The American Journal of Sports

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Effect of Changes in Pelvic Tilt on Range of Motion to Impingement and Radiographic Parameters of
Acetabular Morphologic Characteristics
James R. Ross, Jeffrey J. Nepple, Marc J. Philippon, Bryan T. Kelly, Christopher M. Larson and Asheesh Bedi
Am J Sports Med 2014 42: 2402 originally published online July 24, 2014
DOI: 10.1177/0363546514541229
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Effect of Changes in Pelvic Tilt

on Range of Motion to Impingement
and Radiographic Parameters of
Acetabular Morphologic Characteristics
James R. Ross,*yz MD, Jeffrey J. Nepple, MD, Marc J. Philippon, MD, Bryan T. Kelly,k MD,
Christopher M. Larson,{ MD, and Asheesh Bedi,yk MD
Investigation performed at University of Michigan, Ann Arbor, Michigan, USA
Background: The current understanding of the effect of dynamic changes in pelvic tilt on the functional acetabular orientation
and occurrence of femoroacetabular impingement (FAI) is limited.
Purpose: To determine the effect of changes in pelvic tilt on (1) terminal hip range of motion and (2) measurements of acetabular
version as assessed on 2- and 3-dimensional imaging.
Study Design: Controlled laboratory study.
Methods: Preoperative pelvic computed tomographic scans of 48 patients (50 hips) who underwent arthroscopic surgery for the
treatment of FAI were analyzed. The mean age of the study population was 25.7 years (range, 14-56 years), and 56% were male.
Three-dimensional models of the hips were created, allowing manipulation of the pelvic tilt and simulation of hip range of motion
to osseous contact. Acetabular version was measured and the presence of the crossover sign, prominent ischial spine sign, and
posterior wall sign was recorded on simulated plain radiographs. Measurements of range of motion to bony impingement during
(1) hip flexion, (2) internal rotation in 90 of flexion, and (3) internal rotation in 90 of flexion and 15 adduction were performed, and
the location of bony contact between the proximal femur and acetabular rim was defined. These measurements were calculated
for 10 (posterior), 0 (native), and 110 (anterior) pelvic orientations.
Results: In native tilt, mean cranial acetabular version was 3.3, while central version averaged 16.2. Anterior pelvic tilt (10
change) resulted in significant retroversion, with mean decreases in cranial and central version of 5.9 and 5.8, respectively
(P \ .0001 for both). Additionally, this resulted in a significantly increased proportion of positive crossover, posterior wall, and
prominent ischial spine signs (P \ .001 for all). Anterior pelvic tilt (10 change) resulted in a decrease in internal rotation in 90
of flexion of 5.9 (P \ .0001) and internal rotation in 90 of flexion and 15 adduction of 8.5 (P \ .0001), with a shift in the location
of osseous impingement more anteriorly. Posterior pelvic tilt (10 change) resulted in an increase in internal rotation in 90 of flexion of 5.1 (P \ .0001) and internal rotation in 90 of flexion and 15 adduction of 7.4 (P \ .0001), with a superolateral shift in the
location of osseous impingement.
Conclusion/Clinical Relevance: Dynamic changes in pelvic tilt significantly influence the functional orientation of the acetabulum
and must be considered. Dynamic anterior pelvic tilt is predicted to result in earlier occurrence of FAI in the arc of motion, whereas
dynamic posterior pelvic tilt results in later occurrence of FAI, which may have implications regarding nonsurgical treatments for FAI.
Keywords: femoroacetabular impingement; pelvic tilt; computed tomography; acetabular version; computer modeling

Femoroacetabular impingement (FAI) has recently been

recognized as one of the most common causes of hip pain
and osteoarthritis in young active adults.12 FAI results
from abnormal bony contact between the proximal femur
and acetabulum during range of motion and is generally
the result of developmental osseous pathomorphologic
abnormalities. Pelvic tilt, defined as the angle between

the line connecting the midpoint of the sacral plate to the

femoral heads axis and the vertical axis,20 may play
a role in the occurrence of bony impingement and the
development of symptoms in patients with bony deformities of FAI. Alterations in pelvic tilt may allow patients
to compensate for secondary restrictions in terminal hip
range of motion but are currently poorly understood. Pelvic
tilt is a natural component of the patients posture and may
vary significantly among patients, between genders, during different activities of daily living and sport-specific
activities, and even between standing and supine radiographic studies.10,26

