A twisted pelvis, also known as pelvic torsion, is an extremely common distortion pattern but often remains undiagnosed. The result can be significant chronic pain that seems to have no clear explanation.
Without understanding this phenomenon, it's impossible to see the cascading muscular effects that can result.
Back pain, hip pain, knee pain, shoulder pain, neck pain, and more can potentially be traced back to this primary root cause.
To help us understand what we mean by a twisted pelvis or pelvic torsion it’s helpful to have a clear sense of the bony anatomy of the pelvis.
The pelvis is composed three bones:
To understand what we mean by torsion, let’s look to Miriam-Webster:
1: the twisting or wrenching of a body by the exertion of forces tending to turn one end or part about a longitudinal axis while the other is held fast or turned in the opposite direction also : the state of being twisted
2: the twisting of a bodily organ or part on its own axis
3: the reactive torque that an elastic solid exerts by reason of being under torsion
Pelvic Torsion, then, is a condition in which one pelvic bone is twisting in one direction and the other pelvic bone is either 1) fixed in place or 2) is twisting in the opposite direction.
In the example below, the arrows indicate the rotational direction of this twisting motion.
Here, the torsion is an anterior (or forward) rotation of the right pelvic bone, with the left pelvic bone in an oppositional rotation.
Right anterior, left posterior pelvic rotation, front view.
Right anterior, left posterior pelvic rotation, quarter angle view.
NOTE - The images here don't show the actual position of the pelvic bones in a torsion pattern because the imaging I’m using doesn’t have this flexibility. Therefore the bones, here, are in a neutral position. The red arrows are meant to imply the torsion pattern.
The immediate impact of pelvic torsion is to change the height of the hip joints in relation to one another.
In other words, the hip joints are no longer level. One hip joint is positioned higher and the other is positioned lower.
The result is a functional leg-length difference.
When a pelvis is balanced, the hip joints are level and the legs are more or less equal in length. (Except in cases of trauma, surgery or congenital defect.)
When there’s a torsion, one hip joint is pulled up higher than the other causing a functional leg-length difference.
In this example, a right anterior (forward) rotation has the effect of pulling the right hip joint upwards.
If you look closely at the right hip joint perhaps you can see how this happens.
Can you visualize how a right rotation around the rotational axis would elevate the right hip joint? And how that would result in the entire right leg being pulled upward?
The overall result is that the entire right leg becomes functionally short.
This does not mean that one leg is actually shorter than the other.
This is an example of a functional leg-length difference, as distinct from a congenital leg-length difference.
A congenital leg-length difference is one we're born with and in which the leg bones themselves are a different length.
A congenital leg-length difference is routinely and appropriately addressed with a shoe lift of some kind.
A shoe lift, however, should not be used as a solution for addressing a functional leg-length difference as it would simply lock the imbalance in place.
As we will see, a functional leg-length difference can be corrected — i.e. brought back into balance — while a congenital leg-length difference can only be compensated for.
When the legs are a different length, our balance is disrupted whenever we’re upright in gravity. In other words, the body has to do a lot of extra work in order to hold itself upright.
We refer to the event of being knocked off our center of gravity as a loss of equipoise. This is also referred to as a loss of verticality or loss of alignment, and this can be a root cause of an array of potential problems.
Equipoise in the body is the state in which, when we’re upright, no muscles are compelled to continuously brace in opposition to the force of gravity.
When the body is in equipoise:
But when equipoise is disrupted, a complex array of compensations can result.
The following examples demonstrate this disruption.
Here a functionally short right leg is shown to initiate a back-and-forth muscular counter-balancing that results in an “S” Curve in the spine.
The body’s automatic response to the short right leg in Figure 1 is to contract muscles on the opposite side, shown in Figure 2, as a counter-balance.
But the muscular response in Figure 2 pulls the body too far in the opposite direction thus triggering the need for another counter-balance, shown in Figure 3.
In Figure 3 the head has been pulled too far to the right and a final counter-balance is needed to bring the head more or less upright, shown in Figure 4.
The result is an “S” curve in the spine and a series of muscular compensations in which muscles are forced to brace in order to hold the body upright.
In the following, we see how this muscular counter-balancing can result in a “C” curve in the spine.
The compensation for the short right leg in Figure 1 is shown in Figure 2 where the entire torso on left engages as a counter-balance.
But in Figure 2 the head is pulled too far to the left.
This triggers the need for the counter-balancing shown in Figure 3 where the neck muscles compensate to bring the head more or less upright.
(Figure 4 is enjoying equipoise.)
To summarize, when equipoise is lost:
Over time, these compensations can become the source of significant pain and dysfunction in the body.
Certain muscles become locked short -- which means tight, braced, stuck -- while other muscles become locked long -- which means strained, overstretched, weakened.
The muscular compensation such as is shown the “S” curve and “C” curve examples results in two opposite muscular effects:
1. Some muscles are forced to strongly contract
This is suggested by the red arrows above. A shortened or shortening muscle will always be found in the CONCAVE part of the curve.
