Alignment of innominate bones in physiatric practice considering a reversible triad of pelvic obliquity, leg length difference, and scoliosis: a consecutive case-series study

Jussi Timgren, MD, Physiatrist


Context— Pelvic obliquity, leg length difference, and scoliosis present themselves as a reversible triad among patients with musculoskeletal pain.

Objectives—The purpose of this study was to examine the prevalence of reversible pelvic obliquity, and to assess the manifestations of asymmetry in skeletal posture.
Design—This was a consecutive case series study.

Setting—This study was set in the physiatric practice by one practitioner.

Patients—All consecutive first-visit patients during one calendar year, totaling 563, seeking relief for diverse manifestations of pain or discomfort were included in the present study.

Interventions—When the practitioner diagnosed pelvic obliquity, the patients were instructed to perform an alignment restoring self-correcting muscle energy maneuver.

Main Outcome Measure(s)—The practitioner examined the patients in the standing, prone, and supine position and compared the level of the iliac crests, inferior scapular angles, and anteroposterior shoulder position. With the patients in the standing position, the level of the iliac crests and scapular angles was determined either by using a Palpation Meter® or manually. During the second visit, the maintenance of the symmetry and degree of pain were evaluated.

Results—Reversible pelvic obliquity was found in 553 patients out of 563 (98.2%), and all except one were able to establish innominate alignment during the visit. The ilium was anteriorly rotated in 45.1% of the patients, causing ipsilateral leg lengthening and compensating scoliosis with a contra-lateral convexity. Among the patients, 53.1% presented with upslip of the ilium associated with leg shortening and scoliotic convexity, both ipsilateral. Of the 377 patients coming to the follow-up visit, 82,2 % reported significant or moderate improvement on their functional ability and reduction of pain. The maintenance of the symmetry was significantly associated with the alleviation of the symptoms.

Conclusion—Reversible pelvic obliquity is very common but mostly overlooked in patients having musculoskeletal pain. It presents itself in two clearly different forms. The restoration of innominate symmetry using the patients’ muscle energy is practicable and does not require any manipulative skills.


As early as in 1936, orthopedic surgeons Pitkin and Pheasant described a malalignment syndrome of the pelvis, which they called “Sacrarthrogenetic telalgia”. 1 It consisted of the following three features: a dysfunctional sacroiliac joint causing referred pain in the lower extremities, an oblique sacrum resulting in compensatory spinal scoliosis, and an asymmetrical position of the innominate bones appearing as leg length discrepancy. Their therapeutic goal was to restore pelvic alignment that also straightened out scoliosis and restored equal leg length.

Since then, numerous studies have evaluated sacroiliac joint dysfunction, scoliosis, and leg length discrepancy as separate factors. However, the possible interdependency of these three signs has received little attention in medical research. Hjul et al. 2 described six types of pelvic postural asymmetries using lumbar radiographs. They also examined coexisting scoliosis and leg length inequality. However, they did not consider the possibly repairable nature of the asymmetries.

In 1980, DonTigny proposed that anteriorly rotated dysfunction of the sacroiliac joint is causing pelvic obliquity, a high iliac crest, an apparent lengthening of the ipsilateral leg, and a laterally deviated lumbar spine contribute to the etiology of the low back pain. Based on his experience, he proposed that this condition could be corrected by mobilization of the SIJ. 3 In his book, The Malalignment Syndrome, 4 Schamberger demonstrates the repairable nature of pelvic obliquity and its relationship with leg length difference and functional scoliosis. He described how asymmetrical alignments of the pelvis, trunk, and extremities result in asymmetrical weight-bearing patterns, diminished ranges of motion, and increased tensions in muscles, tendons, and ligaments contributing to a variety of musculoskeletal symptoms.

A dysfunctional sacroiliac joint is widely recognized to be a source of low back pain. 5 6 On the other hand, the diagnosis continues to be a controversial issue. Clinical signs, provocation tests and positional palpation tests are considered to be unreliable for diagnosing pain originating in the sacroiliac joint. 7 8 9

The purpose of this consecutive case series study was to examine the prevalence reversible pelvic obliquity facilitated by the practitioner using the patients’ muscle energy and to assess the manifestations of asymmetry in skeletal posture.


