Saturday, September 26, 2015

Asymmetrical Pelvic Tilts

The following is a summary of an article by Rolfer and Educator Robert Schleip. I am summarizing here so as to describe it in terms of acupuncture and sinew channel relationships, and to relate it to what is taught in Sports Medicine Acupuncture®.

Schleip discusses and gives strategies for a pelvic torsion which involves one ilium which is in an anterior tilt relative to the other, which is in a relative posterior tilt. Specifically he discusses how this relates to the acetabulum and the sacroiliac joint and how this relationship informs understanding of sacral base elevation. This pattern is a frequent finding in sacroiliac joint dysfunction and could also be seen in facet syndrome, Yaoyan pain and a host of other conditions affecting the low back and hip.

Regardless of whether an ilium goes into an anterior or posterior tilt, the distance remains the same between the acetabulum and the sacroiliac joint. However, the vertical distance increases on the anterior tilted side and decreases on the posterior tilted side. The vertical distance is described in reference to two horizontal lines, one through the acetabulum and the other through the sacroiliac joint. In an anterior tilt, the sacral base moves anterior and superior, increasing the distance between the horizontal lines. This effectively raises the sacral base. The opposite is true on the posteriorly tilted side. The sacroiliac joint moves posterior and inferior, decreasing the distance between the two horizontal lines and effectively lowering the sacral base.
Fig 1: Neutral Ilium.
Notice the length between the
horizontal lines, and notice the
length of the line between the
acetabulum and the SI joint.
Fig 2: Anterior Tilted Ilium.
Notice that the line between acetabulum
and SI joint is the same, but the vertical
distance between the two horizontal
lines has increased.

The sacral base is assessed at the dimples which are just medial to the PSIS. If this pelvic torsion was the only postural disparity in the body, an elevated sacral base would be observed on the anteriorly tilted side. This all assumes that the heads of the left and right femur are at an equal level. But there are many situations that will cause either a functional or a structural leg length discrepancy. A structural leg length discrepancy would be based on bone length (femur or tibia) and would be either congenital or occur as a result from trauma. A functional leg length discrepancy would include various muscle imbalances which effectively shorten a leg. Things such as foot over-pronation, rotations in the tibiotalar joint compressing the ankle, and rotations in the tibiofemoral joint compression of the knee, medial shifts of the knee, etc., are all possible things that could reduce length in the leg and lower the femoral head relative to the other side.

Again, imagine that the leg length discrepancy (regardless if it was functional or structural) was the only postural disparity. The side with the higher femoral head would also be the side with the more elevated sacral base in this case. But what if the body, in an attempt to create a level sacral base compensated by going into a posterior tilt on the elevated side? This would lower the sacral base on this side and help to balance the base of the spine, which would be advantageous to this person both in terms of spinal function and comfort.

If the right ilium were to go into an anterior tilt
and the left were to go into a posterior tilt, this
would raise the sacral base on the right side.
If the right leg were longer (structurally or functionally)
the left ilium could go into a posterior tilt to lower the
sacral base as a compensation.

In Sports Medicine Acupuncture, we discuss various postural disparities and describe ways to measure and record these. Treatment with acupuncture, manual therapy, and corrective exercises is derived from these observations. We describe an elevated ilium as being a transverse plane deviation. This means that this deviation would move away from a transverse plane. We also describe this asymmetrical pelvis (one side anteriorly tilted, the other posteriorly tilted) as a transverse plane deviation even if it does not involve an elevated ilium. This would be an exception to the rule, as it does not move away from a transverse plane. However, based on the discussion above, whenever there are asymmetrical tilts of the ilium, there is movement away from the transverse plane, at least based on the sacral base's relationship to the legs and spine. This is true even if there does not appear to be an elevation on one side or the other, as this would involve some compensation, likely based on leg length.

When there are asymmetrical ilium tilts and/or left or right pelvic tilts (right or left elevated ilium), we use acupuncture points on the Gallbladder and Liver channels to affect the Gallbladder and Liver sinew channels. This reduces tone on structures such as the iliopsoas and adductors in addition to more lateral structures such as the ITB and gluteal muscles, and the abdominal obliques. In particular, we use motor points on the muscles of the Gallbladder and Liver sinew channels, and we use various distal point combinations on the Gallbladder and Liver primary channels.

The pelvis is a supremely important structure in terms of its influence on the entire body, and it is vital for it to be in a balanced position to allow qi to move efficiently through the channels. It is also important to relate the legs to the pelvis and the pelvis to the spine by correcting disparities in these structures by balancing yin and yang. This can be accomplished by addressing overactive (excess) muscles and inhibited (deficient) muscles to improve structural support in the legs and balance the pelvis in relationship.

Schleip gives some interesting commentary regarding when to address this pelvic asymmetry and when to see it as an intelligent compensation and leave it alone. His general statement is that when the sacral base is higher on the anterior tilted side, you would likely want to work with unwinding this pattern. If the sacral base was higher on the posterior tilted side, you would consider seeing this as an intelligent compensation and unwinding it might further reduce balance in the spine. He comments that the reality is that gravity is a very effective therapist, and that unwinding the pelvis in the second situation would more than likely only be temporary as the body would return to the torsion to balance the base of the spine.

I agree with Schleip, though I would like to add a couple of things. He is discussing using myofascial release techniques and also mentions work by chiropractors and osteopaths. Forcefully manipulating a segment of the body to fit some outside idea of what is considered ideal can sometimes be a disservice to a patient. In this case, forcing the pelvic tilts to be balanced when they are effectively leveling the sacral base could effectively unbalance the base of the spine. However, addressing muscle imbalances with an acupuncture needle by needling things such as motor points and distal points and then using corrective exercises in a balanced way can correct the underlying muscle imbalances and allow the body to find a natural balance. This will often balance the tilts. If the pelvic torsion is compensating for something such as a structurally longer leg*, it will likely not change the anterior and posterior tilts as they are there for a reason. However, it will reduce the fixation of the segment and improve movement possibilities which will reduce pain and improve performance.

This should be the ultimate goal, and practitioners who look at the structure should remember that this is done because structure and function are so related. If the structure can not change, but the function improves, then this is a successful intervention. The key is to address what you see, improve function, but don't get too dogmatic about forcing a patient's structure to comply to some ideological standard. Some people have normal, naturally occurring asymmetries or regions which are compensating in a useful way to a congenital deformity.

* For a functionally longer leg, correcting imbalances affecting the major joints (such as the ankle, knee and hip) will return length as it will start to unwind this structure. In this case, you could expect to see a much more lasting change in the pelvis, as it has a stable support below.

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