Mr. M. walked from the waiting room to my treatment room with a slight, but noticeable, limp. I observed that his pelvis was visibly unlevel (pelvic obliquity) and wondered if the limp and the obliquity were connected.
“My doctor is pushing me to schedule back surgery,” Mr. M. said with a conflicted tone. “I just can’t seem to commit to surgery because I am not convinced my back is the issue. I almost never have back pain.”
“And the pain you feel?” I asked.
“I have nerve pain down my right hamstring to the calf and foot. The surgery would be a fusion of L5–S1, and they also plan to stabilize a spondylolisthesis of about 5 millimeters. From what I have read, a 5-millimeter spondylolisthesis isn’t very much. I have a hard time understanding how it explains all my symptoms. But, as my doctor reminded me, I am a dentist, not an orthopedist,” he said. “I also feel pain from my hip to the buttocks that can often wrap around the front of the pelvis to the inside of the knee. I feel that pain more often now than the pain to the calf and foot.”
This was perplexing. Pain to the front of the thigh and the medial knee is not typical for an L5 distribution. What would explain this? I thought about hip obliquity presentation and asked Mr. M. to stand. The right hip not only looked superior but visibly larger. Lying supine on the table, the right leg was significantly longer, and neural symptoms typically occur on the long-leg side.
“Has anyone mentioned the possibility that you have an anatomically short left leg?” I asked.
“My wife is a physical therapist and she wondered about that,” Mr. M. replied.
What I could not shake from my thoughts was the image of his hip seeming physically larger. Looking very closely, one side of his face also seemed smaller than the other.
“I have a goofy question. Is your left foot the same size as your right foot?” I asked hesitantly.
“The right is almost a size bigger,” he said. “How did you know that?”
“You may have an exceedingly rare presentation called a hemipelvis,” I said. “Not only is your leg shorter on the left, but the whole left side of your body is smaller than the right.”
Mr. M. was a bit stunned, but the hemipelvis idea explained a lot for him. We decided to meet again a week later, and his wife accompanied him. Before climbing on my table, he happened to say, “The hemipelvis thing is bizarre. I don’t think my pants fit the same way they did even a week ago. The nerve pain I am feeling now seems to have gone from hypersensitive to a dead-like feeling.”
These two sentences struck me broadside. That made no sense—a hemipelvis is not progressive. Neural sensations don’t go from hypersensitivity to hyposensitivity in a week. Something was seriously wrong, and a hemipelvis wasn’t the source. Perhaps I, like his physician, got lost in interesting details that did not matter to his presenting symptoms.
With Mr. M. prone, I was immediately struck by the quality of the tissue texture in his right hip, which had changed in one week. There was a circular 7-centimeter area of dense tissue with clear margins. I had his wife feel it with me, and she too looked perplexed.
“What do you think that is?” she asked.
“I have no idea,” I admitted. “In almost 39 years, I have never felt anything like it, and that raises a large red flag for me. I don’t know what this is, but it is time sensitive and needs to be addressed immediately. I don’t mean to scare you, but I think you should see a different doctor who will look at this tissue and figure out what is going on. Do it tomorrow. The disc issue, the spondylolisthesis, and the hemipelvis are irrelevant.”
I felt bad seeing the alarm on their faces as they left my office. What if I was wrong?
Mr. M. emailed me three days later. He was diagnosed with stage 4 pelvic osteosarcoma and was leaving immediately for Johns Hopkins. In his email, he wrote that I was the only health-care provider who listened to him and did not make him feel like he was crazy. It was a compliment, but one with sad overtones. Providers heard neural symptoms and assumed the source must be spinal, even when other symptoms did not fit that hypothesis. If it doesn’t fit, it isn’t it. Don’t try to make it fit into the box. Look for other explanations. Listening closely to the client is a good place to start.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars, president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois, and a trustee for the Massage Therapy Foundation. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com, or email him at doug@nmtmidwest.com.