Pelvis ilium rotation is a frequently overlooked cause of lower back pain and sciatica.

There are three mechanisms whereby rotations can cause back pain.

Single or double ilium rotations in an anterior direction cause the iliac crest(s) to dig into the lower back. The iliac crest(s) compress the sciatic nerve(s) exiting the lumbar vertebrae. Lordosis (swayback) is a visual indicator of a double anterior pelvis rotation.

2. If one iliac crest is elevated with respect to the other, the transverse processes of the L3-L5 lumbar vertebrae tilt high-low like a see-saw. Those boney extensions may compress sciatic nerves exiting the spinal column.

3. Vertebrae tilt can also exert asymmetrical pressure on the disc between vertebrae. That is, the disc is compressed on one side, causing the disc to bulge out. Here’s an analogy. Imagine a cookie made of thick frosting (the disc) between two wafers (the vertebrae). When you pinch the wafers together, frosting oozes out.

Whether it’s an iliac crest, a transverse process, or a bulging disc that presses on a lumbar nerve, the result is sciatic pain that may radiate into the left and/or right buttock and refer down the leg.

Image source: TheSpineHealthInstitute.com

HYPERTONIC MUSCLES THAT ROTATE THE PELVIS ANTERIOR

Excess tension in one or more of these thigh muscles attached to the anterior pelvis may be involved in pulling the pelvis bone anterior (forward):

A. Muscles attached to the Anterior Superior or Inferior Iliac Spine (ASIS or AIIS):

Sartorius

Tensor Fascia Lata (TFL)

Rectus Femoris (middle quadricep)

B. Muscles attached to the pubis:

Pectineus

Adductor brevis

Adductor longus

Gracilis

C: Muscle attached to the anterior face of the ilium bone:

Iliopsoas

FAQs

Before I describe three cases of left-sided anterior pelvic rotation that caused back pain, let me respond to two frequently asked questions.

How do you determine which muscles are too tight?

The short answer is palpation. A too tight muscle feels hard. A long thin muscle like the Sartorius or Gracilis feels like a stick – unyielding. A very hypertonic muscle has lost its ability to expand and contract. It cannot stretch.

Muscle fibers in a healthy muscle lengthen and contract in parallel, like pistons in an engine.

When hypertonic, a particular muscle’s fibers may be too tight overall, or specifically in the area of a “knot.” A muscle knot is formed when muscle fibers have torn and healed imperfectly, like scar tissue. Those muscle fibers are no longer linear. These tangled fibers remain “locked up,” unable to lengthen or contract. This creates tension in the muscle and fascia system.

Here’s another analogy. Imagine you twist the fabric in the middle of a table cloth and tie a string around that small bunch of fabric. No matter what you do, you cannot get that cloth to lay flat again. The “knot” distorts the entire cloth. Now imagine if the edges of the table cloth had been clipped to the table. Twisting fabric into a knot pulls the clipped fabric even tighter, thus creating tension in the entire cloth. To release that tension, the fabric would either have to separate from the clip or tear.

Quadricep muscles can be very powerful, especially in athletes. The tension or “pull” that damaged quads exert on the knee or pelvis bones can also be very strong. Eventually something has to give. Either the muscle tears, or the bone moves.

How do you relax a muscle that is too tight?

Forcefully stretching a tight muscle that has a compromised ability to stretch usually results in muscle fiber tearing. I use a combination of Bowen Therapy’s cross fiber moves and Applied Myoskeletal therapy manual techniques to get the muscle to relax and knots to unravel.

CASES

Case 1: Athletic female in late 40s

Client 1 presented with non-stop extreme pain in the lower back and left buttock/hip area due to a pinched Sciatic nerve. She said she’d endured pain at a level of 9 out of 10 for six weeks. Previous treatment included massage therapy, chiropractic, physiotherapy, acupuncture, and painkillers. She’d had an X-ray which revealed osteoarthritis in her lumbar spine. She had subsequently requested that her physician book an MRI.

First Session Assessment & Treatment: The iliac crests were even as assessed when Client 1 stood and again when seated. However, when I assessed her ASIS supine, they were not aligned. The left ASIS was inferior, indicating an anteriorly-rotated left ilium causing compression of the Sciatic nerve exiting the lumbar spine vertebra.

Her right erector spinae muscle (Longissimus thoracis) had a huge knot. In her left leg I discovered and released very tight muscles including the Sartorius, Gracilis, TFL and Rectus femoris (quad). She also had a big calf muscle knot in the medial left Gastroc.

Second session: Twelve days later she reported the pain had dropped to 4. I proceeded to release the remaining tension in muscles attaching to the left ASIS, as well as in both inguinal ligaments.

She then revealed she’d injured her left knee three months earlier at a boot camp. For about six weeks she’d had pain in her left calf and the left knee hurt, but then the knee suddenly stopped hurting. However, that’s when the lower back pain started.

I told her that the left Sartorius and quad tension must have been so strong at the ASIS attachment that it pulled the left ilium forward, thus relieving that tension in the thigh muscles and on the knee. However the left ilium anterior rotation meant the left iliac crest began digging into her left lumbar lateral to L4-L5, compressing the sciatic nerve.

Outcome: She did not return for a third session. Her lower back pain resolved in two sessions. I hope she cancelled the MRI.

***

Case 2: Formerly athletic female in her mid 40s

Client 2 presented with a constellation of long term issues and pain in many areas of her body, including her back. She’d ruptured her L5-S1 disc a decade earlier.

