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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Perspectives on Acupuncture Point BL-58

Feiyang BL-58 is an acupuncture point on the Urinary Bladder channel. It is on the posteriolateral portion of the leg. In A Manual of Acupuncture, Peter Deadman locates this point on the lower leg, 7 cun directly superior to Kunlun BL-60, lateral to and approximately 1 cun inferior to Chengshan BL-57. This places the point about halfway up the leg (a bit inferior to this) and posterior to the peroneal muscles. BL-58 is the Luo-connection point of the Urinary Bladder channel. Deadman lists its actions as:

Fig. 1: BL-58 at the myotendinus
junction of the gastrocnemius. Note 
the deeper soleus which is more visible 
in fig. 2 as the gastrocnemius is removed.

• Harmonise the upper and lower
• Expel wind from the taiyang channel
• Treat hemorrhoids
•  Activate the channel and alleviate pain

The indications of this point relate to these actions, particularly:

• Harmonize the upper and lower: Many indications are listed involving the head and neck and symptoms associated with the sense organs such as the eyes. These include things such as headaches and dizziness, visual dizziness, and pain in the neck and occiput.
• Expel wind from the taiyang channel: Indications include lumbar pain, heaviness of the body with inability to sit or stand, difficulty walking, sciatica, and inability to flex and extend the toes.
• Activate the channel and alleviate pain: This also incorporates many of the indications above.

Fig.2 BL-58 with the muscle
belly of the more superficial
gastrocnemius removed.
This illustrates the location at
the belly of the deeper soleus.

I would like to give a few interesting perspectives on this acupuncture point, in order to explain some of its action. These perspectives are derived from the work of five primary sources, in order of reference below: 1) the late Dr. Janet Travell, M.D., author of Myofascial Pain and Dysfunction: The Trigger Point Manual; 2) Andrew Nuget-Head, director of the Association for Traditional Studies; 3) My colleague Matt Callison, L.Ac, M.A., director of Acusport Seminar Series; 4) Luigi Stecco, Italian physiotherapist and anatomist; and 5) my own lectures with the Sports Medicine Acupuncture Certification Program, exploring the sinew channels (Jingjin) described in the meridian system and how they relate to anatomical regions of the body.

Fig. 3: TrP 3 as described
by Travell, and its referral
to the SI joint region.

Anatomically, this point is at the lateral portion of the myotendinous junction of the gastrocnemius muscle, and in the belly of the deeper soleus muscle (fig. 1 and 2). This point is in a region of a particular soleus trigger point that Dr. Travell describes as referring pain to the sacroiliac joint region (fig. 3). Pain in the region of the sacroiliac joint can have many causes, sacroiliac joint dysfunction being a primary one. But she describes cases where trigger points in the soleus at the region (corresponding to BL-58) can be a contributing factor. I have used this point often with sacroiliac joint dysfunction and have seen many instances where it referred to the sacroiliac joint. Actually, when I use this point to treat sacroiliac joint problems, I will often try to propagate sensation to the joint.

This discussion of Dr. Travell’s trigger point referral patterns leads me to the next reference, Andrew Nuget-Head. I have not yet had the opportunity to work with Andrew (though I hope to in the near future), but have had the good fortune to discuss much of his work with Sean McCann, L.Ac., a good friend of mine who studies and works closely with him in his clinic. Much of their training focuses on the importance of needle manipulation to propagate sensation to the desired place (creating a warming sensation in the abdomen for cold in the Stomach by manipulating ST-36, for instance). While a major skill set taught is how to properly propagate sensation, and the explanation is that this can be accomplished at just about any point, the reality is that certain points are much easier to work with in this way and yield better clinical results for the task at hand. Deadman’s A Manual of Acupuncture offers a tremendous range of points for things such as lumbar pain. While all of these points might be useful to a skilled practitioner, the challenge is to discern which will be the best and easiest to use for the ‘flavor’ of lumbar pain presented by a particular patient. I feel that the particular ‘flavor’ of lumbar pain for BL-58 is the treatment of pain associated with sacroiliac dysfunction, and this is consistent with the general natural tendency of referral of the point when it is reactive.

With the pain referral in mind, it is useful to explore some of the indications associated with BL-58 listed above. One sees sciatica, inability to sit or stand, difficulty walking. All of these are consistent with pain that can be experienced with sacroiliac joint dysfunction.

Matt Callison describes vertebral facet fixations and their impact on particular muscle weakness. He finds that certain muscles will test bilaterally weak in manual muscle testing when there are corresponding vertebral facet fixations in particular regions. In the presence of sacroiliac joint fixation, the cervical extensors will test weak when testing the left and the right side individually. Releasing the fixation will turn the weak muscles back on and they will test strong when performing manual muscle tests after treatment. (In Sports Medicine Acupuncture, we teach particular Extraordinary Vessel pairs, local needle techniques, and joint mobilization techniques to accomplish this.)

