This is a question that comes up all the time in clinic. People have often been told their hips, pelvis or back is out. For most people this means that there is some pain in the back or pelvic area. You may feel some tightness or pulling in back or hips that may feel like you are being pulled out of alignment. But what is really happening?
You may sleep in a funny position, bend, twist or lift something heavy in an awkward position and you feel a sharp pain in your lower back.
Many people have been to a Chiro or Physio that will just put your back back in. This is an oversimplification of what is happening. In reality there is nothing in your back that is going “out”. For this to happen you would be dislocating a joint, which would be extremely painful and would need some serious work to get the joint back in.
What is really happening?
There are many ways you can injure your back that may make it feel like it is “out”. Here are the most common reasons:
protective muscle spasm. The body is great at protecting itself. Say you go to lift that heavy box while you are moving house. It’s in an awkward position and you have to twist your back to get to it. By putting your spine in a compromised position there is a risk you may damage a spinal disc or sensitive facet joint so the body tightens up the lower back muscles to stop you from hurting yourself. The only problem is that the tightness can then lead to pain. The body can be a bit over protective when it comes to injuries.
Disc bulge. If you have injured a disc in your spine, whether it is a herniation to the disc (fancy talk for disc bulge) or a tear to the outer layer of the disc (annular tear) you will lean away from the side that is painful. This will give you the feeling that your back is out as you will be tilting your spine. When the inflammation in the disc settles or heals you will find that your spine will naturally go back into alignment.
Joint injury. This encompasses irritation or degeneration (a nicer way to say osteoarthritis) to the spinal facet joints as well as the sacroiliac joint (SIJ). Again if you have pain in a joint your body will try to avoid leaning on the joint so you will lean away, also giving you a sense that you are out of alignment.
With most of these injuries there will be an element of releasing the tightened, injured tissue as well as allowing the injury to heal and not re-aggravate it. This is where avoiding heavy lifting, twisting, running or sitting or standing for too long is important.
I can be a little pedantic when it comes to a diagnosis. People are often told they have injuries that don't really exist such as your back being out or your hips being uneven. Basically there is no such thing as your back being out. If you are told this then dig a little deeper and challenge your practitioner to be more specific. If they can't then you may not be getting a clear idea of why you are in pain.
Uneven hips, leg lengths, rotated pelvis and the ubiquitous "bit of scoliosis".
We hear these diagnosis’ all the time. The truth is there is little solid evidence to link these issues with pain. Most people have uneven hips, different, leg lengths, a rotated pelvis and yes, even some scoliosis. Scoliosis is the most common diagnosis that gets thrown around. Don't get me wrong a severe scoliosis can cause pain but a little bit of scoliosis is as likely to cause your pain as having a crooked nose may be affecting your sinuses. I always comment that we need to change what a normal spine looks like in the text books as no one has a perfect spine. If you compare everyone to a straight spine or aligned hips then of course we are all dysfunctional.
There have been many studies over the years and few of them have found a direct link to pain from things like leg length, rotated pelvis or uneven hips. Some studies have shown positive results from giving patients heel lifts to correct the leg length, but again these are big test groups and it certainly doesn't work all the time.
Practitioners such as Chiro's, Osteo's, Physio's, sports doctors, podiatrists, orthopaedic surgeons and massage therapists spend a lot of time scrutinising all of these things. Again if one of your legs is 5cm longer then you will notice some major issues up the chain. I have read, studied and have been told from many practitioners that there can be up to as much as 5mm-1.5cm difference between legs without issue. Most people can't actually decide on what the average is so if one practitioner says that 5mm difference is a problem then everyone suddenly has a problem.