Over time, shortened muscles can become chronically tight, braced and ischemic (reduced blood flow).
I refer to these muscles as Locked Short.
2. Some muscles are forced to lengthen or overstretch
What’s not emphasized in the images above is the CONVEX side of the curve where muscles are forced to lengthen.
Over time, muscles that are constantly forced to lengthen can become overstretched, strained, weak and ischemic (reduced blood flow).
I refer to these muscles as Locked Long.
Perhaps you can visualize the strain on the muscles on the CONVEX side of the curve where they are forced into a chronically overstretched position.
Understanding the characteristics of -- and differences between -- locked short and locked long muscles is not only essential in diagnosing pain, but also for resolving it --quickly, efficiently and without aggravating symptoms.
For example, the pain felt in a locked short muscle will often be described as deep or aching or felt in a broad area. The impulse to grab or press on the muscle is common because that feels somewhat relieving.
The discomfort in a locked short muscle can often be improved by:
On the other hand, the pain felt in a locked long muscle tends to be sharp, intense or burning.
Instead of covering a broad area, it’s often more focused. I’ve heard it described like a knife jabbing the area.
Sometimes it has a "tearing" feeling.
Often it feels as if the muscle is extremely vulnerable, like it might go into spasm if you move wrong.
Because of this fragile quality, the worst, most intense, most intractable pain is often located in locked long muscles.
That’s not to say that pain in a locked short muscle can’t produce significant pain. It certainly can. Locked short muscles are often the site of myofascial trigger points which can cause radiating or referred pain, for example.
But it’s easier to bring some temporary relief to a locked short muscle using one of the strategies listed above.
Locked long muscles do not respond positively to these treatment strategies.
In fact, using strong or deep direct pressure or comprehensive deep stretching or rigorous movement, activity or exercise — can significantly aggravate and sometimes further injure a locked long muscle.
Because locked long muscles are overstretched, strained, weak and, over time, worn down, such muscles can become, as we’ve said, fragile. It doesn’t want strong stimulation and must be treated gently.
This distinction is critical to understand because otherwise every muscle and every pain is treated the same way.
Where strong, assertive treatment can be helpful for a tight, stuck, locked short muscle, treatment for a strained, locked long muscle should be limited to gentle mobilization and, in some cases, very gentle hands-on massage treatment.
But the only way to truly relieve the strain and pain in a locked long muscle — and to do so in a lasting way — is to get that muscle out of its overstretched, strained position.
By the same token, the only way to get a locked short muscle to let go of its persistent grip of chronic tightness in a lasting way is to restore equipoise and remove the struggle against gravity.
To resolve these problems, pelvic torsion needs to be corrected. But to do that in a lasting way, its root causes need to be understood.
Back in the mid 1990’s when I was first learning about pelvic torsion, we were taught a variety of mobilization techniques to correct it.
We would literally get a hold of the rotated pelvis and use a corkscrew technique to bring it back into balance. We would also perform mobilization techniques to free-up the sacroiliac joints and hip joints as these were thought to be contributing or reinforcing factors.
These mobilization techniques worked to a degree; in the moment you could observe a positive change and relief could be felt. But what I found was that the correction wouldn’t last. And for some the mobilization techniques alone didn’t really work at all.
As I continued to research this problem in my clinical practice, I found myself focusing more and more on a set of muscles which occupy the very core of our bodies: the primary hip flexor muscles.
Our primary hip flexors are the iliacus muscle and the psoas muscle.
These two muscles are collectively referred to as the iliopsoas because they share a common attachment at the upper inner thigh. But they are distinct muscles with different starting points.
The psoas has its origin along the lumbar spine, while the iliacus has its origin on the inner part of the pelvic bone (called the iliac fossa).
What I started noticing was that the muscular pattern I routinely saw when pelvic torsion was present was this:
The iliacus on one side and the psoas on the other side were both locked short.
See if you can visualize this.
In this example, a locked short right iliacus pulls down causing the hip bone to rock forward. The result is that the right pelvic bone gets positioned in an anterior, or forward, rotation.
Simultaneously, a locked short left psoas pulls up causing the left pelvic bone to become fixed in place and unable to rotate forward.
The result is that the right and left hip bones become stuck in oppositional rotation (resulting in a leg-length difference, loss of equipoise, etc).
But the strangest thing I started noticing was that every client who had ANY degree of pelvic torsion had the same pattern:
That is, a right anterior rotation with the left side fixed in place, as I’ve shown above.
When I first noticed this, I dismissed it as a coincidence. Why would there be just one pattern? That couldn’t be right.
But I kept seeing it, again and again. Every client with pelvic torsion had the right ASIS* positioned lower and the left higher.
*(ASIS = Anterior Superior Iliac Spine, the bony protuberance as the front of the hip.)
In my evaluations (always done lying down, not standing) here’s what I saw:
Seeing this again and again, I began to wonder if I was experiencing the “frequency illusion.” This is a cognitive bias in which your brain, excited by having learned something new, gets seduced by selective attention.
