Opinion Piece: “My Pelvis is out of alignment”

As a practitioner I hear this all the time from incoming patients that they have been told they are out of alignment. In particular in the pelvis, sacrum and spine. From my perspective it seems like there are often 2 distinct camps on this. People that view that alignment, biomechanics, and postures lack much importance at all in terms of pain and those that often may use pelvic, sacral, and spinal imbalances as a reason for someone’s pain. I like to think I land somewhere in the middle, but lately have definitely been leaning to the former camp as I always have, but even more lately. However, I don’t think you can discount these things completely.

 

One thing that comes to my head when I hear people speak about how alignment doesn’t matter for pain is “have these people never felt out of whack before?” I know it seems like half of incoming patients seem to feel this way, friends of mine feel this way, family feel this way, and heck I even feel this way. Often times research and case studies are used to show that alignment and pain are very poorly correlated and I agree with all of it. I have a lot of patients whose bodies are completely all over the place that function great with no pain. So what’s going on with these people that feel out of whack, have been told they are out of alignment , believe they are out of alignment and that’s why they are in pain? Are they crazy?

 

I do palpation of their ASIS and maybe do a pelvic torsional supine to sit test both of which have very low reliability and I find that their left pelvis is slightly anteriorly rotated by half a thumb width. A finding that their last practitioner used to determine they were out of alignment and then now in pain. I used to do this stuff all the time right out of school, but have gone away from it because of a few reasons.

 

Everyone’s pelvis is going to be twisted, upslipped, rotated and whatever else you want to say to some degree. So how can we say that your twists and turns are causing you pain, but not Jonny’s twist and turns? I’m completely on board with this as practitioners from the alignment doesn’t matter camp would agree. The second reason I went away from caring too much about pelvic rotations is that even if I were to find someone slightly anteriorly rotated on the left and maybe they were experiencing some back pain “because of this”, what am I going to work on to potentially help this person? Probably their hip and core function.

 

See, when a pelvis is spotted as “faulty” and we worry about correcting it, the majority of our correctional work is going to come down to doing manual therapy/exercise to restore the lumbopelvic/hip muscular system. Anyways. Sure there are some muscle energy techniques that are often used by practitioners to help restore alignment. I use just a couple every now and again and if that is a tool you like to use and people are getting better then go ahead. However, in the end, lets get that core working better and lets get that hip working better. If you are a practitioner that believes the Sacrum can have 20 different tilts and twists I’m not disagreeing with you or saying you are wrong, but it’s just not what I see as the most important way to approach a patient. If you get results with what you do then that’s great.

 

I think one thing that people from the camp of alignment matters might be holding on to is the fact that I think with some level of skill and observation I do think you can see people’s imbalances. Sometimes when I hear people say you can’t feel anything in the body I wonder if I am a bit crazy when I can clearly see someone in standing leaning one way, twisted, one lumbar erector group bulging out, and one glute way less prominent. This stuff can be pretty darn visible sometimes, but I agree with them…..does it really matter?

 

I believe pelvic alignment “issues” may arise from 2 things: Lack of proximal stability or lack of ability to load a distal extremity. So lets get that extremity working a bit better in terms of mobility/stability through the foot, ankle, knee, and hip and lets increase the ability for the individual to create proximal stability to control motion centrally to distally.

 

So a patient comes in all twisted, leaning etc etc. and they have been told they are all out of alignment and their old practitioner used to put them in alignment and they would get check ups every once and a while to be put back in alignment….what would I do?

 

I explain to them that everyone is twisted so using that for a reason for their pain can’t really be utilized. I explain to them that yes I can see what their previous practitioner was thinking and that they probably do have some imbalances around the pelvis that may be causing them to load certain areas more than others. However, this imbalance is there for a reason, and the only way to maybe stop yourself from falling into that certain pattern of movement is to improve your distal mobility/loading strategies of your limb and improve your proximal stability so you have a solid base to move upon. Patient’s often like hearing this because it gives them the hope that their imbalances can be fixed vs something that is just how they are built and need to be worked on to be better off. It also empowers them to get moving where often times individuals like this have been hesitant to get back into things because they feel so out of whack they wouldn’t want to make things worse.

 

Sometimes when I talk to other practitioners on my views on this we somehow get on to the somewhat related topic of SI joint injuries. Some people think everything somewhat close to that area is an SI issue, some people think SI injuries don’t exist, some people think an SI injury only exists if the pain is directly on the SI…….Physio is fun isn’t it??? I think SI injuries are often over diagnosed it seems and often times it’s a lumbar or hip issue, but I do think they exist. What causes them though? Probably a jammed dysfunctional hip joint causing instability in the pelvis that the weak core can’t control either. So…..it all comes back to the hip and the core in the end. Get those working a bit better and those pelvic alignment issues that have been making you feel out of whack will definitely improve.

 

In the end, I think pelvic alignment matters very little in the grand scheme of things. I think it could mean something, but even if it does it is going to be corrected by working on hip and core imbalances so lets just do that anyway while slowly building the person back up in terms of global strength and return to activity loads.
Looking forward to hearing everyone’s thoughts!

Dave

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6 comments

  1. I definitely view thrust manipulations (or “adjustments”) and mobilizations as neurological resets as opposed to “repositioning” something. Moving a joint in such a fashion would thus decrease tone in surrounding muscles and provide novel stimulus to the PNS and CNS.

    I think that people who believe that they are “out” and need to be “adjusted” get relief from such treatment because: they believe that it will work (placebo), and because it does work, but not for the reason why they think it will (novel neurological input, and not “relocating” a rogue joint). By this logic, practitioners become victims of the same pitfalls.

    Manual therapy works, but best in conjunction with exercise. So go for it and adjust that SIJ, but also retrain the psoas/glute/arch/core/thoracic spine/CV region, or whatever it is you pick up that is driving the dysfunction, because restoring the movement is the key…. well, at least that is my opinion.

  2. Jon Ross · · Reply

    Dave,

    What a great article. I enjoyed how your article was written with perspective, this really shows that you put a lot of consideration and thought into your work. The pelvis can be a difficult area to assess, there seems to be so many schools of thought on this area, which I find can really make it difficult to determine the most appropriate intervention. In my experience I would have to agree that hip and spine function are the best outcome measures when working with this area.

    Keep the good reads coming.

    1. Thanks Jon!! Miss you my man!

  3. Just snooping around and seeing if this place is still active! I love this topic by the way… the language we use with patients is so important. Everyone comes in thinking something is “out”.

    Hope you are well Dave 🙂

    1. I plan on getting back to blogging consistently in the new year! Hope you are well too Nat!

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