With this relationship between the sacroiliac joint and the cervical extensors, one can again explore the indications for BL-58 and see the action of harmonizing the upper and lower with indications present such as pain in the neck and occiput, dizziness, etc.

Note that BL-58 is not one of the Extraordinary points taught by Matt Callison for sacroiliac joint fixation. The combination of GB-41/SJ-5 and specific local needle technique associated with the sacroiliac joint, along with joint mobilization, is taught within Sports Medicine Acupuncture® classes. GB-41/SJ-5, via its relationship with the Daimai, has effect on different sinew channels and, therefore, affects sacroiliac balance in a different way than do points affecting the Urinary Bladder and Kidney sinew channel (remember that BL-58 is the Luo-connecting point—more on this in a bit). But additional points are added to expand the therapeutic outcome, such as BL-58; this is not commonly used to affect the cervical spine, and I personally rarely use it for this, but I list the description above to illustrate the relationship between the sacroiliac joint and the posterior cervical extensors and tie the anatomy into the classical indications of BL-58.

Luigi Stecco describes how fascial linkages between muscles are a peripheral source of proprioceptive communication for the nervous system. What this means is that muscles have many more ‘attachment’ sites than are listed and shown in anatomy books. About 30% of the muscle force is transmitted through cross-links to other muscles via these myofascial fuzz fibers.

Through careful anatomical study, Stecco has proposed that much of this crosslinkage is used as a way for the muscles of the body to communicate via tension with each other and coordinate movement, especially between agonists and antagonists. He describes something he calls a myofascial unit which describes a particular relationship between monoarticular muscles (muscles that cross only one joint, the soleus in this case) and biarticular muscles (muscles that cross two joints, the gastrocnemius in this case), and attachments between these and their antagonists. He proposes that movements of joints in particular directions are coordinated by what he refers to as centers of coordination. These centers of coordination are areas where the monoarticular muscles and biarticular muscles share a fascial connection which help direct and coordinate the muscle action via tension acting on muscle spindles. If the fascia becomes densified in these centers of coordination, this can disrupt proprioception and can lead to pain and dysfunction.

Fig. 4: Image
illustration of a cc 
for ankle movement from 
Fascial Manipulation
for Musculoskeletal Pain,
by Luigi Stecco

BL-58 corresponds to one of these centers of coordination and it is a region where, as he describes it, the myofascial vectors of the gastrocnemius and soleus converge. This is a myofascial union, between the more superficial gastrocnemius and the deeper soleus. These structures and their movements are organized via their fascia within a sequence of myofascial tissue that travels up the back of the leg.

This leads to the work I have been doing: relating the sinew channels more clearly to actual anatomical structures. In Sports Medicine Acupuncture Certification, I describe the sinew channels from a precise anatomical perspective. For the Urinary Bladder and Kidney sinew channel, I describe myofascial connections in the posterior leg and thigh. In particular I outline the gastrocnemius connections to the hamstrings, particularly to the biceps femoris and semitendinosus and into the sacrotuberous ligament which connects to the posterior sacrum. I ascribe this to the Urinary Bladder sinew channel. There is another deeper myofascial connection which includes the soleus attaching to the semimembranosus and adductor magnus and into the pelvic floor muscles which connect to the anterior sacrum. I ascribe this to the Kidney sinew channel. Therefore sacroiliac movement, at least relating to the flexion/extension aspects (called nutation and counternutation) is moderated by the balance (or dysfunction due to imbalance) between the Urinary Bladder and Kidney Sinew channels.

It is interesting to see that BL-58, a Luo-connecting point, is indeed a point at an influential union between the gastrocnemius and soleus. Needling this point affects a region of proprioceptive communication between a Urinary Bladder sinew channel muscle and a Kidney sinew channel muscle. These two sinew channels strongly influence mobility at the sacroiliac region. Known trigger points described by Dr. Travell refer pain to the sacroiliac joint. Indications of this point can certainly be interpreted as sacroiliac joint dysfunction. Actions of this point include the expulsion of wind, a pathogenic factor that causes rigidity. Anyone who has diagnosed sacroiliac joint dysfunction would agree that there is a notable amount of rigidity that is associated with this syndrome. When properly diagnosed, BL-58 is a useful point in treatment, especially when it propagates sensation to the sacroiliac joint.

