They are a core part of our posture and support the spine, as well as being lifted by the legs. Here is where our journey begins.
Hips can become misaligned due to a fall, being overworked with running or climbing stairs, or just twist in response to the myriad of muscles surrounding them. The sacrum is the fulcrum of the hips, much like the Keystone of an arch holds the weight of all the stones that make up the archway. From a Naprapathic standpoint it is the key to realignment and better health of the legs, but this is just the beginning.
What started the cascade of events that led to pelvic rotation?
We think of two types of pelvic rotations: Posterior or Classic Pelvic Rotation, and Anterior Pelvic Rotation. Get out your protractor! In Myofascial Release we can see these relationships when we go to the side of the person and look straight at the trochanter; the side protuberance of the bone of the leg that is on the side of the hip. Using that as the horizontal axis we are going to use our pointers and place one fingertip on the inferior border of Anterior Iliac Spine (ASIS) and the other on the Posterior Iliac Spine (PSIS). Aim your fingers toward each other and you will have an angle in relation to the horizontal axis. Measure the angle in degrees:
Women: Typically should have no more than a 10 – 15 degree angle,
Men: Typically should have around a 5 degree angle.
Anything outside those ranges is abnormal. If the angle has increased, indicating a pelvic tilt that is anterior, we will have lumbar compression and the muscles associated with that stress. If the angle is decreased, indicating a pelvic tilt that is posterior, we will have sacral shear and the muscles pulling the pelvis in a posterior fashion along with loss of a lumbar curve. These landmarks are easily seen from the side view.
Along with supporting the spine, the pelvis has many ligaments and muscles attached in order to help us move our legs, sit down, turn to look to the side, and control most of our body movements. We use the term “syndrome” in most of our diagnostic evaluations because so much is going on here; and we use orthopedic tests to tell us more about that.
Deerfield Motion Reflex is the most important orthopedic test in our diagnostic tool bag. Dr. Deerfield discovered a surprising and accurate relationship between the lower legs and knee flexion and the corresponding tensions of the pelvis and lumbar spine; in fact that tension can also be felt all the way up into the neck.
Here is just an overview of what Deerfield Motion Reflex orthopedic test tells us: Have the patient lie on their stomach with arms relaxed and face looking nose down into the face cradle. Standing at the end of the table, preferably a low chiropractic exam table if possible, look down at the heels and flex the feet slightly. Compare the heels or malleolus, and determine which one is superior. Make a mental note and flex the knees. Which event happens: does the superior malleolus stay inferior when flexed, or does it go long? If the superior malleolus stays inferior with knee flexion we have now witnessed what Deerfield calls a Posterior Pelvic Rotation. The muscles of the thigh have contracted and the leg on the side of posteriority is shorter in contrast to the other leg. More on that in a moment. If, however, the malleolus was superior in the straight leg, but goes long or the leg appears to grow longer with knee flexion, this would indicate the tension is in the lumbar spine.
Posterior Pelvic Rotation.
The findings for a Classical Pelvic Rotation are easy to predict: When the bone of the pelvis, just one side you understand, goes into a posterior tilt it causes the muscles of the hamstring to become tight and shorten, and the anterior muscles such as the rectus femoris to become weak and lengthened. The sacrum gets literally pulled toward the posterior pelvis and the opposite side PSIS ligaments are pulled causing the pain fibers to fire. A patient will say, “I feel pain here,” as they point to one side PSIS. When they are standing, that posterior side will be visible with the Ilium higher on that side. That can be explained in multiple scenarios related to the rotation and the pull on the ligaments from the ilium that attach to the lumbar spine. Either the lumbar vertebraes will be pulled toward the posterior ilium in response as the ligaments shorten, or the lumbar vertebraes will be rotated toward the opposite side as the psoas pulls on the vertebraes on the side of posteriority causing the vertebral rotation. Either way we have to treat the entire syndrome as it appears: treat according to findings.
Anterior Pelvic Tilt.
The other side of the ilium is going to tilt in an anterior rotation because it has to; no choice. It will never not rotate. Remember that everything in the body is connected in one way or another; nature has designed everything in the body to communicate this way. Amazing, I know, but we also need to educate ourselves in order to know what to do in order to resolve the problem. It is a problem: patients will complain about hip pain, low back pain, lower abdominal pulling, weakness of legs, digestive disorders, or neck pain, knee pain, ankle pain, and so on. Where is it all coming from, and what do we treat first? Treat according to findings and START at the Pelvis which is our center of gravity.
Begin with creating a strong foundation for the spine; treat the anterior pelvic rotation first, then move to the posterior side, and after that the lumbar spine will follow: IN THAT ORDER. Why? It works, that’s why. No kidding. If you treat the OUTCOME of pelvic rotation — the posteriority — without first treating the cause — the anteriority — you will just have to repeat your steps. I for one am all in favor of treatments that are concise and easy on the body. Believe me your patient will thank you, and say things like, “that feels good.” Not, “ouch, that hurts!”