The American Journal of Sports Medicine, Vol. 42, No. 10

DOI: 10.1177/0363546514541229
2014 The Author(s)

2402
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Vol. 42, No. 10, 2014

Effect of Changes in Pelvic Tilt on ROM

Radiographic evaluation is a critical component of the

diagnostic evaluation and treatment decision-making process in patients with prearthritic hip disease. An understanding of the effect of pelvic tilt on the appearance of
the hip on pelvic radiographs is important, especially
when assessing young adults with hip pain.5,7,8,10,26,28,29
Previous studies have demonstrated a relationship
between pelvic tilt and the distance between the superior
border of the symphysis pubis and the position of the sacrococcygeal joint or tip of the coccyx.26,28 In patients with
alterations of pelvic tilt on baseline radiography, current
standards of radiographic evaluation attempt to reposition
the radiograph to an appropriate pelvic tilt.28 However,
this standardization is simplistic and fails to account for
inherent differences in pelvic tilt among patients and the
ability for dynamic muscular control to adjust tilt and
thereby improve the functional range of motion. Failure
to understand the influence of alterations in pelvic tilt
may lead to inaccurate characterization of acetabular
deformities and could result in over- or underresection of
the acetabulum due to an inaccurate assessment of acetabular retroversion. In this regard, our current understanding of the varying relationship between the acetabulum
and the femoral head on the basis of a patients native
pelvic tilt is poor.
The purpose of this study was to determine the effect of
changes in pelvic tilt on terminal hip range of motion to
impingement via computer-based software analysis, as
well as to identify any change in the anatomic location of
the impingement. Second, we aimed to determine the effect
of changes in pelvic tilt on acetabular version parameters
on two-dimensional and three-dimensional (3D) imaging
studies. We believe that changes in pelvic tilt will significantly change the acetabular appearance as well as terminal hip range of motion.

MATERIALS AND METHODS

We retrospectively identified a consecutive series of 50 hips
in 48 patients with symptomatic FAI who underwent preoperative computed tomographic (CT) scans and were treated with arthroscopic hip surgery for FAI between June
and August 2012 at a single institution. FAI was diagnosed
via symptoms and physical examination findings in all
patients and confirmed with corresponding radiographic
pathomorphologic findings on plain films and 3D imaging
(24 hips [48%] with isolated cam, 1 hip [2%] with isolated
pincer, and 25 hips [50%] with both). No other hip conditions were noted (Perthes, slipped capital femoral epiphysis, etc). This study was performed under an institutional

2403

review boardapproved protocol. The average age of

patients in this series was 25.7 years (range, 14-54 years).
Fifty-six percent of the patients (n = 28) were male, and
54% (n = 27) of the surgical procedures involved the right
hip. In addition to a standardized plain radiographic
series, the patients underwent high-resolution CT scans
of the pelvis (and distal femur for assessment of femoral
version) as part of their clinical care and preoperative surgical planning. A modified CT protocol using decreased
radiation exposure of 2.85 mSv was used to maximize
patient safety, as described by Milone et al.23 Positioning
of the patient in the scanner was standardized, with the
legs in native abduction or adduction and the patellae
pointing directly anterior. The patient was positioned
supine with a natural resting pelvic tilt. This resting,
supine pelvic position was considered the patients native
pelvic tilt.
Static radiographic parameters (2-dimensional and 3D)
and dynamic range of motion measurements to impingement were calculated for 3 pelvic positions: 110 (anterior
tilt), 0 (native), and -10 (posterior tilt) (Figure 1). The preoperative CT scans were uploaded into a computed tomographybased computer software program (DYONICS PLAN
Software; Smith & Nephew) to generate patient-specific
3D models of the hip joint. This software program also
allowed manipulation of the pelvic tilt and subsequent generation of virtual plain radiographs. These virtual radiographs, which simulated an anteroposterior (AP) pelvic
radiograph, were analyzed for parameters of acetabular
and pelvic orientation. Two-dimensional radiographic
parameters, including the presence or absence of the crossover,25 prominent ischial spine,16,17 and posterior wall
signs,25 were determined. When a crossover sign was present, the retroversion index was also calculated.26 Additionally, the sacrococcygeal distance,26,28 lateral center-edge
angle (LCEA),33 and acetabular inclination (AI)30 were
measured. The sacrococcygeal distance was defined as
appropriate if 20 to 40 mm in male patients and 20 to
55 mm in female patients, as described according to
Tannast et al.28 Three-dimensional radiographic parameters measured included acetabular version measurements
at the 1:30 (cranial) position and 3:00 (central) position.22
Additionally, the software system measured the femoral
neck version relative to the posterior condylar axis of the
knees as well as the alpha angles of the various clock-face
positions in 15-minute increments circumferentially around
the entire femoral head on radial sequences.
Simulated hip range of motion was performed with the
3D-generated model as previously described.2,3 The pelvis
was fixed in the predefined position, and the femur was
free to move in all directions but constrained to rotate