Experimental design

This study consists of a retrospective analysis of all first visits to one physiatrist during the calendar year from January to December 2010. The practitioner assessed the pelvic, scapular, and shoulder position of all the patients. If pelvic obliquity was diagnosed, the patients were instructed to perform an alignment restoring self-correcting maneuver, after which the status of the pelvis and scapulae was reassessed. During a follow-up visit, the practitioner repeated the previous assessments requesting the patients to evaluate their pain and functional ability.

The study protocol was approved by the ethics committee of Helsinki University Central Hospital.


The total number of patients was 563 and 59 % of them were female. The age distribution was between 7 and 89 years, the mean age being 46 years.


In some of the patients, the difference in the level of the iliac crests and inferior scapular angles was measured using a Palpation Meter, PALM® (Performance Attainment Associates, St. Pail, MN, USA), and in the rest of the patients, the manual assessment was used. The Palpation Meter has been found to be a valid, reliable, and precise instrument for measuring the scapular position 10 11 and pelvic crest height difference. 12 13 14 It combines a caliper and an inclinometer which produces the difference in height by a sine function slide ruler. Furthermore, all patients were tested by positioning a 12-mm thick wooden plate under their feet.


The practitioner noted the medical history and examined the patients in the standing, prone, and supine position. The level of the iliac crests, inferior scapular angles, and anteroposterior shoulder position were compared.


When the iliac crest was higher on one side, a 12-mm thick wooden plate lift was placed under both feet for lift. The leveling of the pelvis with a lift under one foot but increased elevation with the same lift under the opposite foot further verified the existence of pelvic obliquity.

The practitioner repeated the assessment after the self-correcting muscle energy maneuver described by both DonTigny 15 and Schamberger 4. Accordingly, the patients were instructed to perform a strong isometric contraction of their hamstrings and gluteus maximus (Figure 1). For patients with a hip or knee prosthesis, an alternative method of a cross-over stretch was used to avoid exposing the hip joint to strain (Figure 2).

Figure 1 The self-correcting muscle energy manoeuvre

Initial posture: In the upright sitting posture with slightly elevated foot, extended arms embrace the

upper shin beneath the knee.

Procedure: The thigh is isometrically extended against the crossed fingers, gradually augmenting

the intensity for 3 seconds, until maximal force is reached. No visible movement is produced. The same manoeuvre is done on both sides once.

Figure 2 The alternative self-correcting muscle energy manoeuvre Initial posture: With feet side by side shoulder-width apart, one foot is placed on a 25–45 cm high stool.

Procedure: The hand on the elevated side reaches as far down as possible towards the opposite foot. Then, by turning around, the opposite foot is placed on the stool, and the reach of the other hand is repeated. The procedure is repeated for four times,


The pelvic obliquity was considered to be reversible when after the mobilization, the iliac crests were in level and the same lift under both feet in turn equally elevated both iliac crests. During the follow-up visit, the patients were asked to evaluate their treatment using a semi-quantitative scale from 3 to 1 as follows: 1) significant improvement (patient estimated as having over 50% alleviation of symptoms), 2) moderate improvement, and 3) no response.

The practitioner performed Adam’s Forward Bend Test by patients by whom visible spinal asymmetry remained after establishing the innominate equilibrium.

Statistical analysis:

Maintenance of symmetry was correlated with the treatment response by a 4-field matrix (improvement, no improvement, maintenance of symmetry, or relapse of asymmetry). Statistical analysis was performed using a  -test.

The present study focused on the innominate equilibrium and comorbidity-related symptoms caused by intervertebral discs, joints, nerves, or myofascial trigger points were not considered.



The localization of pain in individual patients varied from lower and upper back, neck, head, and the four extremities. The practitioner interpreted the pain to be mainly of myofascial origin. The duration of the presenting symptoms was definable in 506 of the 563 patients (89,9%). The average length of symptoms was 4.7 years (median, 2.0 years).

The vast majority of the patients, 553 (98.2%), had an oblique pelvis where the self-correction maneuver re-established symmetry of the innominate bones. One patient with obliquity could not restore symmetry. His obliquity was undefinable, possibly down slip. Only nine patients out of 563 presented with pelvic symmetry.

