Key Points

• A tilted pelvis that causes a tilted spine can result in a head that is not level; however, the body’s righting reflex, which keeps the head level, will compensate for the tilted pelvis by curving the spine. 

• If we do not address the tilted pelvis, none of our work into the spine itself has any chance of lasting because the scoliotic curve is a needed compensation for the tilted pelvis.

• The root cause of pelvic dysfunction typically falls into two categories: muscular imbalance at the hip joints or dysfunctional patterns in the lower extremity.

When a client presents with a postural dysfunctional pattern of the spine, it is natural to assume the cause of the dysfunctional pattern resides in the spine, and, therefore, the treatment of the condition should be focused on the spine. However, factors outside the spine often create altered spinal postures. So instead of focusing only on the spine, we need to expand our area of assessment to include other regions of the body as well.

The spine can be likened to a statue that sits on a pedestal. In this analogy, the pedestal is the pelvis, and the entire spine from L5 upward is the statue; in effect, we think of the lumbosacral (L5–S1) joint as where the statue meets the pedestal (Image 1).

If a statue stands on a pedestal that is tilted, then the statue itself would have to be commensurately tilted. In this analogy, if we see a tilted statue, we do not look at the statue as being the cause of its poor posture; rather, we look at the foundational pedestal as being the cause. Therefore, if we straighten the pedestal, we straighten the statue (Image 2). Another way to visualize a tilted structure is to compare it to the Leaning Tower of Pisa (Image 3). The tilt of the Leaning Tower of Pisa comes from its foundational base, not the building itself.

In a like manner, if the pelvis is tilted, then the spine will end up being tilted (Image 4A). A tilted spine will result in a head that is not level, which throws the eyes and inner ears off level, creating proprioceptive confusion and making it extremely difficult to orient ourselves in space. To counteract this, the human body has a reflex known as the righting reflex that keeps the head level. In this case, the righting reflex will compensate for the tilted pelvis by curving the spine to bring the head back to level. In effect, a scoliotic curve is created to compensate for the unlevel pedestal/pelvis (Image 4B).

Therefore, whenever a client presents with a scoliotic curve (or any abnormal spinal curve, for that matter), the question must be asked: Is this a primary postural distortion pattern whose cause is located within the spine? Or is this a secondary compensatory distortion pattern resulting from an unlevel pelvis? To determine this, we must assess the posture of the pelvis. To create a rubric for how to approach this, let’s look at one cardinal plane at a time, beginning with the frontal plane.

Frontal Plane

At the outset of any standing postural examination, checking pelvic iliac crest height is essential. Are the two iliac crests level? Or is one lower than the other? If one iliac crest is low, then the spine would tilt in the frontal plane to that side, unless we compensate with a scoliotic curve (Image 5). What would be an effective treatment strategy for a client with a compensatory scoliosis?

Certainly, we might choose to direct some of our work toward the soft tissues of the spine. In this case, massage should be primarily focused on the locked-short myofascial tissues in the concavity(ies), but also addressed to the locked-long myofascial tissues in the convexity(ies). And we might choose to employ grade-IV slow-oscillation joint mobilization for hypomobile joint dysfunctions to free up any long-standing intrinsic myofascial tissue adhesions that have built up. But if we do not address the tilted pelvis, none of our work into the spine itself has any chance of lasting because this scoliotic curve is a needed compensation for the tilted pelvis. So, we must also address why the pelvis is laterally tilted lower (depressed) on one side—and address its cause.

We can place the cause(s) of the tilted/depressed pelvis into two categories: (1) An imbalance of musculature across the hip and lumbosacral joints, and (2) dysfunctional patterns in the lower extremity that might result in a short limb on that side.

Muscular Imbalance at the Hip and Lumbosacral Joints

Let’s begin with muscular imbalance at the hip joints. There are two groups of musculature that cross the hip joint in the frontal plane: abductors and adductors (Image 6A). Abductors at the hip joint, in closed-chain mechanics, function to pull the pelvis down into lateral tilt/depression on that side (which would also cause the pelvis to elevate on the other side) (Image 6B). The second frontal-plane group is the adductors. Adductors, when pulling in a closed-chain scenario, would, by pulling the pubic bone down on that side, end up elevating the iliac crest (hiking the hip) on that side (which would laterally tilt/depress the opposite-side pelvis) (Image 6C).

Therefore, if a client presents with a pelvis that is laterally tilted down on the right side, we would look to assess the relative baseline tone of the abductors and adductors to see if they are the cause, or a contributory cause, of this altered posture. We might expect to find tight (locked-short) abductors on the right side, and/or we might expect to find tight (locked-short) adductors on the left side. If either of these patterns are found, then soft-tissue manipulation to these tighter locked-short muscle groups should be part of the treatment strategy.