*Address correspondence to James R. Ross, MD, Broward Orthopedic Specialists, 5301 N Dixie Highway, Suite 203, Fort Lauderdale, FL 33334, USA
(e-mail: orthodocjimross@gmail.com).
y
Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.
z
Broward Orthopedic Specialists, Fort Lauderdale, Florida, USA.

Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado, USA.
k
Hospital for Special Surgery, New York, New York, USA.
{
Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics, Edina, Minnesota, USA.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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2404 Ross et al

The American Journal of Sports Medicine

proximal femur and the acetabular rim was determined

using standardized clockface nomenclature. The clockface was standardized between hips so that 12:00 was
lateral and 3:00 was always anterior in both right and
left hips.4,21,24
To assess interrater reliability of the various CT measurements, 10 patients CT scans were reuploaded and
measurements made by a second observer. A 2-way analysis of variance using SPSS (IBM Corp) was performed to
determine the absolute interobserver reliability (intraclass
correlation coefficient for numerical and kappa for categorical variables). Femoral measurements demonstrated
excellent interobserver reliability (version, 0.98; maximum
alpha angle, 0.88; alpha angle range for 12:00 to 3:00
vector, 0.84-0.95) All CT acetabular measurements also
demonstrated excellent interobserver reliability (1:30 version, 0.99; 3:00 version, 0.99; LCEA, 0.98; AI, 0.97; crossover sign, 1.00; posterior wall sign, 0.80; prominent
ischial spine sign, 0.62). Finally range of motion also demonstrated excellent interobserver reliability (flexion, 0.96;
IRF, 0.96; FADIR, 0.96).

Statistical Analysis
Statistical analysis was performed with Excel software
(Microsoft Corp) to compare the changes in radiographic
parameters and range of motion to impingement between
the different pelvic tilt conditions. A paired Student t test
was used for comparison of continuous variables, while x2
testing was used for categorical variables. P values \ .05
were considered significant.

RESULTS
Native Pelvic Tilt

Figure 1. Patient example demonstrating the virtual radiograph and three-dimensional model of the hip in (A) posterior,
(B) native, and (C) anterior pelvic tilt positions.

about the proscribed rotation axis, against the congruous

acetabular surface. A posteriorly and superiorly directed
force was applied to the femur to maintain reduction of
the femur during simulation.3 The femur was positioned
with the posterior femoral condylar axis parallel to the horizontal axis of the pelvis (native femoral version). During
the simulated range of motion maneuvers, the femur was
moved in a specific motion until contact between the femur
and acetabulum occurred (detected by the resultant translation of the femoral head). This point of collision was
defined as the occurrence of mechanical impingement,
which was recorded in degrees of motion. Three range of
motion simulations were performed: (1) internal rotation
in 90 of hip flexion (IRF), (2) internal rotation in 90 of
hip flexion with 15 of adduction (FADIR), and (3) maximum hip flexion. The location of contact on both the

The mean maximum alpha angle for all hips was 71.2 6
11.1 (range, 50 to 94) and was located on average at
the 1:15 clockface position. The mean alpha angles at
12:00, 1:30, and 3:00 were 50.0, 65.5, and 50.9, respectively. The mean femoral version was 17.1 6 9.0 (range,
4 to 35) among this patient population.
In native pelvic tilt, the mean cranial acetabular version
(1:30) was 3.3 6 8.4 (range, 12 to 24), while central
acetabular version (3:00) was 16.2 6 6.7 (range, 3 to
30). The mean sacrococcygeal distance in the supine position was 33.8 6 14.3 mm (range, 0 to 65 mm). Eighty percent of patients (40/50) were noted to have appropriate
sacrococcygeal distance in native pelvic tilt, as defined by
Tannast et al.28 Forty-eight percent of the patients (24/
50) had positive crossover signs. The mean retroversion
index was 24.3% (range, 11.3% to 38.5%) among the
patients with positive crossover signs. The mean LCEA
was 32.2 6 5.3 (range, 21 to 44), and the mean AI
was 5.0 6 4.1 (range, 5.3 to 14.2). The posterior wall
sign and prominent ischial spine signs were present in
38% and 28% of hips, respectively. Male patients had a significantly lower mean sacrococcygeal distance compared
with female patients (25.4 vs 44.5 mm, P \ .0001). Among

