Back pain and a variety of other musculoskeletal complaints and injuries are more likely to occur if an athlete is out of alignment, which is the case in over 80%. This blog takes a closer look at the detrimental effects of malalignment on athletic activities. It will:

  • Summarize the clinical problems that can develop because of the biomechanical changes caused by malalignment of the pelvis and spine
  • Consider whether failure to advance in some sports is primarily a “natural process of elimination” or if it may, at times, be determined by the restrictions and asymmetries imposed on an athlete by the malalignment and therefore could be preventable


Malalignment may be caused by injuries in the form of strains, twists, and falls (e.g., football, judo, wresting). It can also develop as a result of preferring one side for carrying out an action (with most sports incorporating a right-hand/leg dominant pattern), poor posture (e.g., slouching), changing one’s way of carrying out movement patterns in order to avoid or minimize pain, or repeated asymmetrical throws and torsional stresses that are a part of many sports (Fig. 1).

Fig 1

Malalignment puts athletes at increased risk of developing a problem and/or recurrent injuries, especially those who are already out of alignment and those who take part in competition, tend to overtrain, or engage in sports that involve repeated:

  • lifting and bending forward and backward, which increase the mechanical stresses on the low back, particularly at the junction of the base of the spine and pelvis (e.g., weightlifting)
  • extreme twisting stresses on the pelvic ring of bones and the trunk (e.g., tennis, golf, dance routines, gymnastics, wrestling)
  • landing on one leg after a routine or jumping from one leg to the other (e.g., figure skating, gymnastics, running)
  • collisions and falls (e.g., lacrosse, hockey, football, rugby, basketball)

Soft tissues and joints that are already being subjected to abnormal forces because of the malalignment may eventually be unable to cope with the addition of an acute or repeated stress placed on them in the course of certain sports activities. This can result in inflammation, microtears, sprains or strains of muscles/tendons/ligaments, stress fractures, and early joint degeneration. Fig. 2 shows the most common problems seen.  For example, with both an “upslip” or a “rotational malalignment” of the pelvis, most often the foot and ankle on the:

  • right side tends to roll inward or pronate, putting extra stress on structures on the inside of that leg (e.g., the ligament crossing the inside of the right knee joint or MCL; Fig. 3: R)
  • left side tends to roll outward or supinates, stressing structures on the outside (e.g., the left TFL/ITB complex that crosses the outer hip and knee region; Figs. 3: L)

These stresses will be aggravated whenever the athlete works out on a sloped surface or goes counter-clockwise on a track (Fig. 4: #1).

Fig 2

Fig 3

Fig 4

Sometimes, athletes involved in a particular sport may think that the problem triggered by the malalignment is just part and parcel of that activity—something they come to expect—because teammates have had similar experiences. They may come to believe that their discomfort is just one of the things they have to put up with—a price to pay for participating in that sport.


Problems in sports that occur secondary to pelvic malalignment and rotational displacement of vertebrae basically are caused by the stress patterns that result from the:

  • Limitation of joint ranges of motion in certain directions
  • Side-to-side differences in muscle tension and strength
  • Alterations of weight-bearing, leg length, balance, and recovery
  • Secondary irritation of joint structures, soft tissues, and parts of the nervous system

All of these can eventually give rise to typical sites of pain, abnormal sensations, and other unwanted problems.

The changes associated with some presentations of pelvic malalignment may limit sports performance by:
  • Interfering with achieving the desired or required range of motion, either by:
    • limiting joint range in a direction specifically needed for a certain sport (e.g., reaching upward and back to throw a ball; rotating the trunk in kayaking and golfing; Fig. 5), or
    • limiting movement patterns that rely on a combination of trunk, pelvic, and limb motion (e.g., high jump, hurdles, gymnastics; Figs. 6, 7).


Fig 5

Fig 6

Fig 7

These limitations can create problems especially in those sports that may require all parts of the body to move through a full range of motion at any time, sometimes at high speed (e.g., gymnastics, lacrosse, court sports; Figs. 1, 8, 9, 10)

  • Provoking discomfort or pain and/or increasing wear and tear of soft tissues and joints
  • Affecting strength and endurance because of the apparent muscle weakness, reorientation of muscle fibres, wasting, and early fatiguing
  • Altering weight-bearing and balance, which, in turn, can affect controlled progression through a set routine, landing, and recovery (e.g., gymnastics, figure skating, classical dance/ballet; Fig. 10)
  • Disturbing symmetry, posture, and style (e.g., diving, synchronized swimming, weight-lifting; Figs. 11, 12)

Fig 8

Fig 9

Fig 10

Fig 11

Fig 12