Live Q&A Replay: Pelvis Pro
Meet your instructor: Dr. Sarah Duvall, PT, DPT, CPT
Having trouble playing the video? Watch on Youtube here.
Topics and Questions
Scroll down for further helpful resources on each question.
IT Band
1) Is there a connection between a client having IT band pain and adductor weakness?
2) How IT band tightness/discomfort play into accessing the hamstring. Relationship of tight deep glutes and same leg inner thigh tightness/pain.
3) How does the IT band come into play? Mine likes to freak out when I do the first proximal hamstring activation in the video.
Chat commentary
Use towels (even though this visual is for lower abs) to help find hamstrings
This video can also be helpful - Having Trouble Finding Your TAs?
Make sure to find proximal (sit bones moving up toward the back of the knee and rotating under like a wheel, rather than knee bending) and not just distal when trying to keep TFL out of firing with isolated hamstring work (distal will go with TFL)
Deep Hip Rotator/ Hamstring Substitution or Weakness
4) I have almost constant pain/discomfort in my glutes and the top of my hamstrings. Piriformis stretching makes it worse!
Deep Butt Pain and Tightness
Fix Deep Hip Rotator Tightness
Add an Adductor Squeeze for Glute Work
5) When I try to find my proximal hamstrings I feel a deep tension gripping in the depth of my right foot. Right side also has anterior femur glide and feels a bit catchy and torn. I feel a pulling tightness that stops me from really going into the hip hinge.
6) Please address cramps (Charlie horse) in hamstrings during certain yoga exercises
7) Sciatic nerve pain or burning pain deep in glute max when doing exercises?
Hamstring Tightness and Pain
8) After doing the exercises from your webinar I had pain in my right hamstring. What is that an indicator of? How should I get it stronger?
Chat:
Include this visual
Hamstring/foot position for medial hamstrings
Additional question: Can you keep your butt down for that exercise? I have a sore lower back.
Answer: Yes. The fact that you have a sore lower back makes me want to dive into more with finding proximal hamstrings as well as glute max to help lift you.
9) A runner with tight hamstrings, definite APT, feels like she pulled proximal hamstring. Also feels glute med on that side does not fire when she runs or even walks.
Someone was asking if should be using abs in the hip hinge with front leg hamstring drag:
Here’s a visual to take into consideration when finding hamstrings in supine to make sure you’re not overworking recuts or not having a balance in your ab engagement to get into the position depending on the goal of your exercise. When You Tuck, Do Your Lower Abs Flatten?
Question: Do RDL’s help?
Answer: They can but often it’s easier to find that hamstring engagement in more of a split stance vs side by side and working towards single leg would be particularly important for a runner and assessing asymmetries between sides
You can also increase the challenge of that last exercise by actively keeping the slight heel float (so no towel prop) but keeping all of the same mechanics
Obturator Internus Tightness and Pain
10) How do I differentiate OI from piriformis pain?
11) Could you address chronic obturator internus tightness/pain and give recommendations. It seems exercises done to strengthen glutes and TAs also flare the OI tightness/pain. What’s the best way to train someone who has pelvic pain here?
12) Every glute exercise gives some stress on the pudendal nerve. But the muscles would need the exercises to feel better. How can I get out of this pain and nerve stress circle?
13) Cramping and spasms as well as a deep ache in her left piriformis and posterior hip following hamstring strain. She reports the sensation of "locking up in my SI joint" and muscular spasm.
Deep Breathing Or Shallow Breathing
Piriformis Squat Progression
Can You Keep Side Planks Out of Your Back?
Finding Hamstrings in Side Plank
Labral Tear
14) I am dealing with a significant labral tear. What can I do to help it?
Two Reasons Why The Psoas Feels Tight
Improve Pelvic Floor with Posture
SI and QL Tightness and Pain
15) Can deep hip internal rotators and adductor tightness cause QL pain?
Chat commentary:
Could also do this on your right side to find left hamstring to help find your left abs
16) What can be done to relieve chronic QL pain?