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Vol. 42, No. 10, 2014

Effect of Changes in Pelvic Tilt on ROM

2405

TABLE 1
Two- and 3-Dimensional Measurements in the Native, Anterior, and Posterior Pelvic Tilt Positions
Radiographic Measurement
Cranial acetabular version (1:30), deg
Central acetabular version (3:00), deg
Sacrococcygeal distance, mm
Lateral center-edge angle, deg
Acetabular inclination, deg
Positive crossover sign
Positive posterior wall sign
Positive ischial spine sign
Retroversion indexa

Native,
Mean

Anterior
(110) Tilt, Mean

Posterior
(10) Tilt, Mean

3.3
16.2
33.8
32.2
5.0
48%
38%
28%
24.3%

2.6
10.4
54.9
32.4
3.6
86%
74%
68%
45.1%

\.0001
\.0001
\.0001
.58
\.0001
\.0001
.0003
\.0001
\.0001

12.3
22.2
11.7
33.1
5.8
14%
14%
0%
15.4%

\.0001
\.0001
\.0001
\.0001
\.0001
.0002
.006
\.0001
.007

Interobserver
Reliability
0.995
0.995
0.949
0.981
0.966
1.0
0.800
0.615

This measurement was performed only in those patients in whom crossover signs were present in native pelvic tilt.

patients with sacrococcygeal distances between 20 and 45

mm, female patients had a significantly greater mean acetabular anteversion at 3:00 (19.4 vs 13.3, P = .008). There
was no significant difference in cranial version, although
male patients had a trend toward greater retroversion.

Anterior Pelvic Tilt

A simulated 10 increase in anterior pelvic tilt resulted in
a significant relative retroversion of the acetabulum, with
mean decreases in cranial acetabular version of 5.9 (P \
.0001) and central acetabular version of 5.8 (P \ .0001)
(Table 1). Additionally, the sacrococcygeal distance increased
by an average of 21.1 mm (P \ .0001). This also resulted in
an increased percentage of positive radiographic signs of acetabular retroversion, namely, crossover (48% in native vs
86% in anterior tilt, P \ .0001), posterior wall (38% in native
vs 74% in anterior tilt, P \ .0001), and prominent ischial
spine signs (28% in native vs 68% in anterior tilt, P =
.003). Seventy-three percent of patients (19/26) without crossover signs in their native tilt developed crossover signs with
10 of anterior pelvic tilt. There was also a significant
increase in the mean retroversion index in those patients
with a crossover sign in their native position (24.3% in native
vs 45.1% in anterior tilt, P \ .0001). Although anterior pelvic
tilt led to a small but significant decrease in the mean AI by
1.4 (P \ .0001), there was no significant change in the LCEA
(32.2 vs 32.4) (P = .58).

Posterior Pelvic Tilt

Conversely, a 10 increase in posterior pelvis tilt resulted
in a significant increase in relative anteversion of the acetabulum, with increases in the mean cranial (9.0, P \
.0001) and central (6.0, P \ .0001) acetabular version
(Table 1). The sacrococcygeal distance decreased by an
average of 22.1 mm (P \ .0001). There was also a significant decrease in the percentage of hips with positive crossover (48% in native vs 14% in posterior tilt, P = .0002),
posterior wall (38% in native vs 14% in posterior tilt, P =
.006), or prominent ischial spine (28% in native vs 0% in
posterior tilt, P \ .0001) signs. In addition, there was

a significant decrease in the mean retroversion index in

patients with crossover signs in their native positions
(24.3% in native vs 15.4% in posterior tilt, P = .007).
Only 29% of the patients (7/24) with crossover signs in
their native tilt continued to have crossover signs with
10 of posterior pelvic tilt. Posterior pelvic tilt resulted in
significant but small increases in both the mean AI by
0.8 (P \ .0001) and the mean LCEA by 0.8 (P \ .0001).