First Session Assessment & Treatment: With a new client I always start by aligning the pelvis.

Her right iliac crest was elevated when standing and seated, creating functional scoliosis. Her left leg was short. Note: When the entire pelvis is anteriorly rotated, the iliac crests and leg lengths are even, barring other tight muscle issues.

With the client on the table prone, I palpated both iliac crests and discerned by touch that the left iliac crest was fractionally anteriorly rotated. That is, it was digging into her lower back. I proceeded to investigate the usual muscle culprits, and discovered that, at the attachments to her left knee, her Sartorius and IT band were hard and unyielding. The left Rectus femoris had a big knot inferior to the ASIS. Her right Glute minimus was extremely tight. After releasing the tension in these muscles, at the end of the session her leg lengths and iliac crests were even.

Second session: Eight days later her iliac crests remained even when seated, but when standing the right was slightly elevated. During the week she’d experienced an achy discomfort in her back. I told her that her back muscles were reacting to her straightened spine.

I released back muscles, including tight erector spinae, as well as the right Gracilis, a deep knot in her left Vastus lateralus inferior to the ASIS and a severely contracted right SCM.

Third Session: Her iliac crests were level standing and seated. I discovered and released a deep muscle knot in her left Glute minimus and another huge knot in a left quad.

Outcome: With her ASIS even and pelvis aligned, and scoliosis resolved, I proceeded to address neck and jaw issues. In future sessions I’ll check to ensure the pelvic alignment holds.

In this case, again the primary trigger for the left ilium anterior rotation was strong tension in damaged left quad muscles. Resolving the rotation was complicated by right-side tight muscles.

***

Case 3: Athletic female in mid 40s

Client 3 said she’d been struggling with back pain for about eight months. An X-ray showed functional scoliosis. Other therapies she’d tried were ineffective.

First Session Assessment & Treatment: Her right Iliac crest was elevated. Her inferior left ASIS indicated a left-side anterior ilium rotation. I released a very tight right erector adjacent to her spine which was contributing to the elevated right iliac crest. Releasing a tight left Sartorius and a knot in the left Rectus femoris halfway down the length of the muscle resolved the left pelvic rotation. At the end of the session her ASIS and iliac crests were aligned.

Second Session: Thirteen days later her right iliac crest was higher than the left again. I discovered that her left Rectus femoris and Sartorius had returned to being severely tight at their superior attachments, and the quads were all tight again at the attachments to the left knee. I released right iliacus muscle fibers as well, where the groin was swollen and very sore due to blocked lymph.

Third Session: Nine days later she reported that after the second session she “felt crazy pulling in the left pelvis for two days,” and then her back was sore again. The right iliac crest was elevated standing and seated, and the left Sartorius was super tight again. Clearly I had missed something. Muscles other than the typical culprits were recreating the anterior rotation. I asked myself what other muscle(s) pull the pelvis forward.

I palpated the left iliopsoas muscle and discovered what felt like scar tissue deep in the muscle superior to the inguinal ligament. Client 3 then revealed that she’d had several sessions of deep tissue massage over a period of a few years. The massage therapist “dug in hard” to release her psoas. The deep tissue manipulation must have torn those muscle fibers. That explained the blocked lymph drainage in the right groin and the compromised function of the iliopsoas on the left.

I proceeded to spend considerable time in that session to “melt” the scar tissue in the left iliopsoas. At the end of the session her ASIS and iliac crests were aligned. She had a left ilium anterior rotation caused by her damaged iliopsoas.

Outcome: More sessions are needed to release the deep damaged iliopsoas muscle fibers on the left and right.

This case is an example of how, although the right ilium was elevated compared to the left, in actuality the left iliac crest was low due to the anterior rotation. For an explanation of why the elevated side is not necessarily the problem side, read my blog post entitled Pelvic Rotations and Upslips.

AN OBSERVATION

I have treated more than two dozen women from their 20s to 70s with one-sided (left or right) ilium anterior rotation, and several others with posterior rotations. Most had borne at least one child. Significant tension in a male client’s thigh, however, caused the entire pelvis (both ilia) to rotate anteriorly. Female ilia appear to be more flexible and mobile than those of men. Pressure during an advancing pregnancy stretches the ligaments in the pelvis, enabling it to widen to accommodate the growing fetus. Post pregnancy, the ligaments remain looser, so it is easier for strong muscle tension to cause double or single anterior or posterior ilium rotations.

KEY TAKE-AWAYS

1. Treating the area of pain is not necessarily going to solve the problem. Bowen Therapy is a whole body, hands-on approach. Several muscles may be contributing to a complex problem. Assessment and palpation are necessary to find them!

2. Damaged muscle fibers won’t stretch. Exercises, balls, and rollers won’t release knots and scar tissue.

3. Aggressive deep tissue massage can tear muscle fibers, compromising the muscle function and blocking lymph flow.

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Madeline McBride’s engineering training in mechanics and structural design informs her ability to identify muscles in tension and torsion that pull the body out of alignment. She has become a North American expert in resolving pelvic rotations. Using the muscle relaxation techniques of Applied Myoskeletal Therapy, Energetic Structural Balance and Bowen Therapy (no equipment! no stretching!), she is usually able to resolve skeletal alignment issues and related pain within four sessions. Long-standing, complex issues may take longer due to the body’s entrained compensation. She teaches pelvis and jaw assessment and restoration of alignment to physical therapists. Find her workshops and subscribe to her blog posts at www.McBridePainClinic.com

The Thigh Muscle-Back Pain Connection