Then, assess the musculature that crosses the lumbosacral joint, from the pelvis up onto the trunk; this is lateral flexion musculature (Image 7). Examples of lateral flexors are quadratus lumborum and paraspinal erector spinae musculature. Tight lateral flexor musculature on the left side would elevate the pelvis on the left, thereby depressing in on the right. If this is found, it is a reasonable extrapolation that this musculature could be causing/contributing to the dropped iliac crest on the right side, and therefore should be treated.

Dysfunctional Patterns in the Lower Extremity

Now, looking beyond the pelvis and its musculature, we need to look for any other conditions that might drop the pelvis on the right side. Some of these possible conditions include unilateral overpronation (dropped arch structure of the foot), genu valgum at the knee, or even a structurally short limb (femur and/or tibia). If any of these conditions exist, they must also be addressed for a true and lasting improvement of the scoliosis to occur.

Sagittal Plane

Now, let’s explore sagittal-plane dysfunctional patterns of the spine and see whether the pelvis is the cause, or contributes to the cause, of the condition. Although no exact “pelvic-neutral” posture is agreed upon by all, it is safe to say a neutral pelvis would have a sacral-base angle that is approximately 30 degrees. The sacral-base angle is measured by the intersection of two lines: one horizontal line and the other across the base of the sacrum, hence the name (Image 8). A healthy sacral-base angle creates a healthy lumbar lordotic curve of extension. However, if the pelvis is excessively anteriorly tilted and the sacral-base angle increases to 45 degrees, then we can see there will be a hyperlordosis as a compensation to attempt to bring the center of weight of the trunk back over the pelvis. This is unhealthy because it increases weight bearing on the facet joints and decreases the size of the intervertebral foramina. And if the pelvis does not have sufficient anterior tilt and the sacral-base angle is decreased to 15 degrees, then the lumbar spine will be hypolordotic and the curves of the spine will be lessened. This is unhealthy because it increases weight bearing on the disc joints. Therefore, if a client presents with either a hyperlordosis or a hypolordosis of the lumbar spine, musculature that tilts the pelvis in the sagittal plane should be assessed.

There are two groups of sagittal-plane musculature across the hip joint that might be involved. Hip flexors in closed-chain mechanics function as anterior tilters of the pelvis; hip extensors in closed-chain mechanics function as posterior tilters of the pelvis (Image 9). If the client presents with a hyperlordotic lumbar spine, then we would look for tight/locked-short hip flexors (anterior tilters), and/or weak/locked-long hip extensors/posterior tilters. If found, these muscle groups would need to be treated as part of our treatment strategy. If the client presents with a hypolordotic lumbar spine, then we would look for tight/locked-short hip extensors (posterior tilters), and/or weak/locked-long hip flexors/anterior tilters. If found, these muscle groups would need to be treated.

We now turn our attention to the musculature that crosses from the pelvis onto the trunk in the sagittal plane. Our two groups are anterior abdominal wall muscles (rectus abdominis and the abdominal obliques) and the posterior trunk extensors (i.e., paraspinal erector spinae and transversospinalis musculature) (Image 10). Anterior abdominal wall muscles do flexion of the trunk, but in closed chain, they are posterior tilters of the pelvis. Paraspinal extensor muscles do extension of the trunk, but in closed chain, they are anterior tilters of the pelvis. If a client with excessive pelvic anterior tilt and a hyperlordotic spine has tight paraspinal extensors, then they should be treated as part of the treatment strategy. If a client with decreased pelvic anterior tilt and a hypolordotic spine has tight anterior abdominal wall musculature, then they should be the primary focus of treatment as part of the treatment strategy. And in each case, the relatively weaker locked-long musculature should be strengthened.

Looking beyond the pelvis and its musculature, we need to look for any other conditions that might change the tilt of the pelvis in the sagittal plane. One possible condition is hyperextension of the knee joints, which would likely result in excessive anterior tilt. We could also look at habit patterns that might result in dysfunctional sagittal-plane pelvic tilt, such as wearing high-heeled shoes. If any of these conditions or factors exist, they should be addressed.

Transverse Plane

The transverse-plane postural involvement of the pelvis and its relationship with rotational spinal dysfunctional curvatures is slightly more challenging to see but can be reasoned out in a similar manner to how we addressed the sagittal- and frontal-plane dysfunctions. Looking first at the musculature that crosses the lumbosacral joint from the pelvis onto the trunk, we can see that muscles that rotate the trunk to one side would, in closed-chain mechanics, rotate the pelvis to the opposite side (Image 11). A pelvis that is rotated to one side will likely create a rotational distortion pattern of the spine as a compensation to bring the head to be oriented anteriorly. 