Range of Motion to Impingement

A 10 increase in anterior pelvic tilt resulted in a significant
decrease in IRF of 5.9 (P \ .0001), with an anterior shift in
the location of the femoral impingement (2:45 vs 3:15; P \
.001) (Figure 2, Table 2). Similarly, the increase in anterior
pelvic tilt also resulted in an 8.5 decrease in FADIR (P \
.0001), with a significant anterior shift in the femoral (3:00
vs 3:45, P \ .0001) and acetabular (1:30 vs 1:45, P = .0002)
impingement locations, respectively. A 10 increase in posterior pelvic tilt, on the other hand, resulted in a 5.1
increase in IRF (32.0 vs 37.1, P \ .0001) and a 7.4
increase in FADIR (24.0 vs 31.4, P \ .0001). There was
a superolateral shift in the femoral (2:45 vs 2:30, P \
.0001) and an anterior shift in the acetabular (1:00 vs
1:15, P = .03) impingement locations with IRF testing. Similar shifts were noted on the femoral (3:00 vs 2:45, P \
.0001) and acetabular (1:30 vs 1:45, P = .01) rims with
FADIR testing. A 10 increase in anterior or posterior pelvic tilt also resulted in a 10 respective loss or gain in flexion, with no significant change in the contact positions.

DISCUSSION
The role of dynamic and static alterations in pelvic tilt in
FAI is poorly understood. Our present study demonstrates
significant changes in functional acetabular version and
secondary terminal hip range of motion to impingement
with relatively small changes in pelvic tilt. Ten-degree
increases in anterior pelvic tilt reduced the impingementfree range of motion arc of internal rotation by 5 to 9
on average, which may have implications regarding nonsurgical treatment of hip disorders. On the other hand,

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2406 Ross et al

The American Journal of Sports Medicine

Figure 2. Clockface positions of femoral and acetabular impingement in (A) flexion, (B) internal rotation in 90 of flexion (IRF), and
(C) internal rotation in 90 of flexion and 15 adduction (FADIR) maneuvers.
posterior pelvic tilt improved the impingement-free range
of motion arc of internal rotation, which may compensate
for anterior impingement in patients with FAI. Additionally, changes in pelvic tilt resulted in significant changes
in measurements of cranial and central acetabular version,
as well as multiple plain radiographic parameters conventionally used to diagnosis pathologic acetabular retroversion in symptomatic patients with FAI. This is a critical
finding with regard to defining pathomorphologic characteristics on imaging studies in patients with hip disorders,

and clinicians must understand this relationship when

evaluating these patients, as changes in pelvic tilt can
influence the acetabular orientation.
Analysis and identification of acetabular deformity is
critical in the decision-making process when evaluating
patients with hip pain and defining the most appropriate
joint preservation treatment options.11,18,27 Previous studies have demonstrated the effect of alterations in pelvic tilt
on plain radiographic parameters of acetabular morphologic characteristics.7,8,10,26,28,29 Interpretation of plain

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Vol. 42, No. 10, 2014

Effect of Changes in Pelvic Tilt on ROM

2407

TABLE 2
Range of Motion to Impingement and the Corresponding Femoral and Acetabular
Impingement Locations in Native, Anterior, and Posterior Pelvic Tilt Positionsa
Radiographic Measurement

Native, Mean

110 Tilt, Mean

10 Tilt, Mean

IRF, deg
Femoral impingement
Acetabular impingement
FADIR, deg
Femoral impingement
Acetabular impingement
Flexion, deg
Femoral impingement
Acetabular impingement

32.0 6 12.6
2:45
1:00
24.0 6 12.9
3:00
1:30
119.3 6 10.8
5:15
1:30

26.1 6 13.5
3:15
1:15
15.5 6 12.7
3:45
1:45
109.3 6 10.9
5:15
1:30

\.0001
\.0001
.11
\.0001
\.0001
.0002
\.0001
.74
.57

37.1 6 12.4
2:30
1:15
31.4 6 13.8
2:45
1:45
129.3 6 10.8
5:15
1:30

\.0001
\.0001
.034
\.0001
\.0001
.01
\.0001
.29
.99

FADIR, internal rotation in 90 of flexion and 15 adduction; IRF, internal rotation in 90 of flexion.