Just a word of advice here: you will have to have them come back for treatments at least weekly if you want this problem to resolve. The ligaments that attach everywhere around this huge complex do not receive much oxygen because they are not vascularized; no blood vessels here so no oxygen. They need encouragement and repeated stretching, but it must stay below the plastic range so they don’t get damaged and it takes time for the body to respond to stretching. Anyone who stretches with their workouts will have first hand experience about how difficult it can be to stretch and how long it takes to get results. Please tell me you stretch with your workouts! If not, ask me how.
Naprapathic treatments are just that; stretching routines. We lengthen tissues, apply techniques to massage away tension and trigger points, and use various means to relieve pain and regain alignment. They are very very very gentle and if they do cause pain, we stop! I get a lot of myofascial release into the tissues long before I ever do any stretching, especially in the cervical area. But when I finally do go to the spine and do adjustments, they are going to hold longer and there should not be any pain or discomfort; I want to hear, “Doc, I feel so much better! Look at how far I can turn my head now!” Makes my day.
I conduct a visual inspection of the patient before they lie down on a table. I look at them from the front, the sides and from the back. Topographical cues tell me what is going on and I explain what I am seeing to the patient, sometimes mimicking their posture so they see what I am seeing. Rather comical if you ask me, and a little laughter never hurt, especially when you are worried because you have been in pain and your legs are numb!
I look for horizontal lines that tell me about the spine. Shoulders should be in a straight line and natural curves of the spine should be there also. Too far in one way or another, whether tilting or leaning, or too much curvature tells me a lot about what is pulling on the spine.
Next I have them lie face down. Gravity is now removed from the equation and I can get a better picture about how the body is holding itself together. Some of the distortions that are seen standing will be absent when gravity is no longer a factor.
I know Oakley Smith would not like me now, but I am going to work on the superficial tissue first. Dr. Smith created the science of Naprapathy and he thought we needed to do our initial evaluations without interfering with the superficial structures. I do not agree; these are after all superficial findings and do not in any way give us a true picture of underlying causation. I get it out of the way, and I used to be chastised in clinic because I spent too much time on each patient. Guess what? I did it anyway. I know more than most people coming in to this profession and myofascial release is good for everyone, including infants. The problem is not resolved, but I can certainly see it more clearly now.
I use my orthopedic test to determine where I will begin the treatment: pelvis or lumbar spine. Then I treat above the pelvis at the waistline, below the pelvis with the knees and ankles, and finally the cervical spine.
Following these simple steps in order will insure a lasting result, and patients will heal. As long as they don’t fall on the ice or constantly overwork their muscles everything going on will resolve. Pain goes away, muscles become strong, brain fog disappears and patients can return to their work schedule, their workout, and enjoy their lives.
Follow-up care is very important. I cannot stress enough how getting evaluated on a regular basis can insure the health of the spine and entire body and brain. Once a month is awesome, but that may happen after a few months of regular weekly treatments. Here is my protocol.
Initial visit to evaluate the spine and begin proper care.
Weekly visits until symptoms resolve and the patient is comfortable in their own skin, as it were.
Bi-weekly visits continue until the pelvic rotation is resolved and the tissues “stay” in alignment.
Then the patient graduates to monthly treatments. Missing a month every so often is going to be okay, as long as it does not extend beyond eight weeks.
Point in case: a patient was coming to me weekly, fell on the ice, or sneezed the wrong way and threw her back out; the lumbar spine was insulted by the extreme trauma. After just two treatments the problem was resolved and we were back to weekly treatments. She followed with regular care for about 6 more months and was released.
Another patient was coming in twice a month, but experienced an automobile accident. I encouraged her to come in just hours after the accident and began with a very gentle treatment working on the muscles mostly and very gentle stretching of the neck. Just two weeks and she had no residual symptoms and certainly no whip lash injury; we had avoided the possible build up of lactic acid by relaxing the pain fibers and keeping the blood supply to the area that was traumatized by the impact. See how this works?
In yoga class I can look at someone and give them verbal cues to help lengthen the psoas, prescribe yoga postures that will help lengthen the posterior muscles of the spine and relaxation that will gently stretch ligaments. I’m just awesome like that. You should come to one of my yoga classes!
In massage school they erroneously tell massage therapists not to treat anyone immediately after an auto accident or a serious fall. WRONG! That is the most crucial time to go in there and calm everything down. Avoid any surgeries or broken bones, but everything else needs touch!
Okay, I am off my soap box and encourage you to see spines differently. If you see someone who is hunched over, twisting in a weird way, or complaining about their knee pain they probably have a posterior pelvic rotation and need to see a bodywork professional. Tell them to see a Naprapath, and if one is not near them, seek help from a Myofascial Therapist. They will thank you.
Yours in Health, Naturally