Everyone falls…eventually. A bad fall can knock the pelvis bones out of alignment, and the result can be sciatica and unrelenting back pain.

The pelvis is comprised of three main bones—the left ilium, the right ilium, and the sacrum in between. The triangle-shaped bony sacrum consists of fused vertebrae S1 to S5. It’s an extension of the lumbar spine, and is attached at the L5 vertebra. The coccyx, known informally as the tailbone, is attached to the bottom of the sacrum via the sacrococcygeal joint.

While the sacrum is firmly fixed to the lumbar spine at L5, the ilia—two large curved bones that cradle our pelvic organs—move independently in response to strong muscle tension or due to the force of an impact such as a fall.

ASSESS PELVIS ALIGNMENT

To quickly assess whether the pelvis is aligned, therapists compare the tops of the ilia (iliac crests).

Unfortunately, the higher of the left and right ilia is commonly referred to as an upslip.

In fact, rather than one ilium being high, the other may be low due to an ilium rotation. To complicate matters, the iliac crests may be level when standing, but not when seated. Rarely, one iliac crest may be high when the client is standing, and low when the client is seated—a reversal.

The observation that one ilium is higher than the other is just that—an observation, not a diagnosis. I repeat, one iliac crest may be low relative to the other. The problem may be on the low side. I note the discrepancy in the client record as a left or right elevated iliac crest. More investigation is required to determine the cause.

After noting the relative levels of the iliac crests with the client standing, then seated, the third assessment is to have the client lie supine. Compare the superior/inferior positions of the two ASIS to see if they are level. If they are not, it indicates that one ilium is rotated, either anteriorly or posteriorly. Finally, muscle assessment will reveal which ilium is in rotation.

It’s Complicated…

If the iliac crests are level, the ASIS are level, and the leg lengths are even, many therapists would assume there’s no problem. However, there are at least four rotation combos where the iliac crests and the ASIS are level, but the client definitely has a big problem.

1. Anterior-Posterior. I had a client with level iliac crests and ASIS but it turned out she had a posterior ilium rotation on one side (tight hamstrings), and an anterior rotation on the other (damaged Psoas major). The rotations offset each other, but sure did not eliminate pain in her lumbar region and hips.

2. Double Anterior. When the iliac crests are even, and the ASIS are level, there are two big clues that indicate a double anterior rotation. First, the lumbar curve is significant. See the image of the lordotic back below. Second, the iliac crests are so dug into the lower back that you cannot get the tips of your fingers around the top of the ilium bones. The result is compressed lumbar nerves causing back pain and sciatica. Double anterior rotations are very common. When we sit too much, our Psoas muscles tighten. Obesity and late term pregnancy are other causes of a double anterior pelvic tilt.

3. Double Posterior. When both ilia are rotated posterior, the result is a flat lumbar, hips forward stance.

4. Single Rotation + Back Muscle Tension. Quadratus lumborum (QL) or erector muscle tension cannot cause an ilium to rotate anteriorly or posteriorly. However, back muscle tension can mess up your iliac crest assessment because it can elevate one ilium at the same time as the other ilium is rotated posteriorly, so they appear even. Another possibility is that back muscle tension elevates an anteriorly-rotated (low) iliac crest, making it appear level with the other iliac crest. Whatever the combo, the result is that the iliac crests appear level. I never said assessment was simple!

The ilium rotations in the image below are normally caused by excessive muscle tension in the Psoas, thigh or hamstring muscles.

WHEN AN UPSLIP IS TRULY AN UPSLIP

An X-ray definitively illustrates whether the ilium has moved up (upslip) or down (downslip) in relation to the sacrum. For example, if you land hard on one leg, the compressive impact force can push the ilium up in relation to the sacrum. That leg will be short compared to the other. The sacroiliac joint (SIJ) will be locked on that side.

Treatment of an upslip is possible. It involves loosening the muscles and ligaments, and then applying enough traction (tension) on the femur to disengage the locked sacrum and ilium bones and pull the ilium down into position relative to the sacrum.

Say you bungie jump with the cord attached only to one leg. The tensile force and jerk can yank that ilium down in relation to the sacrum. That leg will be long compared to the other. The SIJ will be locked on that side. I am unaware of any successful efforts in the use of upward compression via the femur to resolve an ilium downslip.

In the left ilium above, a strong frontal impact has rotated the ilium backward such that it is parallel to the sacrum rather than curved in to cradle the organs. Unless an external rotation is caused by a tightly contracted Piriformis and/or Gemellus muscle, this type of external rotation of the ilium is impossible for bodyworkers/physical therapists to correct.

SOMETHING’S GOTTA GIVE

Strained muscle fibers cannot expand or contract. They are locked. Damaged. Out of commission. Therefore when someone deliberately stretches a damaged, contracted muscle, it increases the tensile force on the system. The muscle may not be able to tolerate that extra tension. There are three possible outcomes:

1. more muscle fibers tear;

2. one of the tendons tears at the attachment to the bone; and/or,

3. one of the bones (e.g., ilium) rotates to release the tension. Case 1 in my blog post entitled The Thigh Muscle - Back Pain Connection describes an ilium anterior rotation caused by excess thigh muscle tension.

THE GOOD NEWS

Most ilium rotations are caused by strong muscle tension. A therapist skilled in assessment, muscle tension palpation and manual muscle release techniques can address most ilium anterior and posterior rotations. By the way, Bowen Therapy, aka the Bowen Technique, uses a cross fiber move that is very effective in unlocking muscle fibers and releasing tension. Rotations caused by muscle tension (and some osseous upslips) can be fixed! Remember, it’s not a true upslip unless it’s an osseous (bone on bone) upslip.

THE BAD NEWS

Ultrasound scans are useful for identifying tears. But what if the problem is caused by contracted muscles pulling bones out of alignment? An X-ray will merely show whether the ilium bones are misaligned, not why. Muscle tension will not show up on any type of scan. If the therapist does not do any pre- and post-treatment assessments, including palpation for muscle tension, then treatment is going to be a shot in the dark. If your therapist assigns exercises to restore alignment, take your wallet elsewhere. Any improvement from exercise, especially stretching, will be temporary. It will not resolve the underlying cause of the muscle tension distorting the ilium alignment, and can make the situation worse. Find a manual therapist who knows how to release muscle strains, knots and scar tissue.

MORE INFO & TRAINING OPPORTUNITY

You may be interested in reading my other blog posts on the topics of back pain and pelvis rotations.

I see so many ilium anterior rotations originating from a damaged iliopsoas (I cannot treat them all!) that I now offer a three hour, in-person Iliopsoas Damage workshop to manual therapists. It’s astounding how many people suffer from pain for months or years, when their ilium rotations could be resolved quickly if their therapists only knew how!

Author Bio: Madeline McBride, M.A.Sc., P. Eng., studied civil engineering at Queen’s University and the University of Waterloo. Those mechanics and structural design courses inform her ability to assess in 3D, and problem-solve how muscle tension pulls a client’s skeletal structure out of alignment. Her engineering background, combined with John Garfield’s next generation Applied Myoskeletal Therapy (AMT) training and André Dücker’s Energetic Structural Balance (ESB), produced this Canadian expert in restoring pelvis and spinal alignment. Madeline is able to resolve ilium rotations and related back and hip pain within one to four sessions. Long-standing, complex issues may take longer due to the body’s entrained compensation. Read her blog posts at www.McBridePainClinic.com