radiographs in patients with current definitions of appropriate pelvic tilt via the sacrococcygeal distance28 at presentation is fairly straightforward. The interpretation of
radiographs with a sacrococcygeal distance that is outside
of the currently defined normal range, however, is more
difficult. This is most commonly encountered in female
patients with increased anterior pelvic tilt on radiographs.
Repeat radiographs with altered projections or computer
software manipulation of the projection have been proposed.29 However, these strategies ignore any role that
static or dynamic muscular alterations in pelvic tilt may
have on the underlying hip kinematics and ability to compensate for proximal femur or acetabular deformities.
Additionally, changes in pelvic tilt between supine and
standing radiographic studies have also been demonstrated.10 The present study demonstrates significant
alterations in hip kinematics with relatively small alterations in pelvic tilt. Assessment of pelvic tilt may be important to understand the functional restriction of motion in
the setting of FAI.
In addition, rehabilitation for patients with FAI should
include attempts to improve dynamic muscular control of
the pelvis with resultant changes in pelvic tilt, which might
compensate for impingement in some instances. The
changes in contact with changes in pelvic tilt give some justification for nonsurgical treatment of hip-related disorders.
This might be most appropriate for milder deformities and
might explain the improvements seen after nonsurgical
treatment of FAI in milder deformities.9,13 The concept of
increased anterior tilt increasing anterior impingement
and increased posterior tilt decreasing impingement, along
with imaging studies defining the pathomorphologic characteristics present might better direct nonsurgical and postsurgical rehabilitation protocols.
Pelvic tilt has historically been measured when evaluating spinal deformity, but recent literature has also documented the importance of pelvic tilt when evaluating
acetabular deformity. Janssen et al15 demonstrated
a mean standing posterior pelvic tilt of 11.5 6 6.2 among
asymptomatic volunteers. This was confirmed by Lee
et al,19 who also reported a mean posterior standing pelvic
tilt of 11.5 6 5.3 (range, 6 to 24). Babisch et al1 demonstrated variability in pelvic tilt when comparing supine

and standing pelvic radiographic studies among patients

with osteoarthritis of the hip. They demonstrated a mean
increase in posterior pelvic tilt of 6.7 6 3.8 (range, 1
anterior to 14 posterior) from supine to standing. Thus,
standing plain radiographs would allow the most accurate
assessment of native pelvic tilt. One must keep in mind,
however, that appropriate tilt on an AP pelvic study is
evaluated using a surrogate measurement, such as sacrococcygeal distance, and that true measurement of pelvic
tilt is done on a lateral radiographic assessment.
Physicians who perform hip preservation surgery commonly do not obtain true lateral pelvic radiographs to
determine the pelvic tilt and have thus relied on surrogate
measurements from the AP pelvic radiographs. Siebenrock
et al26 noted a correlation between pelvic inclination with
sacrococcygeal distance on AP pelvic radiography. The sacrococcygeal distance was later confirmed to be the most
accurate indicator of pelvic tilt on AP pelvic radiography.28
Our study confirms that changes in pelvic tilt have a corresponding change in the sacrococcygeal distance. We demonstrated that 10 of anterior pelvic tilt increases the
sacrococcygeal distance by an average of 21.1 mm, while
10 of posterior pelvic tilt decreases this distance by an
average of 22.1 mm.
Our study confirms previous studies6,14,26,31 that demonstrated the radiographic appearance of the anterior and posterior acetabular rims is significantly affected by the
amount of pelvic tilt and thus must be considered to avoid
misinterpretation and subsequent inappropriate treatment.
Siebenrock et al26 demonstrated that a 9 increase in pelvic
tilt led to a change in the rate of positive crossover signs
from 50% to 100% of acetabula. In our study population,
86% of patients had crossover signs after 10 of anterior pelvic tilt (compared with 48% in native position). Previous
studies have also shown that conventional radiographic
evaluation of acetabular retroversion using the crossover
sign has limited sensitivity (57%-92%) and specificity
(55%-61%) for identifying true acetabular retroversion via
CT scan.6,31 The authors of both studies argued that pelvic
tilt is responsible for a large component of this discrepancy,6,31 which we also noted in our study.
Our study also demonstrated very small changes in
LCEA and AI with 10 increments of pelvic tilt. The