Challenge: Find your Internal Obliques
Improve Your Side Planks with This Exercise
Chat commentary:
Even upper body can affect pelvis/SIJ
17) I have a chronically higher left back pelvis with glute medius, ITB , vastus lateralis, hip flexors and QL tightness.
Challenge: Find your Internal Obliques
Closing Abdominal Separation 100%
Chat commentary:
18) Wondering about SI joint area discomfort and tightness, around sit bone on that side. And can somewhat tight adductors be a sometimes culprit in this menagerie? And tight QL?
Adductor Pain and Tightness
19) Groin pain with activity.
Sidelying Knee Lift Progression Part 1
Sidelying Knee Lift Progression Part 2
Sidelying Knee Lift Progression Part 3
20) Severe pain in the left groin area and difficulty weight bearing due to pain. Lots of foot ER with femur IR. After mobilizing pubic symphysis, groin pain was gone immediately. What exercises would help to hold pubic symphysis in place?
They definitely feed off of each other. You will often need to address the hip more before foot stuff sticks, but adding in foot awareness to hip stuff can help the hips. The ability to pronate and lengthen the arch is just as important as being able to engage the arch. You need this ability to go in both directions. So, those that tend to have that deep butt pain will often rock to the outside of their foot and it’s almost like the foot is mimicking the hip for holding tension. Check out Anna’s foot series.
Tibial Internal Rotation Test for Knee Pain
Easy Tibial Internal Rotation for Knee Pain
Bridge with a Tibial Twist for Knee Pain
Pelvic Orientation
21) What are some of your favorite ways to help someone gain posterior pelvic tilt ROM for those stuck in APT world, especially postpartum?
We can either succumb to this position, leave it compressed and fall into an anterior pelvic orientation (usually see this with back pain because you end up hanging into extension) or you can counter it with some glute gripping and go into a posterior orientation. This will create further compression on the backside, tacking down your tailbone (pulling it into further counter nutation and creating the bulge up top). It also flattens out your lumbar spine and creates more of that flat bottom appearance. I’ve heard so many moms remark in that post-postpartum period, what happened to my glutes, it’s like they just disappeared.
- Functionally, this creates a loss of relative movement between the sacrum and pelvis. Losing the relative movement limits how well we can lengthen through our glutes. When it comes to a hinge or a squat this will mean either lengthening through hamstrings, spilling the pelvis forward, or lengthening through the lower back with lots of rounding. Then if you try to round further in your lumbar spine, you can’t because you’re already well into that range. So maybe it’s not that your back is stiff, but that it’s already at its end range.
- This is why it’s absolutely imperative that you don’t grip anything in your lower glutes when you find your hamstrings. Your hamstrings pull your innominates under, they don’t insert on the sacrum. So, by just getting hamstrings and letting everything around the sacrum go, you can create relative sacral nutation and that will be the first step in freeing the tailbone. Then, if you layer in adductors, you can get things to open, even more, moving further into nutation. When this happens, those glutes will pop - in a good way and the low back will feel free.
Releasing Tight Back Muscles - One Simple Exercise
Hip Bridges: Isolate Hamstrings
22) How to deal with a hamstring and “middle of the butt” pain on the left leg and the right leg seems to have a hip flexors issue, particularly limited internal rotation. Makes my walk feel unstable and “crooked”.
- Sitting can be tough because for most chairs you have to get to at least 90 degrees of hip flexion. If you don’t have the ability to eccentrically lengthen through your glutes to get down to this position, you’ll often go into a posterior pelvic tilt early, resulting in sitting on the backside of your sit bones more than the bottom and compressing all the posterior pelvis structures into a shortened position.
