I wonder how many times you have had a client say, ‘I’ve been told that I have one leg longer than the other’? I know I certainly have, but there are only a few people who have a leg length discrepancy, usually confirmed by an X-Ray. This discrepancy may be a result of physical dysfunction or from a structural issue at birth, such as scoliosis. However, a leg length discrepancy is more often due to a physical pelvic and lumbar imbalance affecting the positioning of the femur in the acetabulum. It can also cause, and be caused by, issues in the knees, feet and ankles.
There are two general physical reasons that a pelvic imbalance occurs. One is direct trauma or injury such as a fracture or tissue injury to the pelvis, leg or ankle. The other is caused by tissue dysfunction from overuse, misuse disuse or underuse. This is where the client has continually loaded a specific area of their body for too long and created an imbalance, or they have not used that area of their body, and it has now become weak and dysfunctional both of which can be viewed as an adaptive pattern. Overuse, misuse, disuse and underuse are the most common issues that manual therapy practitioners see where the client complains of back and gluteal pain, piriformis syndrome or sciatic like symptoms.
The pelvis is a basin-shaped structure at the lower end of the spine and is attached to the sacrum and the coccyx. The pelvis protects the internal abdominal contents, including the bladder, rectum and, in women, the uterus. The pelvis is made up of three hip bones, which are joined posteriorly by sacroiliac joints to the sacrum and anteriorly by the cartilaginous pubic symphysis. Attached to the pelvis are muscles of the abdominal wall, the buttocks, the lower back, and the thighs. Each side of the pelvis called the right and left innominate bone, is made up of three fused bones: the ilium, the ischium, and the pubis. Together they form the acetabulum, which is a cup-like depression ‘ball and socket’ joint for the femur.
The easiest way to approach an assessment for the pelvis is to first assess the client in standing, without shoes and on a level floor. The landmarks we will assess are-
- Anterior superior iliac spine (ASIS)
- Posterior superior iliac spine (PSIS)
Kneel in front of the client and palpate to locate the ASIS using your thumbs. Move to the back of the client and palpate to locate the PSIS.
- The heights on the anterior superior iliac spines in the anterior view; these should be level on the horizontal plane.
- The heights on the posterior superior iliac spines in the posterior view, these should be level on the horizontal plane.
Write down what you see on a body chart or a piece of paper. From the anterior view, do you see their right ASIS lower or higher than their left ASIS? Take care to make sure that you note their right and left side and not yours. From the posterior view, do you see their right PSIS lower or higher than their left PSIS? If you see the right ASIS lower than the left ASIS, then you should see the right PSIS higher than the left PSIS. If you see the left ASIS lower than the right ASIS, then you should see the left PSIS higher than the right PSIS. If you do see either of these two scenarios, then you have what’s called a pelvic rotation or pelvic obliquity.
If you imagine the sides of the pelvis as two wheels when you walk, your leg goes forward, but the pelvis on that side must roll backwards. When your leg is backwards, your pelvis on that side must roll forwards. So, the two wheels on either side of your body move in opposite rotations to each other in a forward and backward motion as you walk or run. So ideally, when you assess the body in standing, the two ASIS and the two PSIS should be level on the horizontal plane. However, we don’t just run and walk all day. We sit for extended periods of time; we sleep curled up. We do lots of sports and activities where we use certain parts of our bodies more than others, and this can create an imbalance to the movement of the pelvis positioning it in a pelvic obliquity where one side has a propensity to be more anterior. The opposite side is more posterior position.
It’s not uncommon to assess the pelvis in standing and find a reasonable discrepancy in the heights of the PSIS and ASIS, but the client doesn’t have any pain. No one is perfectly balanced, and we all have a body that is functional to our daily needs. However, sometimes the smallest discrepancy can cause excruciating pain, and this is something that we as manual therapists can help with.
When one side of the pelvis is stuck in a more anterior rotation than its counterpart, the positioning of the femur changes, which is what creates what looks like a leg length discrepancy, the femur is not in the middle of the side of the pelvis, it sits more anterior. When the pelvis is anteriorly rotated, the femur drops down. When the pelvis is more posteriorly rotated, the femur gets pulled upwards. Effectively, an anterior pelvis presents what looks like a longer leg, and a posterior pelvis presents what looks like a shorter leg. Of course, the legs haven’t changed lengths, but it’s their positioning in the pelvis which makes them look like one is shorter than the other. Additionally, the pelvis is also dependant on the position of the lumbar and vice versa. Often, when a client complains of back pain, they will also have a leg length discrepancy.
