Pop quiz: What musculoskeletal issue could result in chronic low back pain, chronic muscle strains, lower extremity tendinopathies, periscapular pain and tightness, glenohumeral and shoulder girdle pain, or tension headaches? I am sure you can think of a few possibilities, but few can result in all. Often, when a patient reports to our care with one of the aforementioned we immediately think locally. Unfortunately, the real problem could be pelvic upslip, anterior pelvic innominate, or both. Despite being oft-overlooked, these malalignments are not hard to identify if you know what to look for.
Upslip and innominate takes the foundation of our core and creates a ripple effect of imbalance through our body; from the trunk, superiorly to the upper extremities, and inferiorly to the lower extremities. It results in a cascade of altered arthrokinematics, changes length tension relationships, and reworks normal neurological feedback loop. I wrote a post some time ago on the Treatment for Pelvic Rotation and Low Back Pain, which describes anterior innominate in detail.
99 times out of 100 upslip (or Posterior Iliac Subluxation) occurs on the left side and anterior innominate (pelvic rotation) occurs on the on the right. Here are some common signs for upslip and anterior innominate.
|Functionally shorter leg length on the left||Functionally longer leg length on the right|
|Left Iliac crest superior vs. right||Anteriorly rotated ilium (Right ASIS appears inferior)|
|Left PSIS superior vs. right||Right PSIS superior vs. left|
|Sacrotuberous Laxity||+ on the left||+ on the right|
|Seated / Standing forward flexion||+ on the left (no movement or superior movement on left)||+ on the right (no movement or superior movement on right)|
|Pubic Spring||+ for pain on left||+ for pain on the right|
Clinically, I have seen many patients report to me complaining of hip pain, low back pain, as well as shin splints and Achilles tendinopathy who also presented with these malalignments. I have also experienced several patients have upper extremity pain with these same malaignments. My wife is a prime example. Routinely she complains of periscapulothoracic pain, tightness of the rhomboid, levator scapula, scalenes and an elevated first rib, these usually lead to chronic tension headaches. Fortunately, by performing a few easy treatments techniques these problems can be fixed. Below I discuss clinician treatment options and self-treatment options.
In my experience treatment of postural disorders is best using manual therapy techniques and focused corrective exercise. I’ve seen many address functional leg length discrepancy by placing a heel lift in a shoe. If this is not an anatomical leg length discrepancy, then a heel lift will do nothing. You must correct the dysfunctional cause. When I see an individual presenting with upslip or innominate I perform three things: trigger point release (TrP), followed by muscle energy techniques (MET), followed by an isolated strengthening exercise.
Treatment of Upslip:
Step 1 – TrP release: For upslip, I almost always find trigger points and hypertonicity in the left Quadratus Lumborum (QL). The QL has 4 TrP, the medial are deep and very hard to access, thus I focus on the lateral (see figure below). Apply moderate ischemic pressure for about 30 seconds – 1 minute to the TrPs. If you feel for fasciculation (local twitch response), hold the point until fasciculation resolves.
Step 2(a) – MET to the Quadrautus Lumborum: When it comes to MET, I always prefer the techniques used by Leon Chaitow. However, I could find no video of his technique (someday I will shoot my own video). The technique demonstrated here is also very effective. Perform 2-5 repetitions of this QL MET technique.
Step 2(b) – MET for Posterior Subluxation (upslip): For this MET, the patient lies supine, while the clinician will holds the left leg and places it in 30° of abduction and flexion. The clinician pulls the leg inferiorly to apply gentle traction. Have the patient take a deep breath in and out normally. The clinician should add additional traction upon exhale. Perform this 2-3 times. After the final repetition, provide a quick longitudinal pull on the leg.
Step 3 – Isolated strengthening of right Quadratus Lumborum via right hip hike (approximation): Stand on a 6-12” box or step, with the right leg hanging off and weight shifted over the left leg. Slowly pull up or hike the right leg. The right iliac crest should move toward the right 12th rib. Hold the up position for 2 seconds and slowly return to the starting position. Repeat for 10-15 repetitions. For increased intensity, add a cuff weight to the ankle.
Treatment of Anterior Innominate:
Step 1 – TrP release to the hip flexors: Two muscles to address here are the Tensor Fascia Latae (TFL) and the Rectus Femoris. The iliopsoas (psoas Major, psoas minor and iliacus) also plays a role in anterior innominate, but I find it near impossible to reach these tissues. However, the techniques discussed in step 2 and 3 below will help turn the iliopsoas off. Apply moderate ischemic pressure for about 30 seconds – 1 minute to the TrPs on the Rectus Femoris and TFL. If you feel for fasciculation (local twitch response), hold the point until fasciculation resolves. For best results, it might be best to slightly flex the hip to take slack off of the Rectus and TFL, allowing for easier and deeper palpation.