If the bones of your legs are different lengths then this is called a structural leg length discrepancy. If the legs appear to be different lengths and the bones are the same length then it is said to be a functional leg length discrepancy. This can occur from muscle imbalances, foot pronation,
The big issue here is that it may not really be the legs that are uneven at all that make it appear that one leg is short or long. If the muscles of the lower back and hips are tight they could be pulling the pelvis up to one side making it appear that that leg is shorter. Also the way the head of the femur sits in the hip joint can influence the appearance of the length of your legs. The only true way to have your leg length checked is by scanning them and measuring the bones. Having someone put your ankles together and say that one leg is short is very unscientific and how do you know if you have a short leg or a long leg, which one is the problem. There are some easy special tests to check where this leg length is coming from. But at the end of the day everyone has a slight difference in leg lengths, just like we have slight differences in foot size.
Another thing to think about with leg length is that most people don't stand up all day and even if they do they don't stand in a square, even position where leg length may influence the pelvis. Most people sit all day, basically from school age, so the length of the legs will have a very small influence on the spine and pelvis anyway. Your leg length will only influence your pelvis in a standing, walking or running position. I think this is often overlooked.
This is the king of the truly ambiguous diagnosis. Get ready to have your mind blown…. wait for it…. there is actually no such thing as a rotated pelvis. If someone tells you that you have a rotated pelvis make sure to ask exactly what they mean by this to make sure they aren't just being vague. What most practitioners and doctors mean by a rotated pelvis is actually called an anteriorly or posteriorly tilted pelvis. Each side of the pelvis can move independently and one may be slightly more tilted. Again this is all very normal and most people have some difference between sides. They are both very different issues. An anteriorly rotated pelvis will require a different treatment to a posteriorly rotated pelvis. There are other pelvic differences that may also get lumped into the rotated pelvis black hole. They are the illusive pelvic inflare or outflare and the high ilium. Pronation and foot biomechanics can also influence the hips and that is a whole other blog piece.
Just think about it for a second. If you are expected to have the perfectly aligned spine, hips and pelvis as well as your legs, feet and arms have to be the same length then we can all be diagnosed as being dysfunctional and we should all be walking around in agony from these misalignments. Whilst it is important to check these postural issues they may not always be the cause or reason you are in pain. Ligament sprains or tears, muscle strain, muscle spasm, disc injuries, joint injuries are much more likely.
The interesting thing with all of these postural considerations there is no consistency. One person with scoliosis or a longer leg may have pain but someone else with exactly the same issue may have no pain. If you broke your leg then you would expect everyone with a broken leg to be in pain. If a “rotated” pelvis was this much of an issue you would expect everyone with a rotated pelvis would be in pain.
What should I do?
Firstly if you throw your back out you should get it looked at and treated as soon as possible. The longer you leave an injury the more likely it won't just get better by itself, you may also injure it further and it may then become chronic.
Here are some tips:
rest and avoid heavy lifting while you are in the acute healing phase of injury. This is a great time to get everyone else around you to lift the heavy couch or groceries.
keep moving. I know the last tip was rest but this doesn't mean just laying in bed watching netflix for weeks. Some gentle stretching and mobility will help your body not stiffen up which will exacerbate the injury.
maintaining a strong core and pelvic region including glutes. This will mean your pelvis and lower spine will be more stable when you are moving about and lifting. Meaning you will be less likely to injure your SIJ or lower back.
Squat to lift. This is very simple advice but most people still bend over to pick things up off the floor. If your bend forward and twist at the same time this is the easiest way to damage your spine.
Correcting your standing or sitting posture can make a big difference to your pelvic position. Don't lean all of your weight to one leg when standing or one hip when sitting. Try to sit up straight on your sit bones so not to create pelvic tilts.
get regular massage to prevent muscle tightness and spasm from building up.
Don't sit or stand in the same position for too long. The body needs to move so if you keep it stationary for too long you are asking for trouble.
If you really think your legs are different lengths then getting a scan or a thorough assessment to assess where the issue is coming from. If the root cause is found then it can be corrected.
So there you have it. To say that your back or pelvis is “out” doesn't really explain what is going on. practitioners often need a simplified way to explain to clients what is going on in their body. But being more specific leads to a more targeted treatment and plan for recovery and also to find out why it may have happened in the first place and to prevent it from happening in the future.
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Interesting further reading and links to research articles