The pelvis can also tilt upwards or downwards on either side like a seesaw which can also present in a leg length discrepancy. If one side of the pelvis is pulled up higher, the leg also comes with the pelvis effectively shortening the leg on that side. Conversely, the other side of the pelvis must drop down effectively lengthening the leg on that side. Some therapists call this an up slip and a down slip and others call it a pelvic tilt. Often, you see both a pelvic obliquity with an up slip and down slip as the pelvis can move in multiple directions at the same time.
When you see an imbalance in the pelvis, you often see other imbalances associated with it such as-.
- One hip higher than the other
- A lateral shift in the pelvis where they don’t look like they stand evenly on their legs
- They stand with one knee slightly bent and the other hyperextended.
- One foot turns out more than the other.
- Their body leans forward with a lumbar lordosis.
- They may wear an orthotic and have or have had foot and ankle problems.
- They also have one shoulder higher than the other.
- And obviously pain in the sacroiliac area, gluteal area and low back.
There are many techniques that we can do to balance the pelvis, but here is one simple technique that you can use to remove some of the strain.
Cross hand release techniques for the pelvis and lumbar.
Assess the pelvis to establish the ASIS which is lower to the floor, this is the functionally longer leg, and this is the side we will treat as this side of the pelvis in an anterior rotation where treating this side will help us remove the tissue strain allowing the pelvis to move back into a more neutral position.
With the client lying supine, we will do a cross-hand release technique for the anterior hip to remove tissue dysfunction. Place one hand on the client’s upper thigh with your fingers pointing to their feet, skin on skin. Place your other hand, crossed over or under your other hand, on the client’s lower abdomen, medial to their ASIS with your fingers pointing to their opposite shoulder, again skin on skin.
- With hands crossed, gently contact the tissue.
- allow your hands to sink slowly and gently down into the tissues until you meet resistance (barrier or end feel) – this is the first dimension
- wait at this barrier until you feel a yielding or melting sensation, allowing you to lean a little more to the floor. There may be numerous sensations of tissue melting which feel soft and somewhat bouncy
- continue with your downward pressure following each tissue change until you feel that your hands have met a firmer resistance, this will be the deeper layers of fascia
- maintaining your pressure to the floor, slowly separate your hands until you meet resistance – this is the second dimension. Wait at these 2 barriers for the tissue to yield under and between your hands
- as the fascia yields to your touch, you will feel motion under your hands – this is the third dimension
- go with the motion to the next barrier which may feel like a twist, shear or unwinding
- continue to hold these 3 components for at least 5 minutes or longer
- always be subtle and sensitive with your hands and never force the barrier
- allow the tissue to reorganise without force.
Disengage from the tissues by gently reducing pressure and removing your hands.
Now ask the client to lie on their side with the side your just treated uppermost. Place a small pillow under their waist to keep their lumbar spine neutral. Straighten their upper leg and position it in line with their spine. Place one hand, skin on skin on their lower lateral ribcage with your fingers pointing to their shoulder. Place your other hand, skin on skin on their iliac crest either over or under your ether hand and perform the cross-hand release again.
What these techniques do is help remove the strain pattern from one of the sides of the pelvis to create balance. We do these techniques on the anterior rotated innominate as it’s easier to push the anterior innominate backwards. The right side of the pelvis is usually the anterior rotated side due to most things being right-side dominant, however, always check to see what ASIS looks lower than its counterpart and do these two techniques on the lower ASIS side.
Cross hand release techniques form the main component of a myofascial release treatment session. The pressure used to apply the technique varies from person to person as everyone’s tissue tension is different. The skill of the technique is not how much pressure is used, but how much resistance is felt in the patient’s body. The practitioner applies the technique to tissue tension and waits for the myofascial tissue and ground substance (gel fascia) to reorganise which can be felt as a yielding or ‘release’ of tissue tension under their hands.
These two techniques are part of a series of techniques used to balance the pelvis. While they are usually very effective sometimes, tissue tension is more complex than the anterior hip or lateral lumbar, and further technique application is necessary. There are also a few different assessments that can be done to maximise on treatment efficacy. Always re-assess their ASIS and PSIS after applying these techniques to see what changes you have made.
Leg length discrepancies are not always about the pelvis. They can be caused by the lumbar, knees, feet and ankles, and indeed, there can be dysfunction with all of or some of these structures when viewing the body from a biotensegrity point of view.
Pelvic asymmetry assessment and pelvic balancing MFR techniques are taught on our new online course Pelvic Balance Pro. This course is a key component of the Certificate in Integrated Myofascial Therapy (CiMFT). The CiMFT is a qualification and provides an excellent comprehensive practical and theoretical knowledge of MFR and leads to the title of Myofascial Release Therapists.
Pelvic Balance Pro can be purchased separately as an individual course (pre-requisite conditions apply).