I have been working with the sinew channels in one capacity or another since 1998, first with my taiji and qigong practice (where we refer to them as tendons and discuss tendon-changing exercises); then through study of structural integration and especially the Anatomy Trains developed by Tom Myers and currently taught in Sports Medicine Acupuncture by Simone Lindner; and next through my own research as I became a faculty member in the Sports Medicine Acupuncture Certification program, especially with the opportunity to closely analyze fresh cadaver specimens. My study of the sinew channels is a work in progress and I am currently engaged in quite a lot of research into various sources (Stecco, Tom Myers and his Anatomy Trains; the descriptions from the Ling Shu and David Legge’s interpretation of these descriptions; Travell’s groundbreaking work; acupuncture sources such as Deadman’s A Manual of Acupuncture, and other sources), while testing these ideas in clinic to see if they predictably produce results. This will likely be a lifelong process. While I feel there is a strong basis for what I describe above, it is subject to change as more clinical data is presented by other practitioners.

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Sciatica and Conditions that Mimic Sciatica

I get questions on a regular basis asking if I treat sciatica. And then, I get further questions asking what I do for sciatica. The first question is easy. Yes, I treat sciatica. The second question is more difficult because, sciatica is not a very precise term and can involve many different but related syndromes. Strictly speaking, these involve irritation of the sciatic nerve, but there are many conditions such as muscle referrals that can be classified as ‘pseudo-sciatica’.

The Mayo Clinic defines sciatica thus:  “Sciatica refers to pain that radiates along the path of the sciatic nerve — which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body.”

A lateral view of the spine. The
intervertebral disc is highlighted red
and the intervertebral foramen
(where the spinal nerve exits) is
highlighted yellow. Disc herniations
mostly occur at the region where
the spinal nerve exits the foramen.

Pain radiating down the sciatic nerve has many causes, but I will highlight two. The most common cause is irritation at the level of the spinal nerve where it is exiting from the spinal cord. Conditions such as a herniated disc, degenerative disc disease and stenosis can compress part of the nerve. Depending on the spinal level affected, this could cause pain that radiates down the side of the thigh and the front/side of the leg to the top of the foot (this would involve compression of the L5 level); down the front/side of the thigh to the inside of the knee and to the big toe (this would involve L4); or down the back of the thigh (this would involve S1). All of these could be the result of trauma, inflammation, and/or aging and degeneration. I treat these by using acupuncture to release the deep back muscles at the level of spinal compression, balancing any postural disparities that might be contributing to compression on the nerve, and ‘opening the acupuncture channels’ which are along the pathway of the pain. In addition, I might use deep tissue massage techniques, stretches to free the nerves and restore proper gliding, and corrective exercise that can be used at home to expand the therapeutic outcome.

The second common cause involves an entrapment of the sciatic nerve by one of the muscles involved in turning the leg out. This muscle is called the piriformis and the condition is called piriformis syndrome. This would involve deep pain in the buttock region and pain radiation down the back of the thigh. This pain is often worse when sitting, climbing stairs, or running; usually there is reduced range of motion in the hip joint. Some authorities consider this syndrome to be common, while others perceive it as uncommon; this depends on how the syndrome is defined. In most people, the sciatic nerve sits below the piriformis, but in about 10% of the population, it actually penetrates through the piriformis muscle. These people would be predisposed to piriformis syndrome. In the Sports Medicine Acupuncture Certification Program in New York, we dissected a specimen that had just this situation. It was unknown to use if this individual had pain of this sort, but it was a much stronger likelihood. 

Sciatic nerve exiting below the
piriformis muscle. On some people,
it actually penetrates through the
muscle, predisposing them to symptoms.

While many physicians see piriformis syndrome as occurring only in this population, others (myself included) feel that a tight and contracted piriformis can also contribute, regardless of the position. I treat this condition with acupuncture to release the piriformis and balance the pelvis, and might also involve deep tissue massage, stretching and corrective exercises.

While these are the main conditions that put pressure on the sciatic nerve, there are many other syndromes that can mimic the pain of sciatica and can cause an incorrect diagnosis. In particular, hypersensitive painful spots called trigger points (TrPs) in the muscles on the side of the pelvis can radiate pain down the leg and mimic sciatica. In particular the gluteus minimus muscle which is deep in the outside of the hip region is a common culprit. Sacroiliac dysfunction and spinal arthritis (referred to as facet syndrome) are also pain syndromes that can refer into the buttocks and legs. Greater trochanteric bursitis can also radiate into the leg and be confused with sciatica. All of these conditions require proper assessment. In my practice, I take the time necessary to perform orthopedic evaluation and use other tools such as palpation to determine what is causing the symptoms experienced by the patient. I look at how the posture might be contributing to the condition. I assess range of motion, what muscles are strong and supporting the structure and which are inhibited and failing to provide support. And I use Traditional Chinese Medical diagnosis to assess imbalances in the channel system. All of these findings then are used to develop a unique treatment plan to relieve the pain of sciatica.

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