’ll go through these tests and treatments later.