Overview of alignment Part 1 of 2 – Understanding The Negative Impacts Of Pelvic Malalignment In Athletes


80–90% of the general population presents with the pelvis, spine, or both out of alignment, making this group vulnerable to suffering needless pain and being prone to injury. Athletes are at even greater risk, and the unfavourable effects that malalignment has on their style and energy efficiency decreases their chances of being able to realize their full potential.


Approximately a third of those affected by malalignment experiences abnormal sensations, discomfort, or outright pain in structures that are put under stress by the malalignment and/or at distant sites that these troubled structures can refer to. Another third has no symptoms but reports discomfort or sensory changes when soft tissue structures and joints are intentionally stressed as part of an examination, or are subjected to increased demand in the course of a longer than usual workout, a competition, or by having to cope with difficult terrain. The most common problems experienced are shoulder, back, hip, and knee pain. For example, in those with back pain, malalignment is recognized as the primary cause for the pain in 30% and a contributing factor in another 20 – 30% of those suffering back pain because of disc degeneration or some other problem affecting the spine or nervous system.
During our normal walking cycle, the right and left hip bone and the sacrum wedged between them move in a figure-of-eight pattern (Figs. 1, 2). For various reasons, these bones can get stuck out of place relative to each other. The most common finding, the so-called “rotational malalignment”, shows one hipbone stuck rotated excessively forward or backward relative to the sacrum (Fig. 3). In the case of an “upslip”, one hip bone ends up stuck displaced upward relative to the sacrum and opposite hipbone (Fig. 4). Hip bones can also get stuck winged outward (“outflare”) or inward (“inflare”) relative to the sacrum (Fig. 5). Athletes can easily learn to do an assessment on their own or with the help of a friend to establish whether they are out of alignment and in which way. If so, there are some simple self-treatment techniques – making use of strategically placed muscles, traction, and leverage manoeuvres – that may allow them to correct or, at least, decrease the degree of malalignment present until they can see their therapist.

Fig 1

Fig 2

Fig 3

Fig 4

Fig 5

Both an upslip and a rotational malalignment are characterized by additional changes in body biomechanics from head to toe. The pelvis tilts upward to one side, resulting in formation of compensatory curves of the spine and with one shoulder ending up lower than the other (Figs. 3, 6). In addition, there results:

  • a difference in leg length, with one appearing shorter than the other when they are lying down or sitting up, legs straight in front of them (Fig. 7)
  • a shift in weight-bearing; most often with the right leg turning outward and the foot rolling inward or “pronating”, the left leg turning inward and the foot rolling outward or “supinating” (Figs. 8A,B, 9, 10, 11Bi,ii). The wear of the soles of the shoes and collapse of the heel cups may reflect this shift (Fig. 12)
  • a side-to-side difference in the:
    • strength and tension in pairs of muscles; one appears weak while the one on the other side proves to be strong; one muscle is tensed-up, its partner relaxed (Fig. 13)
    • range of motion possible in any one direction on comparing pairs of joints (Fig. 14A), while the combined amount of motion possible in the right and left joint remains the same
  • problems with balance and movement

Fig 6

Fig 7

Fig 8A

The tendency to right pronation and left supination results in abnormal stresses on the joints and soft tissue structures (ligaments, tendons, muscles), especially in the legs and when standing and walking, putting them at risk of becoming tender or outright painful (Fig. 11Bi,ii). For example, typical trouble spots result because:

  • Pronation lengthens the distance between the groin and the inner edge of the foot. It increases tension in particular on the knee cap and patellar tendon complex, ligaments spanning the inside of the knee (e.g., medial collateral ligament or MCL), calf muscles/Achilles tendon (AT) complex, and inner ankle ligaments (Figs. 9: right AT tensed, 10: right)
  • Supination lengthens the distance between the crest of the hip and the outer edge of the foot, increasing tension in all the structures on the outer part of the leg (Figs. 10: L, 15: A-F). Particularly vulnerable are the left TFL/ITB complex (tensor fascia lata muscle and its continuation as the iliotibial band, overlying the thigh and knee), outer knee ligaments (e.g., lateral collateral ligament or LCL), and the outer ankle ligaments and shin muscles (e.g., peroneus longus; Fig. 10).

Fig 8B

Fig 9

Fig 10

Fig 11

Fig 12

Fig 13

Fig 13

Fig 15

Fig 14A

Fig 14B

Realignment of the pelvis 

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