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Twisted pelvis ..... fact or fiction ?

Are loads of us wandering around with wonky hips ? Does it cause problems ?

" My last ( Insert healthcare professional here ) told me that my pelvis is twisted and they put it back in last time I saw them. I think my one leg feels longer than the other so could you just pop it back in for me please ? " ..... must be something we hear weekly, at least. As a professional clinician I seriously doubt this is actually what is happening - with very good anatomical and clinical reasons - so please let me explain why I believe this to be true and what the likely explaination maybe for why these therapies work and why you don't need to worry about body parts slipping ' out of place ' .

The two most common misconceptions are that

  1. The pelvis is out of alignment or twisted.

  2. One leg is longer than the other.

So let's look at both of them in a bit more detail.

Can the pelvis really twist out of position ?

The theory of pelvic or sacro-ilaic joint ( SIJ ) mis-alignment or a ' twisted pelvis ' really stems from looking at the anatomy of the pelvic region and the theory of the relationship between the separate bones of the pelvic ring being ' out of place ' and causing pain, usually in the back and leg. .

It was explained to me as think of the pelvis as a bit like Rubik cube..... the two side pelvic bones and the central sacrum are all able to move independently of each other much in the same way that the separate rows of the Rubik cube are able to spin independently of each other. The theory is that sometimes, through injury or dysfunction, one or other of these bones become slightly twisted in relation to their neighbouring bone ( much as the rubik cube above shows ) and pain is caused. Manual therapy attempts to 'restore' the alignment bringing everything back into it's original anatomy and hey presto, the pain goes !

My issue with this is that ( aside from not having much credible research or evidence to back it up ) the anatomy just doesn't back up this theory. The hip and sacral joints are built for stability. They carry the full weight of the body and provide a firm foundation for muscle attachment as well as protecting the internal pelvic organs. Their anatomy simply doesn't allow much movement, indeed when I trained a zillion years ago we were taught that the joints had no movement beyond child bearing age - we know know there is about 4° of movement in the SIJ's. The strong web of tough ligaments, fascia and joint capsules are some of the strongest in the body to the point that in trauma the joints don't dislocate - the bone fails and breaks. Little old ladies don't fall over and dislocate their hips - the bone breaks first.

Many manual therapists conduct all manner of tests observing bony landmarks on the back and pelvis, observing any asymmetries and in some cases taking specific measurements yet the majority of the research demonstrates that much of this is often inaccurate often both because of inconsistencies in the therapists technique and the fact that our anatomy varies wildly from person to person ( yes, really ! )

DISCLAIMER .......The exception

That's not to say that SIJ problems DON'T ever occur - of course they do, It's thought that around 15% of chronic back pain starts from the SIJ and it can be a long, often frustrating, road to rehab. ( sorry ! ) But it's nowhere near as common as some manual therapists would have you believe. The biggest group by far that truely can have problems with pelvic instability and a twisted pelvis is pregnant or post - natal women largely because of the huge anatomical, hormonal and mechanical changes required of these pelvic joints and muscles at this particular time of life. Indeed the only time I can say that I genuinely put a pelvic joint ' back in ' was in a pregnant lady with Sympysis Pubis Dysfunction ( SPD ) ... the look of shock on her, and my, face was comical, it made the most enormous ' clunking sound ! But this is not really a ' misalignment ' in the accepted sense of this article anymore than someone with an inflammatory condition such as Ankylosing Spondylitis or Rheumatoid Arthritis is. These conditions require a different approach and can be treated successfully with compression bracing, stabilisation exercises, medication or injection therapy if required.

Leg length differences

Leg length differencies are really, really common with up to 90% of the general population having a difference - diagnostic scanning suggests the average difference is 5.2mm .... so, I guess the question is, if it's so common that pretty much everyone has one, is it even abnormal ?? The question lies in why the leg length is different and there are two very distinct and separate reasons for a leg length difference :

1. Anatomical

There is some change in the length or architecture of the bones or joints between the hip to the ankle which actually physically alters the length of the leg. Examples could be a poorly healed fracure, Perthes disease of the hip, destruction of a joint through extensive arthritis etc. It's objective and fixed ... i.e it does not change irrespective of position. We don't see these often in clinic but when we do they are clear, obvious and immutable - they do not change with manual therapy and they never will ! Fixing this permenantly goes way beyone the scope of any manual therapist.

2. Functional or Apparant - the clue is in the title... these are far more subtle, changeable and can occur anywhere from the spine, pelvis all the way down to the foot and are said to be the result of subtle changes from the arches of your feet to shortening of soft tissue structures in the lower limb. Can we as therapists measure this type ?? Probably not accurately - all of the literature points to therapists ( from all disciplines ) being inaccurate in measuring leg length discrepencies. Does it make a difference to you as a patient ? Probably not. My own view is that this type of assymmetry is so common that it is almost a norm and probably has negligible effect on the state of your back providing you are not an Olympic athlete looking to gain extra milliseconds on the track. We know that anatomy varies in other areas of our body with little or no effect e.g coronary arteries - why should our legs be any different ? Indeed the water is so muddy it's probably just mud !

So what does manual therapy actually do then ?

Much of manual therapy comes from the power of touch, correcting and reinforcing correct movement patterns and ensuring you have the appropriate tools to manage your condition during your normal daily life. It doesn't mean your therapist isn't highly skilled or that treatment won't or hasn't worked ..... it has, just not using the mechanisms that have been popularised. Don't worry your hips, pelvis and back are strong, No 8- stone therapist is going to pop them ' back in ' ..... largely because they were never ' out ' in the first place. Manual therapy can work and provide some real benefit and pain relief .... just not in the way you've been told.

So in conclusion......

  • It's very, very unlikely your hips or pelvis are out of place / alignment. In fact the amount of rotation available at the pelvis is so tiny that we can't reliably pick this up .... I mean we're good but not that good.

  • You probably do have a functional leg length difference along with 90% of the population but again any differences are tiny and carry little significance so please don't worry about them. Anatomical leg length differences are a different matter entirely usually as a result of bony anomalies, congenital diseases or neurological deficits and can be far more impactful on overall health.

  • Manual therapy can work and provide real solutions to your pain and dysfunction but probably not using mechanisms like putting joints back in or realigning anything.

Your body is strong and stable and with a bit of care and TLC will look after you for the rest of your life. If you would like to book a session to see how we can help with the TLC bit then please either book online using the link at the top of this page or feel free to give us a ring to discuss your needs.


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