The pelvic obliquity manifested itself in two clearly different ways. The practitioner defined them as anterior rotation and upslip of the ilium. Table 1 shows the observed differences between the two categories. The most noteworthy difference between the two is that in the anterior rotation, the 12-mm lift under the ipsilateral leg caused the iliac crest to elevate further, while in the upslip, the placement of the lift caused the iliac crest to descend to the level of the opposite side. Table 2 shows the mutual relationship between the two categories.

Table1. Anatomical differences between anterior rotation and upslip of the ilium


Anterior rotation


Standing with weight equally on both feet

Ilium in anterior rotation

Compensating scoliosis with contralateral thoracic convexity and protruding shoulder

Ilium in anterior rotation

Compensating scoliosis with ipsilateral thoracic convexity and protruding shoulder

Standing on a lift (12 mm) under the contralateral foot

Iliac crests are even

Contralateral iliac crest elevated

Standing on a lift (12 mm) under the ipsilateral foot

Ipsilateral iliac crest further elevated

Iliac crests are even

Lying in the supine position

Ipsilateral leg longer


Ipsilateral leg shorter


Table 2. The number and mutual relation of anterior rotation and upslip


Anterior rotation




254 (45,1%)

299 (53,1%)



206 (37.3%)

178 (32.2%)



48 (8.7%)

121 (21.9%)



The change from obliqueness to symmetry and vice versa was clear and without transitional forms. In both cases, establishing the pelvic symmetry also caused restoration of equal leg length and straightening of scoliosis.

The asymmetry was measured using the Palpation Meter in 130 patients (23.5%). The measured height difference between the iliac crests varied between 28 and 8 mm, with an average of 17 mm. The difference in height of the scapular lower angles varied between 22 and 0 mm, with an average of 13 mm. After re-establishing of the symmetry, the difference between iliac crests was ≤ 3mm. Both methods described in Figure 1 and 2 were equally effective in re-establishing the symmetry. Seven patients with knee or hip prosthesis used the latter method.

In 4 cases, there was a concomitant idiopathic scoliosis with a positive Adams Bend Test (e.g., unilateral elevation of thorax during spinal flexion). In reversible pelvic asymmetry, the Adams test is negative. Idiopathic scoliosis seldom causes rotatory component with protruding shoulder whereas that is the rule in reversible scoliosis.

By 28 patients scoliosis and by 20 patients a leg length difference had been clinically diagnosed in the past, up to 50 years earlier. Nine of the patients mentioned above were given both diagnoses. By all of these patients, both scoliosis and leg length turned out to be reversible.


Of all the 563 patients 377 (67,0%) attended the follow-up visit. The average time between the first and the follow-up visit was 44 days. One-hundred and eighty-one patients (48.0%) who attended the follow-up visit reported a significant improvement in functional ability and reduction of pain, and 139 (36.9%) reported moderate improvement. The number of patients who reported no improvement was 57 (15.1%). During the follow-up examination by 354 (93.9%), pelvic symmetry had been maintained. Table 3. presents the maintenance of symmetry in correlation with the treatment response by a 4-field matrix (improvement, no improvement, maintenance of symmetry, or relapse of asymmetry.) Treatment response was strongly associated with the maintenance of symmetry ( = 32.7, df = 1, P-value < 0.001)  


Table 3.  Correspondence of maintained symmetry and significant or moderate improvement of condition reported by the patients during their last follow-up visit.

Maintenance of symmetry

Relapse of symmetry

Improvement (n)



No improvement (n)



Total (n)





The universality of the reversible innominate asymmetry is the most notable outcome of the present study.  Analogous observations do exist. In our previous study 16 we analyzed 150 consecutive neurologic patients referred to physiatric consultation based on their clinical examination findings in Helsinki University Central Hospital. We observed a reversible pelvic asymmetry associated with either C-type or S-type scoliosis and an apparent leg-length difference in 87% of the patients. Improvement of the patients’ condition correlated strongly between maintained symmetry (P < 0.001) .

 Schamberger 4 estimates that approximately 80–90% of adults present with malalignment. In a study by Shaw 17 that included 1,000 consecutive patients with low back pain, 98% had a mechanical dysfunction of the sacroiliac joint presenting as malalignment of the pelvis and leg length difference. The most common finding reported by Shaw was an anteriorly rotated ilium with locked fixation.

