We’ve all heard it or know someone who has been told their hips are out of alignment. In fact assessment of hip alignment was taught to me during my athletic training and physical therapy curriculum, just 8 short years ago. I still hear it today from a lot of my patients and clients. “The doctor and my old physical therapist said my hips were out of place.” I want to set the record straight here. Your hips do not go out of place.
What do people even mean when they say that? Did you just dislocate your hip? What the practitioner is referring to is the pelvic bones (left vs right) being slightly misaligned. Furthermore, they are implying if they fix that alignment, then your pain or symptoms will go away. As you can see in the picture below, the pelvic ring is made up of 3 bones: the left ilium, the right ilium, and the sacrum. It has 3 joints: the pubic symphysis in the front, the left sacroiliac (SI) joint in the back, and the right SI joint in the back.
Here’s a picture from the back (think staring at someone’s behind) showing all the ligaments connecting the ilia to the sacrum.
Herein lays the problem. As the hips are a big means of generating power and transferring force between the lower extremities and the trunk/upper extremities, the SI joints and pubic symphysis need to be very stable joints to handle that stress. As shown in the picture, the amount of ligamentous presence provides such stability. All of this suggests that the SI joints don’t move very much. A study conducted by Goode et al to review 3D motion of the SI joint using live subjects and cadavers demonstrated the following:
Translation on the X-axis (side to side) ranged from 0-8mm (YES, millimeters)
Translation on the Y-axis (up/down) ranged from 0-7mm
Translation on the Z-axis (forwards/backwards) ranged from 0-6mm
Rotation around any of those axes was anywhere from 0-8 degrees
Now that is not a lot of motion. If you are telling me that you can sense a 6mm difference from one hip bone to the other, then you must be superman. That is argument number 1. Maybe you know somebody that would make a very good counterpoint to this issue. Here comes argument number 2. Everyone is different. Are we all perfectly symmetrical? No, if you meet someone trying to tell you that then you need to walk away before you get angry and accidentally kill someone.
Preece et al investigated pelvic morphology and found that difference in the front and back bony landmarks of the pelvic (ASIS and PSIS – see first picture) ranged between 0 and 23 degrees on 30 different subjects. Side to side comparison of the same landmark (i.e. L ASIS vs R ASIS) varied up to 11 degrees. Lastly, comparing height of one ilium to the other ranged from 0 to 16mm difference. These show that on any given individual, your bony landmarks and alignment could be very asymmetrical. Combine that with argument 1 and then you are left with the question, “how the heck do I tell if the L ASIS is out of alignment if it only moves 8mm and this person’s [normal] alignment could be 16mm different to begin with?” Another study by Barbosa and colleagues showed that 12% of males and 38% of females have pelvic asymmetry.
Let’s say you are still entertaining the idea that your hips are out of alignment. There has been plenty of research on physical examination techniques to ID “misalignment.” O’Haire and Gibbons found that palpating the landmarks (finding ASIS/PSIS/sacrul sulcus/inferior lateral angle with your fingers) yielded average accuracy of one practitioner testing the same subject multiple times to be 33% at its highest. Riddle et al found the accuracy to be slightly higher approaching 50%. That means if I find your bony landmarks, measure them, wait a minute, and try to identify the same spot, I have a 33 to 50% chance of getting it. Then I arbitrarily tell you that your hips are in much better alignment and you magically feel way better.
So there it is. Please, please, please don’t let a practitioner tell you that your hips are out of alignment. Just tell them you want your money back and go somewhere else. You need to find someone that will address the real source behind your back/hip/leg pain. Thanks for reading, and if you have questions please leave a comment!
References
Barbosa, A., Bonifacio, D., Lopes, I., Martins, F., & Barbosa, M. (2014). Análisis descriptivo de la asimetría pélvica en una población asintomática. Acta Ortopédica Mexicana, 28(1), 28-32.
Goode, A., Hegedus, E., Sizer Jr., P., Brismee, J., Linberg, A., & Cook, C. (2008). Three-dimensional movements of the sacroiliac joint: A systematic review of the literature and assessment of clinical utility. The Journal of Manual & Manipulative Therapy, 1, 25-38.
O'Haire, C., & Gibbons, P. (2000). Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: Pilot study. Manual Therapy, 5(1), 13-20.
Preece, S., Willan, P., Nester, C., Graham-Smith, P., Herrington, L., & Bowker, P. (2008). Variation in pelvic morphology may prevent the identification of anterior pelvic tilt. The Journal of Manual & Manipulative Therapy, 16(2), 113-117.
Riddle, D., & Freburger, J. (2002). Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: A multicenter intertester reliability study. Physical Therapy Journal, 82(8), 772-781.