Lateral Pelvic Tilt is a position that finds one side of the pelvis higher than the other. In the picture below, you’ll notice my left side is higher than the right. This picture was taken about four years ago when I was trying to figure out what was causing all my back pain.
My understanding of lateral pelvic tilt, it’s causes and how it produces back pain, comes from the work of the Postural Restoration Institute. It’s been over 3 years of study, attending intensive weekend seminars in NYC, CT, and Boston, considerable financial investment, and lots of practice on myself and clients.
More experientally, I have felt the effects of lower back pain for most of my adult life, from the age of 20-35. I know first hand the misery, depression, and hopelessness that chronic pain can cause.
Everything PRI has taught matches my experience as a back pain sufferer and I have used this information to relieve many other people of back pain stemming from a prominent underlying issue which can often cause lateral pelvic tilt.
note: It’s important to realize that what I am going to discuss is not the only reason you can end up with a tilt. Anything that causes certain muscles to spasm or be hypertonic can cause a tilt. Herniated disks and hip joint damage can contribute to lateral tilts as well.
Postural Restoration Institute’s Two Body Philosophy
Before I begin, I must explain that PRI teaches that humans are inherently asymmetrical beings and that we have two bodies, a left side and a right side. Here is one example of our internal asymmetry. A right diaphragm that is much bigger, stronger, and more favorably positioned and supported for breathing than the left side. The view is from the top looking down. You see the spine behind the dome-shaped diaphragms.
It’s a bit complicated, but this diaphragmatic asymmetry plays a role in lateral pelvic tilt because of how the diaphragms attach to the spine. Over time, and approximately 20,000 breaths a day, the left diaphragm is overpowered by the right, and the right diaphragm starts to pull our spine and center of gravity over to the right. I won’t get too detailed in this diaphragmatic activity because it’s just one part of an overall bodily system that favors the right side of the body, but it is an important part.
For more discussion about our inherent human asymmetry, you can read this page I put together.
The right illium joins the sacrum to form the right SI joint. The left illium joins the sacrum to form the left SI joint.
The sacrum is the base, or the foundation, of the spine, which then runs upwards and ends at the base of your skull.
The importance and precarious nature of the SI joints can’t be overstated. These two joints connect the upper body and the lower body. That’s a big responsibility when you consider all the activities that the human body engages in. Jumping, sprinting, lifting. That’s a whole lot of force being transferred through these joints, and the pain that can result from a dysfunctional SI joint is often debilitating.
In addition, all three bones move upon each other. What I mean is that the illium can move on the sacrum and the sacrum can move on the illium. We often think of one bone moving on another, like the femur (upper leg) moving on the acetabulum (the acetabulum being the part of the pelvis that the leg “sits” in.) What is less appreciated is that the acetabulum also moves on the femur.
To visualize this, think of when you are doing a single leg Romanian deadlift. Your foot and leg are fixed on the ground and not moving. As you perform the movement, your pelvis is rotating on your leg. This might seem obvious, but rarely is this movement, pelvis on leg, ever considered at great length.
Yet its implications are huge because this duality in movement, two bones moving on each other at the same time, is happening all the time throughout your body. But standard approaches to resolving musculo-skeletal pain rarely even consider it.
So the fact that the femur moves inside the acetabulum is a given. But the fact that the acetabulum, and thus the pelvis itself, moves on the femur, is huge. It means that using the proper muscles, we can reposition our pelvis. Why would we want to reposition the pelvis?
More on that coming up.
What my diagram shows is a left pelvis, also known as a left hemi-pelvis or left innominate, that has forwardly rotated.
The arrow for the left hemi-pelvis is showing a forward, or anterior, rotation. It’s running back to front. The arrow for the spine shows that the sacrum and lower spine “go” with the left hemi-pelvis and turn, or orient, to the right.
Here is a video I made further explaining how this pelvic position can cause right SI joint pain.
Weight Shifting, Walking, and Running
Now, this left hemi-pelvis rotating forward and orienting right is perfectly normal. It’s what happens when you walk as your left leg moves forward through the air and your weight shifts to your right foot.
To try and visualize or feel this, you can try this exercise.
Stand with your feet slightly apart and your weight evenly balanced. You can place on your fingers on the front of your hips to help feel what is happening.
First, shift most of your weight on to your right foot. This shift of your weight into “right stance” should result in the left pelvis coming forward and the right pelvis moving back.
Return to an evenly balanced stance.
Now shift your weight to the left. This shift of weight into “left stance” should move your left pelvis back and your right pelvis forward.
This is the natural movement of the pelvis when you shift your weight in standing position, walking, or running.