Minor anatomical asymmetries of the bony structures are very common in the normal population. Ferreira et al. 18 conducted a quantitative assessment of postural alignment in young adults based on photographs, and their findings revealed that small asymmetries represent the normative standard for posture in standing. Positional or structural tests for assessing innominate symmetry are considered to be unreliable. Stovall and Kumar 19 reviewed the anatomical landmark asymmetry assessment of the lumbar spine and pelvis and concluded that “From the current literature review, bony anatomical landmark positional asymmetry assessment in the lumbar spine and pelvis has not been demonstrated to be a reliable assessment method. However, there are unexplored factors that, after standardization, may improve reliability and further the understanding of musculoskeletal palpatory examination.” The method introduced in the present study contributes to a valid assessment of bony asymmetric landmarks. The mean difference in height on the level of iliac crests was rather noticeable at 1.5 cm when measured with the Palpation Meter. When asymmetry was present, the alternating use of lift under both feet additionally magnifies the difference. In their review article concerning limb length inequality, Brady et al. 20 stated that the methods involving the palpation of pelvic landmarks with block correction have the most support for clinical assessment of leg length difference. After self-treatment, the disappearance of the difference offered a final confirmation concerning the reversible nature of the asymmetry. The use of the Palpation Meter provides quantitative precision to the assessment before and after treatment. Qualitative certainty is possible to obtain manually with the help of the lift. The difference before and after the treatment is also observable by most patients themselves both by seeing their mirror image change back to symmetry and the changed impression back to equilibrium when comparing the lift under both feet.


In the present study, no observable anatomical leg length differences were found. It does not seem feasible to prescribe shoe lifts to patients before a reversible pelvic asymmetry has been ruled out. There were also patients in whom scoliosis had been diagnosed years before in their school years, which now proved out to be of reversible nature and others using prescribed shoe lifts with the assumption that the leg length discrepancy is anatomical.

The two major causes of pelvic obliquity anterior rotation and upslip can be distinctly separated under two different conditions although both share an anterior rotatory component of the ilium in the standing position. Correspondingly, DonTigny 3 maintains that a dysfunctional sacroiliac joint can only be anteriorly, not posteriorly, rotated.


The movement of the sacroiliac joint is small and consists of a combination of rotation and translation. 21 In the anterior rotation, the ilium has been locked into a position exceeding its natural rotatory range. In upslip, the physiological translation in the cranial direction has been equally surpassed and also locked. The observed phenomena in upslip, where the elevated iliac crest levels up with the opposite side after placing the lift under ipsilateral foot, warrants further biomechanical clarification.


The rationale for the effectiveness of both realigning maneuvers (Figures 1 and 2) seems to be the fact that both share a forced pull from the inferoposterior region of the ilium through the gluteus maximus and hamstring muscles. The attachment of the former is in the inferior iliac spine and the latter in the ischial tuberosity. The maximal energy used first unlocks the location on the sacroiliac joint, from its maximum anterior rotation, and brings the joint in its physiological middle position. The second maneuver causes an alternating stretch of the same muscles. Both movements result in bringing the anteriorly rotated or up slipped ilium back to the correct position.


Based on the present study findings, the sacroiliac joint dysfunction is concurrent with the distorted position of the pelvis that can easily be observed and measured. Whether this could contribute to the diagnosis of sacroiliac joint dysfunction remains to be elucidated. This observational study did not consider other co-existing factors of pelvic obliquity, such as torsion of the sacrum and innominate inflare or outflare.



Despite the high frequency of reversible pelvic obliquity among patients having musculoskeletal pain, pelvic obliquity remains mostly unrecognized. It presents itself in two clearly identifiable but different forms.  The validity of the manual assessments can also be questioned. However, the described use of the lift under both feet in an alternating sequence greatly enhances the diagnostic accuracy.

 Many patients participating in this study had been seeking help repeatedly for years from diverse sources of treatment in vain, which had led to frustration. However, the relief of long-lasting pain after re-establishing pelvic symmetry justifies considering it primarily to be a consequence of pelvic obliquity. The restoration of pelvic symmetry, leg length equality, and straightening of scoliosis confirms their functional character. Instead of focusing primarily on the dysfunctional sacroiliac joint as a potential cause of pain, the whole picture, however, can first be attained when we consider the pelvis as a functional unit affecting the spine and lower extremities.


The author thanks  Mikko Aronniemi, Ph.D for statistical advice and an anonymous editor for revising the language.