- On top of that, some people tend to clench their pelvic floor or glutes when stressed. So, if you notice it happens more at certain times than others it might be the stress contributing more than the chair itself. So learn to bring awareness to what you’re feeling underneath and try to break that habit. Easier said than done I know. When seated, go ahead and use your hands to widen your sit bones out as well as physically turning your femurs in to get your pelvis and hips to open as much as possible on the bottom. This is a good time to note if you tend to tuck one hip under more, do you feel more flesh under one sit bone more than the other or do you shove one knee forward compared to the other.
- Another thing that can really help is fidgeting with intention while sitting. So, shifting those knees forward and back, rocking your tailbone forward and back, or weighting one side and then the other. The more your exercise program supports opening your pelvic outlet and like we talked about earlier with re-establishing sacral nutation and relative motion the more it will carry over into helping you sit comfortably for longer periods of time.
23) How related is foot pain to hip pain?
They definitely feed off of each other. You will often need to address the hip more before foot stuff sticks, but adding in foot awareness to hip stuff can help the hips. The ability to pronate and lengthen the arch is just as important as being able to engage the arch. You need this ability to go in both directions. So, those that tend to have that deep butt pain will often rock to the outside of their foot and it’s almost like the foot is mimicking the hip for holding tension.
Check out Anna’s foot series.
Foot Foundations: Single Limb Stance
Waking Up Arches and Pronation
Sacral Freedom and Movement
24) Would love to address sacrum/tailbone changes after pregnancy. Since my first pregnancy my sacrum appears more posterior/bulging out. I think it is negatively impacting my ability to flex the lumbar spine. Have you heard of this?
- Let’s take a look at a common pelvis presentation for pregnancy. To accommodate the growing baby your pelvis will position into inlet ER position and counternutated sacrum. This already puts the back of your pelvis into some compression.
- We can either succumb to this position, leave it compressed and fall into an anterior pelvic orientation (usually see this with back pain because you end up hanging into extension) or you can counter it with some glute gripping and go into a posterior orientation. This will create further compression on the back side, tacking down your tailbone (pulling it into further counter nutation and creating the bulge up top). It also flattens out your lumbar spine and creates more of that flat bottom appearance. I’ve heard so many moms remark in that post postpartum period, what happened to my glutes, it’s like they just disappeared.
- Functionally, this creates a loss of relative movement between the sacrum and pelvis. Losing the relative movement limits how well we can lengthen through our glutes. When it comes to a hinge or a squat this will mean either lengthening through hamstrings, spilling the pelvis forward, or lengthening through the lower back with lots of rounding. Then if you try to round further in your lumbar spine, you can’t because you’re already well into that range. So maybe it’s not that your back is stiff, but that it’s already at its end range.
- This is why it’s absolutely imperative that you don’t grip anything in your lower glutes when you find your hamstrings. Your hamstrings pull your innominates under, they don’t insert on the sacrum. So, by just getting hamstrings and letting everything around the sacrum go, you can create relative sacral nutation and that will be the first step in freeing the tailbone. Then, if you layer in adductors, you can get things to open even more, moving further into nutation. When this happens, those glutes will pop - in a good way and the low back will feel free.
25) Whenever I sit for a long time, it’s painful to stand up as pain radiates in my tailbone/buttock area. Any stretches to help minimize the pain?
- Sitting can be tough because for most chairs you have to get to at least 90 degrees of hip flexion. If you don’t have the ability to eccentrically lengthen through your glutes to get down to this position, you’ll often go into a posterior pelvic tilt early, resulting in sitting on the back side of your sit bones more than the bottom and compressing all the posterior pelvis structures into a shortened position.
- On top of that some people tend to clench their pelvic floor or glutes when stressed. So, if you notice it happens more at certain times than others it might be the stress contributing more than the chair itself. So learn to bring awareness in what you’re feeling underneath and try to break that habit. Easier said than done I know. When seated, go ahead and use your hands to widen your sit bones out as well as physically turning your femurs in to get your pelvis and hips to open as much as possible on the bottom. This is a good time to note if you tend to tuck one hip under more, do you feel more flesh under one sit bone more than the other or do you shove one knee forward compared to the other.