If we turn our attention to the transverse-plane musculature of the hip joint, we have lateral and medial rotator muscle groups to consider. Lateral rotators can, in closed-chain mechanics, create opposite-side rotation of the pelvis. And medial rotators can, in closed-chain mechanics, create same-side rotation of the pelvis (Image 12).

Looking beyond the pelvis and its musculature, we need to look for any other conditions that might change the rotational posture of the pelvis in the transverse plane. One possible condition is overpronation of the foot, which usually creates a pattern of medial rotation of the lower extremity on that side that impacts the transverse-plane posture of the pelvis. Another consideration might be if someone sits with a large wallet or mobile phone in a back pocket. If any of these conditions or factors exist, they should also be addressed.

Treatment Approach

As manual therapists, our primary goal is to loosen any locked-short musculature. Treatment might consist of heat, massage, and stretching. Massage could and should also be done to treat the health of the locked-long musculature as well. If teaching strengthening exercises is within your scope of practice, then these should also be directed toward locked-long musculature.

Addressing the Root Cause of the Condition

The thrust of this article is to explore how postural dysfunctional patterns of the pelvis can result in compensatory patterns that impact the posture of the spine. For this reason, when a client presents with a spinal dysfunctional pattern, it is critically important for us to assess the posture of not only the spine, but also the pelvis. If the pelvis is found to have a dysfunctional pattern, we then look for the possible reasons for that dysfunction. It might be due to some other dysfunctional pattern of the lower extremity that impacts the pelvis, which then impacts the spine. Or it might be due to muscle tone imbalance of the pelvis (locked-short and locked-long muscle groups), perhaps between the pelvis and the trunk at the lumbosacral joint, or more likely, between the pelvis and the thigh(s) at the hip joint(s). If muscular imbalance is found, then it needs to be appropriately treated with manual and movement therapies.

Regarding the prognosis, as with any neuro-myo-fascio-skeletal condition, the amount of time and treatment needed to improve the condition is determined by its chronicity—in other words, how long it has been present. With increasing time, neural facilitation of muscle tone (what is called muscle memory) becomes entrenched in the nervous system, and fascial adhesions (what might be called fuzz) build up in the tissues themselves. But our treatment only stands a chance of being successful if we address the root cause of the condition. For the spine, the root cause is often the pelvis.

Image captions:

1. A right lateral view of the lumbosacral region. The lumbosacral (L5–S1) joint is located between L5 and the base of the sacrum. Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
2. A statue on a pedestal that is tilted (A) and level (B). Illustration by Giovanni Rimasti.
3. The Leaning Tower of Pisa. Illustration by Giovanni Rimasti.
4. (A) The pelvis is laterally tilted down to the right with the entire spine and head tilted to the right. (B) A compensatory scoliotic curve brings the head back to level. Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
5. Two examples of compensatory scoliosis for a pelvis that is laterally tilted down to the right. (A) A C-curve scoliosis. (B) An S-curve scoliosis. Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
6. (A) Frontal-plane hip joint abductors and adductors. (B) Hip abductors depress the same-side pelvis at the hip joint. (C) Hip adductors elevate the same-side pelvis at the hip joint (and therefore depress the opposite-side pelvis). Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
7. Frontal-plane lumbosacral joint lateral flexors on the left side elevate the left side of the pelvis and depress the right side of the pelvis (anterior view). Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
8. Sacral base angle. (A) 15 degrees. (B) 30 degrees. (C) 45 degrees. Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
9. (A) Sagittal-plane hip joint flexors and extensors. (B) Hip flexors anteriorly tilt the pelvis at the hip joint. (C) Hip extensors posteriorly tilt the pelvis at the hip joint. Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
10. (A) Sagittal-plane lumbosacral joint trunk flexors and extensors. (B) Trunk flexors posteriorly tilt the pelvis. (C) Trunk extensors anteriorly tilt the pelvis. Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
11. Transverse-plane lumbosacral joint trunk rotators. Rotators of the trunk to the right (A) can instead rotate the pelvis to the left (B). Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).
12. (A) Transverse-plane hip joint lateral and medial rotators. (B) Lateral rotators rotate the pelvis to the opposite side of the body. (C) Medial rotators rotate the pelvis to the same side of the body.  Permission Dr. Joe Muscolino. Kinesiology: The Skeletal System and Muscle Function, 3rd edition (Elsevier, 2017).