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2408 Ross et al

The American Journal of Sports Medicine

minimal changes in LCEA and AI that we demonstrated

are important, in that evaluation of acetabular dysplasia
and pincer deformity relies on these measurements. Therefore, a pelvic radiograph that is not positioned properly
with respect to pelvic tilt may still be evaluated with these
radiographic measures to determine acetabular deformity.
Additionally, alterations in pelvic tilt would appear to play
a lesser role in altering lateral acetabular coverage in dysplasia. It is important, however, to measure the LCEA to
the most lateral aspect of the sclerotic sourcil, rather
than the most lateral projection of bone. The most lateral
extent of the sourcil, we have demonstrated, does not
change significantly with tilt, but the most lateral projection of bone can be variable with changes in tilt and can
represent changes in orientation of the anterior or posterior acetabular wall.
Our understanding of the pathomechanics of FAI continues to improve. Yet the role of pelvic tilt in FAI has
largely been ignored. Our study demonstrates a significant
relationship between changes in pelvic tilt and the occurrence of bony impingement. Changes in pelvic tilt reorient
the acetabulum and result in significant changes in acetabular version as measured by 2-dimenssional and 3D
parameters. Pelvic tilt is clearly variable among individuals and is often assessed radiographically with surrogate
measures such as the sacrococcygeal distance. We noted
this variability within our study population, of whom
20% had sacrococcygeal distances outside of currently
accepted standards of the normal range (20-40 mm in
male patients and 20-55 mm in female patients).28 Our
study demonstrates that in a population of patients with
FAI, increases in anterior pelvic tilt result in earlier anterolateral bony impingement with flexion, internal rotation,
or adduction for any given underlying proximal femoral
pathomorphologic deformities. Dynamic changes in pelvic
tilt during functional activities and the ability to alter
a patients pelvic tilt through rehabilitation and dynamic
muscular control are poorly understood. However, the
present study suggests that relatively small increases in
posterior pelvic tilt could decrease the occurrence of the
more traditional anteriorly based FAI. Given the results
of this study, dynamic pelvic tilt and muscular control of
the pelvis may be an area for further clinical investigation
regarding nonoperative and postoperative rehabilitation
protocols. Dynamic posterior pelvic tilt may allow athletes
with large, anteriorly based FAI deformities to lessen the
occurrence of FAI, but the process of increasing pelvic tilt
may lead to compensatory increases in motion in the surrounding joints (sacroiliac, lumbar spine). Ultimately, an
understanding of both the underlying hip pathomorphologic characteristics and effect of changes in pelvic tilt on
impingement might allow the most effective nonsurgical
and postsurgical treatment strategies. Further research
into these aspects of pelvic tilt is needed.
The present study was not without limitations. Range of
motion simulations in the study included only bony structure, ignoring contributions of labrum, cartilage, capsule,
and periarticular soft tissue structures. This is reflected
in the high level of IRF (mean, 32; range, 3-60) present
in this FAI population in the native position. Current

technology does not allow the inclusion of soft tissue structures. However, we believe that the trends demonstrated
with alterations in pelvic tilt would likely be similar to
those seen with soft tissue present, even if the absolute
magnitudes were reduced. Additionally, the pelvic position
was fixed in the simulations during range of motion, and in
this regard, we have used a quasi-dynamic model in 3 fixed
positions of pelvic tilt for each patient. Although changes
in dynamic pelvic tilt do likely occur during range of
motion, these changes are currently poorly understood
and are an appropriate target for future research. Additionally, no true measurement of pelvic tilt was possible
in our population, because the CT scans did not include
the entire sacrum. However, rotational alterations in pelvic tilt could be corrected from the native position. Finally,
femoral orientation is likely to influence range of motion
and was standardized with the posterior femoral condylar
axis parallel to the horizontal axis of the pelvis. Although
this orientation may not represent physiologic orientation,
it was uniform between tilt orientations, and by using
a matched-pair study design, this is minimized. The present study included only patients with underlying FAI,
and the findings may not be applicable to those without
such deformities. However, the vast majority of patients
with symptomatic labral tears have evidence of underlying
FAI deformity.32

CONCLUSION
Dynamic changes in pelvic tilt significantly influence the
functional orientation of the acetabulum and must be considered when diagnosing and treating patients with symptomatic FAI. Dynamic anterior pelvic tilt is predicted to
result in earlier occurrence of anteriorly based FAI in the
arc of motion, whereas dynamic posterior pelvic tilt is predicted to result in later occurrence of anteriorly based FAI.
In the present study, small changes in pelvic tilt were predicted to have a significant effect on terminal hip range of
motion, and this may have significant implications for
future nonsurgical and postsurgical treatment strategies.

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