- Another thing that can really help is fidgeting with intention while sitting. So, shifting those knees forward and back, rocking your tailbone forward and back, or weighting one side and then the other. The more your exercise program supports opening your pelvic outlet and like we talked about earlier with re-establishing sacral nutation and relative motion the more it will carry over into helping you sit comfortably for longer periods of time.
Hip Flexor Tightness
26) What's the best exercise or technique to help with psoas tightness and pain. And with a front-shifted pelvis?
- With a front shifted pelvis- assuming that means APT- we may see additional quad or hip flexor tightness and this alone can contribute to psoas tightness. I also see quite a bit of psoas tightness with a high hinge point, but that often has more to do with breathing. And, I definitely tend to see a tight psoas from deep hip rotator gripping.
- Now, let’s think about movement and every time you bend over. Do you control your hip hinge by lengthening from your glutes or by pulling yourself down from the front? I also have some videos on this so I’ll link those with the replay. Are you driving all internal rotation work from the TFL or utilizing some anterior glute med and adductor? Then you can look at the femur position to think about how that affects psoas tension. If a femur is shoved forward in the socket, due to overactivity of deep hip external rotators and/or using a hamstring dominant hip extension pattern, this can put the psoas on constant tension.
- We’ve already talked a lot about finding proximal hamstrings. They are important to anchor your pelvis as you go to eccentrically lengthen your glutes in a squat or hinge pattern. This drives more relative motion at the inlet and creates space for the femur to go back into the socket. Lengthening gives those glutes a better position to contract from. When you come back up from your hinge, do you fall into a swayback posture, thrust femurs forward, or lockout knees? Or are you able to keep rib cage stacked over the pelvis and coordinate the pelvis and knees working together to help keep the femur centered in the socket?
- Then, make sure you eventually add in some progressive psoas strengthening once you have a good foundation of core strength to work from, this can help keep the femur back in the socket from the front side and define its role. So, are you in a place where I’d suggest starting with TA work or are you ready for psoas exercises?
- Also, watch for compensations at the rib cage either flaring ribs or dropping down as this can affect how the diaphragm and pelvis interact which in turn interplays with the psoas. Thoracic rotation and great breathing can play a really important role in what’s happening at the pelvis. The psoas inserts in the back of the diaphragm. If you tend toward a shallow breathing pattern and the back of the diaphragm stays high, then the psoas doesn’t get that nice little release with each breath. So, maybe the best exercise for you would be starting with breathing.
- As you can see the best exercises… well, that’s all going to depend on what areas you need the most because the psoas is a very special muscle that crosses up into the trunk and down into the lower body. It connects our upper and lower half. So, you’ve got to look at pelvis mechanics as well as what’s happening in the torso and in between. I’ve actually seen people that tensed their psoas when they tried to contract their pelvic floor. That simply took a little retraining resolve. But, that’s part of why I wanted to put together a continuing education course on the pelvis. I wanted to equip those that help others with all these little tricks that I’ve learned over the years helping clients troubleshoot complicated issues. So, if you want an assessment to help you navigate the best exercises to start with, shoot me an email and we can help you find someone in your area that’s been through our coursework. They can help you figure out the best place to start.
RockBacks for Glute Lengthening
Two Reasons Why the Psoas Feels Tight
Tight Butt Muscles and Psoas Tension
Shift Back in Squat
Are your Glute Initiating the Squat or is Your Back?
27) Can you address the ache that persists and increases as I walk/run uphill or upstairs…towards the outer edges of my hips. Is that anterior impingement? My flexors in front/side of my hips are SO TIGHT! Is that what is causing the massive aching along the inside of my ASIS pelvis hip ridges and lower back so that I can barely turn over in bed sometimes?
And when I externally rotate my legs and sit with either one or both in front of me, I can barely stand up straight!!