However, what happens if you were to shift your weight to the left foot but the left pelvis doesn’t move back? Normal mechanics dictate that the left pelvis should move back when you shift to the left.
Can this happen?
Yes. All the time. And this is the origin of many of our problems. A left pelvis that doesn’t move back. In other words, a left pelvis that is stuck forward.
In this case, the left hemi-pelvis, the sacrum and lower spine stay oriented to the right. The directions never switch. You are stuck in “right stance”, meaning a forwardly rotated left pelvis, even when you are ostensibly standing on with your weight on the left leg. And you stay in this position during all activities: sleeping, swimming, running, squating, deadlifting, bench pressing, or whatever.
If that left pelvis never moves back, you have lost normal human pelvic mechanics. You are living on your right leg with a pelvis and lower spine oriented right. Here is what right stance looks like:
The picture shows me clearly stuck in right stance. Of course, in 2012 I had no idea that this was so. To me, standing with my weight shifted over to my right leg was “normal”. In fact, I didn’t even know my weight was shifted to the right.
I was simply standing.
All I knew was that my left pelvis was higher than my right (your left pelvis doesn’t have to be higher than the right, mine was because of the tilt). But look at the accompanying postural distortions. You can click on the picture for a closer look. They all stem from a left pelvis that was stuck in a forward position, oriented to the right, and a subsequent shift of my center of gravity to the right.
Look at this picture of a pelvis facing you. Notice the left pelvis higher than the right? Although this isn’t my pelvis, that’s what I probably would have looked like underneath.
SI Joint Pain
Back to my drawing. As I mentioned, if the left pelvis tips forward and stays there, the sacrum and the lower spine will have to go with the left pelvis. So now the left pelvis, sacrum, and lower spine are oriented to the right.
Look what happens to the right SI joint. It gets pulled apart. This was the source of my skeletal pain. A right SI joint that was under constant stress because my left pelvis, sacrum and lower spine were stuck orientated to the right. The sacrum and right illium were pulling away from each other.
Keep in mind that the pain can also occur in the left SI joint, but I’m not getting into that in this post. It’s still caused by the forwardly rotated left pelvis but the mechanics are more complicated.
Lateral Pelvic Tilt
What this means is that sometimes (but not always) a lateral pelvic tilt is just a visible and exaggerated manifestation of the underlying issue, a left pelvis that is stuck in a forwardly rotated position. This position and its impact on muscle function causes some muscles to become overactive, and some of these muscles, particularly the hip flexors (psoas, illiacus, and TFL) and quadratus lumburom (QL) can cause the tilt.
In my long battle with lateral pelvic tilt, I was actually able to get rid of the majority of the visible tilt through massage. While the pain lessened to a degree, it didn’t get rid of it completely.
When I discovered PRI, I finally understood why the pain was occurring, and that to get rid of the pain I had to get my left pelvis out of the forwardly rotated position.
So that’s what I did, and I haven’t had any significant SI joint or lower back pain since. Coming from someone who would get knocked out for weeks at a time due to SI joint pain, this is amazing.
Repositioning of the pelvis is at the core of everything PRI does. It’s what I do with clients all the time. Lots of pain–knee, hip, lower back, and shoulder–has cleared up by pulling the left pelvis back into a better position, and restoring tri-planar motion of the pelvis.
An important thing to realize is that I don’t touch anyone, except to test the position of their pelvis and rib cage.
I teach people to use their own breathing, muscles, power, and ultimately their own brain, to pull the left pelvis backwards (in the saggital plane) to establish true movement of the pelvis, instead of living with a restricted and stuck pelvis.
A pelvis that can move in all three planes of motion is better than a pelvis that can’t.
Important note: while this post addresses what is going on at the pelvis, there is another critically important aspect: what goes on at the rib cage. The pelvis and rib cage connect via the internal obliques.
Since the body is an integrated system, what happens at the pelvis effects the ribs and what happens at the ribs effects the pelvis. In PRI, this region of pelvis/oblique/rib cage connection is called the Zone of Apposition. This post addresses this very critical junction: Do You Have A Zone of Appostion?
So how do you know all I’m saying is true?
There is a test for it.
A forwardly rotated pelvis won’t permit the leg to same-side leg to adduct. Because of how the bones are lined up when the left pelvis is forward, the leg hits the pelvis, and can’t go down.
In the first picture, you are seeing a left leg that will not adduct. It won’t go down to the bench. I am not holding it up. Actually, I’m pressing down.
The second picture is after a pelvic repositioning technique. She now has full adduction of the leg because we pulled her left pelvis back, which then provided space for her left leg to adduct.
If everyone is stuck with a forwardly rotated left pelvis, why doesn’t everyone get back pain from it?