Step 2 – MET for Anterior Innominate: There are several ways to perform MET for innominate. I think our peers (physios across the Atlantic) do a great job of manual therapy, thus I chose a video that was made in the UK (see below). The video here is the method I prefer. I think it is easiest for the clinician and most comfortable for the patient. In addition this particular MET technique can address both right anterior rotation and left upslip. Perform this MET technique for 3-5 repetitions.
Step 3 – Isolated strengthening of the Right Gluteus Max via single leg floor bridge: Lie flat on your back with the knees bent at 90 degrees. Extend the left leg. Engage the abdominals and squeeze the right glute as you press your heel in to the floor to raise the hips. The hips should remain level and not dip to the left or right. The hamstrings should not be overly engaged, so be sure the glute is firing. Also watch for and correct excessive low back arching during this exercise. Perform 8-12 repetitions. For added level of difficulty, perform with the right foot elevated or elevated and on an unstable surface such as a foam roll.
A lot of individuals do not have access or the money to pay a clinician. Thankfully, there are alternatives to the above exercises that you can do at home in the form of self- treatment. When my wife suffers from neck tightness or tension migraines, she takes 5 minutes to do the exercises below and oftentimes, the issue is resolved. Keep in mind the content here is not intended to supersede or serve as physician recommendation and should not be used as a rehabilitation program for all. If you have low back pain or have been diagnosed with the above, make sure you follow their orders.
Self-treatment of Upslip:
Step 1 – Self Myofascial Release of the Left Quadratus Lumborum: Performing myofascial release to the QL is difficult, but not impossible. Grab a tennis ball or other medium density ball. Stand with your back against a wall. Place the ball on the wall and near the area of the left QL TrP. Lean against the ball with mild to moderate pressure. You will likely need to move around and ‘fish’ for the tender sport. Once located the tender spot is located lean back in to the ball with moderate pressure and hold for 30-60 seconds. Repeat for the second trigger point. You can also use a specialized myofascial release tools such as a Thera-Cane or Backnobber to release the QL.
Step 2 – Statically Stretch the Quadratus Lumborum: Immediately following the myofascial release perform a static stretch to the QL. To begin, get in to the child’s pose, with arms extended overhead. Side bend to the right and you should feel a light pull in the left lower back. Breathe normally and relax. Hold the stretch for 30 seconds. Here is a great video from Brent Brookbush who goes over both myofascial release and stretching of the Quadratus Lumborum.
Step 3 – Isolated strengthening of right Quadratus Lumborum via right hip hike (approximation): See description above.
Self-treatment for Anterior Innominate:
Step 1 – Self Myofascial Release to the right Rectus Femoris and right TFL via foam roll: As mentioned above, for anterior innominate we must target the Rectus Femoris and TFL. For the rectus lie flat on the foam roll, the roll should be perpendicular to the front of the thigh. Begin at the hip and slowly roll toward the knee. You should feel tenderness around the area of the rectus trigger point. Hold the tender spot for 30-60 seconds.
Foam rolling the TFL is similar to the Rectus Femoris, but the TFL is difficult to find. I often refer to the TFL as the pocket muscle. If you imagine a the front pockets to a pair of jeans, the entrance to the pocket is where you would find the TFL. You will need to lie down on the foam roll and rotate to approximately 45 degrees to the side, so that the TFL is on the foam roll (near the area of the front pocket). You may have to ‘fish’ for the trigger point by rolling up and down a few inches and/or rotating to a more side lying or flattened position. Once you find the tender spot hold pressure on the spot for 30-60 seconds.
Step 2 – Statically stretch the right Rectus Femoris and right TFL: Immediately following the myofascial release perform a static stretch to lengthen these shortened tissues. The key here is to engage the right glute. The firing of the glute will provide reciprocal inhibition to the Rectus Femoris and TFL allowing for maximal stretch. The images shown here illustrate proper stretching for the Rectus Femoris and TFL.
Step 3 – Isolated strengthening of the Right Gluteus Max via single leg floor bridge: See description of the exercise above.
Despite easy recognition, pelvic upslip and anterior innominate are often missed on evaluation. These pelvic malalignments elicit musculoskeletal dysfunction across the entire, both to the upper extremities and lower extremities. Take the time to perform a quick evaluation on pelvic positioning. If you find left upslip, anterior innominate or both, performing the techniques here can really help alleviate pain and allow correction of the problem. Again, the information provided here should not replace a physician evaluation. If you are experiencing pain, be sure to consult a physician.