I thought this was an interesting question and not your normal description of a common hip/ pelvis issue. But, I wanted to give you my best guess of what’s happening. What you’re describing to me sounds like your iliacus. It sits inside your pelvis and runs along the top rim. I can generally palpate it if I have someone lie on their side and I curl my fingers inside their pelvic rim. It does do external rotation and it is a hip flexor. So, if you sit cross legged or one leg curled in front, it will really tighten up if it’s prone to holding tension. (I showed this on the call.)
I often find that the iliacus tightening down is actually a response to the hip being kind of stuck in the middle. Think of it as a tug of war. You’ve got your iliacus on the inside and your glute medius on the other. If you’ve got any tension, say, maybe your glute medius feels a bit hunky and gets trigger points right up here along the top. Maybe it feels like you’ve got more glute medius working than glute max. I generally see this iliacus tension go hand in hand with decreased glute max strength.
The complete solution is to fully re-establish transverse plan motion in both hips. If you haven’t checked out the hip webinar I’d take a look. The most advanced version of ER/IR that I went through will be wonderful but you might have to work up to it!
28) When we start our workout with my client her quads and hip flexors get a nice stretch, and after they are so tight we can’t get her to “feel” a stretch. She wakes up at night with pain and tightness in the right quad often.
- I love how you are asking about this and using caution, so smart!! So, I actually had a really interesting patient once on her way to compartment syndrome in her quads. She was working with a trainer and her quads became painful, so her doctor told her that the muscles were weak and sent her to PT. The PT worked her quads more and she got considerably worse. By the time she saw me, she could barely stand or walk for more than a minute or two without horrible pain.
- Sounds like your person might be headed down that same road.
- Let me share what I did for her in case it helps. We did a ton of release work on her quads. I got her using myofascial release cups in the shower, foam rolling and massage. Basically doing all we could to ask the muscle to down-regulate tone. We did absolutely no quad strengthening. In fact, we went over how to try not to contract her quads. I noticed she stood with her knee caps up all the time, holding loads of tension in her quads. It seems simple but I got her to drop her knee caps. We then moved into strengthening everything else without quads. So, abs, like small crunches, facedown glute squeezes with a slight knee bend to make sure she wasn’t using her quads. We advanced to hamstring bridges after she started feeling a bit better and we were able to incorporate even more glute, hamstring and calf strengthening. She was really quad dominant to the point where her quads became overloaded. It took a few months for us to get her back to baseline and we were able to move back into quad strengthening. So she did well but she needed more balance and a lot more posterior chain. Hopefully, something in there helped with spurring ideas. Sounds like you’re already on the right track with caution though!
Exercise Recommendations
29) I saw a post recently calling monster walks outdated - if so, do you have better exercise to strengthen the hips?
- Oh, I love it when stuff goes in and out of fashion. But, it’s true, I don’t love monster walks as a starting point. I think anything can be good if you have a great base though. A couple of reasons for not loving them as a starting exercise. One. monster walks are end range. Yikes, end range is hard for people. Most people are compressed too much already. Two. I see a whole lot of TFL activation instead of glutes with these. Which isn’t necessarily bad if you’re looking to strengthen your TFL but most people do monster walks to get glutes. They just aren’t always the best glute exercise. So, I say try them and ask where they feel the work is being done. If it’s all glutes and feels good, then continue on and ignore the social media trends.
30) With the split stance hip hinge: when the back foot is up on the wall, are both hamstrings supposed to be engaged? How do you get that side to engage without something to pull back against?
- Yes and no. It’s engaged in the sense that you’re not letting your pelvis spill forward. So, it’s providing stability for the pelvis. But, an easier way to get the front leg hamstring is to bring the back foot down to the floor and pull back on the front leg. It sounds like you’re off to a great start for exploration though! See if you can feel the pelvis control that front hamstring is doing, especially if you hinge up and down a bit. See if you can feel it pulling you back up. I’ve got a video on getting more front hamstring vs back and I’ll link it in the replay for you.