Pitkin H, Pheasant H. Sacrarthrogenetic telalgia II. A Study of Sacral Mobility. Am J Bone Joint Surgery. April 1936;18(2):365-374.


Juhl JH, Cremin TM, Russell G. Prevalence of Frontal Plane Pelvic Postural Asymmetry—Part 1. The Journal of the American Ostheopathic Association. October 2004;104(10):411-421.


DonTigny. Anterior Dysfunction of the Sacroiliac Joint as a Major Factor in the Etiology of Idiopathic Low Back Pain. Physical Therapy. April 1990;70(4):250-262.


Schamberger W. The Malalignment Syndrome. London: Churchill Livingstone; 2002.


Slipman C, Whyte W, Chow D, Chou L, Lenrow D, Ellen M. Sacroiliac Joint Syndrome. Pain Physician. 2001; 4(2):143-152.


Simopoulos T, Manchikanti L, Singh V, et al. A Systematic Evaluation of Prevalence and Diagnostic Accuracy of Sacroiliac Joint Interventions. Pain Physician. May/June 2012;15(3):E305-E344.


Behdad HR, Sharwin T, Hamilton C, Danielle P. Diagnosis and Current Treatments for Sacroiliac Joint Dysfunction: A Review. Current Physical Medicine and Rehabilitation Reports. Mar 2014;2(1):48-54.


van der Wurff P, Meyne W, Hagmeijer R. Clinical tests of the sacroiliac joint, A systematic methodological review. Part 2: Validity. Manual Therapy. May 2000;5(2):89-96.


Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine. Jan 2006;73(1):17-23.


Rondeau W. The Accuracy of the Palpation Meter (PALM) for Measuring Scapular Position in Overhead Athletes, Dissertation. Chapel Hill: University of North Carolina; 2007.


da Costa B, Armijo-Olivo S, Gadotti I, Warren S, Reid D, Magee D. Reliability of scapular positioning measurement procedure using the Palpation Meter (PALM). Physiotherapy. Mar 2010;96(1):59-67.


Petrone M, Guinn J, Sutlive T, Reddin, A, Flynn TW, Garber MP. The accuracy of the Palpation Meter (PALM) for measuring pelvic crest height difference and leg length discrepancy. The Journal of Orthopaedic and Sports Physical Therapy. Jun 2003;33(6):319-325.


Hagins M, Brown M, Cook C, et al. Intratester and Intertester Reliability of the Palpation Meter (PALM) in Measuring Pelvic Position. The Journal of Manual & Manipulative Therapy. 1998;6(3):130-136.


Azevedo D, Santos H, Carneiro RL, Andrade GT. Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter. Journal of Bodywork and Movement Therapies. Apr 2014(2):210-214.


DonTigny. A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction. In: Vleeming A, Mooney V, Stoeckart R, eds. Movement, Stability & Lumbopelvic Pain. 2nd ed. Edinburgh: Churchill Livingstone; 2007.


Timgren J, Soinila S. Reversible pelvic asymmetry: an overlooked syndrome manifesting as scoliosis, apparent leg-length difference, and neurological symptoms. Journal of Manipulative and Physiological Therapeutics. September 2006;29(7):561-565.


Shaw J. The role of sacroiliac joint as a cause of low back pain and dysfunction. In: Vleeming A, Mooney V, Snijders C, Dorman T, eds. Proceedings from the First Interdisciplinary World Congress on Low Back Pain and its Relation to Sacroiliac Joint. San Diago; 1992.


Ferreira E, Duarte M, Maldonado E, Barsanetti A, Marques A. Quantitative assessment of postural alignment in young adults based on photographs of anterior, posterior, and lateral views. Journal of Manipulative and Physiological Therapeutics. July/August 2011;34(6):371-380.


Stovall B, Kumar S. Anatomical Landmark Asymmetry Assessment in the Lumbar Spine and Pelvis: A Review of Reliability. PM&R. January 2010;2(1):48-56.


Brady RJ, Dean JB, Skinner TM, Gross MT. Limb length inequality: clinical implications for assessment and intervention. Journal of Orthopaedic & Sports Physical Therapy. May 2003;33(5): 221-234.


Lee D. The Pelvic Girdle. Second Edition ed. Edinburgh: Churchill Livingstone; 1999.