I can’t say for certainty, but these are thoughts I have had:
- The human body has many ways of compensating for lack of movement. Some people are master compensators. Since there is a huge neurological and nervous system component to all this, and people’s consciousness and sensory experiences are unique to them, different outcomes are experienced.
- Since this phenomena is pretty universal, there could be a built in neurological degree of acceptability, but once you stray outside this range of acceptability, the body starts to react angrily.
- Modern life may exacerbate these underlying asymmetries and push them to the extremes where the body can no longer compensate comfortably. Sedentary life styles, sitting, and a general lack of movement could all contribute.
What Can You Do About It?
If you live somewhere that there is a PRI trained physical therapist, you could see one of them. Unfortunately, as yet, there aren’t a whole lot of them, although the ranks are growing. There is a directory on the website, however.
NOTE: I get a lot of e-mails about this issue from all around the world, and I do my best to help in any way I can. Everything I know and do comes from Postural Restoration. If you are in the United States, please try to find a PRI provider. They can help you much better than I can through e-mail.
Another possibility is that you’ll respond well to traditional treatment which can treat the pain, though not necessarily the underlying issue, which is the forwardly rotated left pelvis.
Or you can try this technique that is shown in the video below. The therapist is Ron Hruska, the founder of PRI.
A couple notes about the video.
- You don’t have to use a balloon and don’t have to position your right arm above your head. The reason the right arm is above the head is in order to facilitate air flow into the upper right chest area. This area often becomes shut down as a result of compensations stemming from the forwardly stuck left pelvis.
- In this version of the exercise, the patient has both her feet on the wall and is engaging both of her hamstrings. Most likely she has both sides of her pelvis rotated forward and has to bring both sides back. There is no way that you will know if you are forward on both sides, or just the left side, without being tested. If you have a visible tilt, I would probably have you do the single leg version. This means only using the left hamstring. In order to modify the exercise, once you are in the correct position, you simply take your weight off your right foot so that only your left leg is weight bearing.
- If you can feel your left hamstring engage, and you can follow his instructions for breathing (with or without the balloon) you have a good shot at success.
- If you feel your left quad (front of the thigh) you are doing it wrong. Most likely you are pushing your foot into the wall instead of pulling down. You should think of performing a left hamstring curl by “pulling” your left foot down. Have your weight distributed mostly from your mid foot to heal. You don’t want your weight on your forefoot and toes.
- If you are currently in a lot of pain, you might want to hold off on doing this technique. Just getting into the correct position can be painful. Depends on the person.
- Without the supervision of someone well versed in PRI technique, this stuff is hard. There are a number of places that someone can mess up with the result being a repositioning exercise that doesn’t reposition. Also, pelvic repositioning is just the first step of any program. There is more that has to be done. However, I’ve had many clients who feel results and pain relief from just the repositioning techniques.
Here is another video showing the single leg version of the exercise. I use this one with people who are only in the Left AIC pattern, which means only their left pelvis is forward. For these people, which is the majority of us, this technique probably works better than the two legged technique above. As I mentioned, only PRI testing can determine which pattern you are in.
Due to the highly individualized nature of bodily pain, there is no way for me to know exactly what is going on in your particular situation. The more research you can do on your own, the better it will be. In the PRI view, pain not attributed to sickness, arthritis, or injury is often the result of an underlying pattern of muscular activity that has reduced your ability to move efficiently.
Remember, PRI does not treat pain. It addresses the position of your pelvis, ribcage, and neck.
Here is some other content that I have created to help you understand what is going on. People who read and research find resolution to life’s problems much more effectively than those who don’t.
The Left AIC Pattern. This post is a more detailed discussion of the underlying “pelvis rotated forward” pattern that was the basis of my pain. The vast majority of humans are in this pattern. It’s completely normal. When this pattern gets too extreme is when the problems start.
The Right BC Pattern. This post is a more detailed discussion of the compensation that occurs in your upper body in response to what is happening at the pelvis, in particular the ribs around the ribs and spine.
These two patterns, the Left AIC and Right BC, almost always occur in tandem to one degree or another. Both patterns must be addressed.
How to Conceptualize PRI
PRI is really difficult to understand. It’s difficult to understand for trainers, physical therapists, massage therapists, and doctors. The reason is simple: PRI presents a different way to view the function of the human body.
PRI starts with this fact: the human body is asymmetrical. Asymmetry is the starting point.
We have not been taught to view the body as asymmetrical. Symmetry was always assumed, not considered at all, or believed to be desirable.
Until you can buy into the fact that the human body is, and always will be, asymmetrical, it’s hard to understand how PRI works.