Alert for this possibility, I took extra care and time with my evaluations, checking and double-checking. But I kept seeing the same pattern.
At times I did see variations. This could occur in cases where there’d been a surgery leaving scar tissue, especially in the abdomen. Or in cases where there’d been a hip or knee replacement I might see variations.
But in the end, a right anterior, left fixed pattern was what I was consistently finding. I started to use an acronym in my notes:
"RALF" is short for Right Anterior, Left Fixed pelvic torsion pattern.
Having understood the immediate trigger (proximate cause) for pelvic torsion to be a type of hip flexor dysfunction, I now wanted to answer two additional questions:
1) What were the "big picture" forces that caused hip flexor dysfunction in the first place?
2) Why is the “RALF pattern” dominant, as opposed to any other pattern?
Unlike most muscles in the body which form the external structure of our bodies, the primary hip flexors — the iliacus and psoas — are internal and are situated deep in our core, tucked in behind our vital organs.
Considering what could negatively impact them, three common habits of modern life strike me as the most consequential:
As perhaps you can imagine or have even experienced, these three habits of modern life are often inextricably linked with one another, each mutually reinforcing the other two.
Also they go a long way in explaining, not only why hip flexor dysfunction and pelvic torsion are so widespread — even epidemic — but why a clear conventional medical diagnosis is not easy to come by.
These are complex functional problems that can’t be explained by looking at an X-ray or MRI or CAT scan.
Without seeing the whole and considering context, the root causes of much unexplained pain and a lot of mysterious symptoms cannot be easily understood.
As we’ll see in considering the “RALF Pattern,” context is everything.
First, a disclaimer. What I offer here is a hypothesis. I believe the hypothesis has merit but I am making a proposal, not claiming certainty. My hope is that more research will be done.
I believe we can shed light on why the RALF Pattern is dominant by looking closely at the “big picture” forces described above.
With the body seated in a chair -- a habit that starts very early for most of us attending grade school -- all the structures below the diaphragm are put into a compressed position.
Because I was looking for clues for a pelvic asymmetry, I found myself looking for asymmetrical clues in the structures below the diaphragm. The most prominent structure by far is the liver. Here it is in relation to the hip flexors:
And here it is cloaked by the diaphragm muscle:
The contents of the abdomen, including the large and small intenstines and other organs, sit below the diaphragm and liver like this:
If we consider long hours of the compression downward from sitting, does the lop-sided size and underside angle of the liver push everything to the left?
If we accept this possibility, then a picture of the pelvic asymmetry begins to emerge.
The crowding of the abdominal contents into the left side of the abdominal cavity could, over time, reduce the movement available to the left pelvis.
This, then, could optimize the tightening of the left psoas.
On the right -- where greater space in the abdominal cavity would be the result of crowding on the left side -- the right pelvis bone could simultaneously rock forward as a counter-balance.
This position, then, could optimize tightening of the right iliacus.
Over time, the two muscle adaptations taking root in this way could cause the RALF Pattern.
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My proposal of the dominance of the RALF Pattern is not meant to suggest that variations cannot exist.
I certainly have seen pelvic torsion variations in my own private practice.
When I have found variations there have typically been additional distorting factors present such as surgeries and scar tissue, some type of trauma, muscle imbalances or even pathology.
Any of these factors can create additional twists and turns in the pattern and may indeed present a picture that looks different from the RALF Pattern.
But there is another important reason why variations can be seen or assumed:
Too often evaluations for pelvic torsion are performed while an individual is upright in gravity, such as in a standing position.
An evaluation of the pelvis in a standing position cannot provide an accurate picture.
Because in order to see the body clearly we need to temporarily eliminate the body’s muscular struggle against gravity.
Muscular compensations in the body can be extremely complex. When imbalances such as pelvic torsion are present, such compensations can include everything from long-term patterns to in-the-moment muscular contractions.
As the body not only attempts to hold itself upright, it is also continuously trying to escape from, and gain respite, for aches and pains and fatigue. These factors can significantly blur the picture even to the point of an opposite pattern being seen or assumed.
Therefore the only way to get an accurate picture of the pelvis is in a supine position.
I have confirmed this again and again in clinical practice. Once we put an individual in a supine position so that the pull of gravity on surgeries, scar tissue and trauma is minimized, we find the RALF Pattern a very high percentage of the time.
But for those who don't see themselves in the RALF Pattern, I recommend doing a complete flexibility assessment using the Flexibility Diagnostic featured in the first course in my Blueprint Series:
The Flexibility Diagnostic guides you in creating a comprehensive snapshot of all locked short muscles in the body.
This snapshot is the basis for building Your Stretching Blueprint, a highly personalized stretching routine using Active Isolated Stretching.
For those who believe they are not in the RALF Pattern, the Flexibility Diagnostic and the Stretching Blueprint provide a comprehensive approach for:
1) Determining exactly what's happening the body and
2) Addressing your UNIQUE distortion patterns using the highly effective method of Active Isolated Stretching.