31) You emphasized the importance of the proximal hamstrings to help anchor the pelvis, and how poor tone in these muscles can contribute to tight deep hip rotators. Then you had us try a bridge (feet on a chair) with the goal of finding and activating the proximal hamstrings. I don’t completely understand why this is a strong exercise choice for someone who has too much anterior glide of the femoral head(s)? By posteriorly tilting the pelvis to “turn-on” the proximal hamstrings, this position might encourage anterior femoral glide in a person who already lives in that position. Why not aim for a mini hip lift in neutral while (self)palpating the proximal hamstrings? Wouldn’t that achieve the same goal without “promoting” excessive anterior femoral glide?
- So, in my experience the more hip flexion the less anterior femur glide.
- I tend to see the most anterior glide in hip extension, especially end-range type activities. Like the face-down hip extension test in the webinar. By going into more hip flexion and getting the knees up to 90 degrees, it usually helps push the femur back more, unless there is glute gripping. Then they just shove the femur forward which they will do in any position.
- In the 90-90 we’re using the hamstrings to act on the pelvis, pulling the pelvis under. What shoves the femur forward with a hamstring dominant pattern in prone is the lever for their distal attachment, not the proximal attachment since that’s on the pelvis itself.
- I find a hip flexed position to be easier for people to not get glute gripping because the glutes and deep hip rotators are put in such a lengthened position. Every muscle has a sweet spot it likes to work, this is called the length-tension relationship. In hip flexion, the glutes are really lengthened making it a bit harder for them to kick in. Whereas with the bridge position, it seems harder to keep them out of it. But, that said, I do use a bridge instead of 90-90 sometimes. It works exactly the same way. You’re using the hamstrings to act on the pelvis. I use this mainly for people that don’t have 90 degrees of available hip flexion. So, someone might need to start with the bridge or vice versa depending on what they are bringing to the table. I also find those in a giant anterior tilt sometimes do better with a bridge and less hip flexion. That’s because we go ahead and let the glutes kick in as well to pull them under. Then, I’ll usually progress them to the 90-90 position. So, great question and it depends on what the person needs! I love how you’re thinking about this.
32) Wouldn’t another potential strategy be to train the piriformis and pelvic diaphragm to help stabilize the pelvis and the SIJ?
- Absolutely, agree 100%. That’s why I usually work to down-regulate deep hip rotators before bringing in external rotation strengthening. Grippers are often weak and do need strengthening, but sometimes you need to send them on vacation first, get other parts to do their job, then bring them back and teach them what they’re supposed to do. If you go straight to strengthening then will just overload and makes things tighter.
- A quick side note on the diaphragm that you might find interesting. The diaphragm can also be a bit of a cheater for stability. When the other core muscles, like the intercostals and abs are weak, the diaphragm will act more in its role of postural stability than breathing. So, the next time you see someone slip into a shallow breathing pattern when they do strengthening exercises, I want you to pause and wonder if their diaphragm just switched to more of a stability role and then see what you need to strengthen to help the diaphragm go back to working more for deep breathing. So, with everything, it depends.
33) The webinar immediately helped my hip to feel better with the last exercise and I was able to find my proximal hamstrings! What should I do next to get them firing correctly?
- The struggle is real when it comes to improving that APT. Let me see if I can make this easy and pull from videos that are on social media. You can try a hamstring iso bridge, I love those. I’ll post that with the replay. Progressing that to single leg is very powerful. You can even do those prone hip lifts as an exercise, just change the name to facedown glute squeezes. Working more dynamically into the hip exercise on the wall will also be really helpful. Even consider adding weight. And then all the abs combined with breathing! I’ll post a good breathing exercise for you as well. That should be enough to get you started in the right direction.
Bridges Vs. Hip Thrusts - Which is Better?
Back Pain When Breathing- Solved
Pelvis Pro
In this digital course, you’ll become a true pelvis pro - visualizing biomechanics and understanding what lies below the surface.
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Earn Continuing Education Credits (CECs).
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Registration opens June 6th, 2022. Join the presale list today to save $150.