16 Nov Are Your Hips Really Out of Alignment? Are Your Legs Different Lengths?
It’s a pretty common story we hear in physical therapy practice on a weekly (maybe daily) basis: “I’ve been told by my (insert healthcare provider here) that my hip alignment is off and my hips are out of place. Can you put them back quick before we start our session today?”, “I don’t think my pelvis is aligned right, my one leg feels longer than the other. Can you take a look?”, or “Can you do a quick check for me? My alignment is off.” I doubt it. But we should probably dive a little bit deeper than that shouldn’t we? There is a ton to unpack here. To be honest, it’s probably one of the most emotionally charged topics within this field. That being said, I hope I can bring some good discussion to the table today, and help provide some reassurance for you. I’ll say it again, and trust I do so with a positive and optimistic demeanor (not a dismissive one): I doubt the notion that your hips really are out of alignment, and for good reason in your favor! Let’s try and break this down mechanically, culturally, psychosocially and take a look from an evidence-based perspective — visiting some pertinent literature along the way. Read on if I’ve caught your attention!
A Mechanical Perspective On Hip Alignment: What does it mean for my hips to be out of alignment?
Prior to graduating from physical therapy school and actually joining the field as a practicing clinician, I would have never imagined the challenge that accompanied topics like hip alignment, innominate rotations, and leg length discrepancies. These words hold deep-rooted beliefs and heavy connotations carried by many of our patients, reinforced through years and years of various, mostly well-intentioned, musculoskeletal healthcare providers. Some clinicians may even use these terms publicly, almost as an advertisement, to draw in clientele (1).
Now, I would hope that the clinician who discussed your hip malalignment with you in the past at least had a detailed conversation with you and followed up with a purposeful clinical examination afterward. If this is the first thing you heard while walking in a clinic without a nice exchange of dialogue or your clinician putting their hands on you — this relationship probably isn’t going to work out. There are many skilled manual therapists, far more skilled than I, but none of us are skilled enough to draw conclusions like this just upon observation. In fact, we probably aren’t skilled enough to make these claims based on physical examination either! (We’ll touch on this here in a bit.) Regardless, there are several different entry-points that can lead a clinician down the “hip malalignment” path including:
- Innominate “malalignment” (innominate rotation, nutation, counter-nutation, etc.) found on hip alignment examination.
- A leg length “discrepancy” found on hip alignment examination.
- Patient complaints of sacroiliac (pelvic) pain or low back pain that leads us to evaluate hip alignment
Many of these terms can be confusing and intimidating for those not well-versed in the field. Let’s break each one down individually.
Mythbusting Cracking Joints
Grossly speaking, your pelvis is essentially divided into 3 parts. Here’s a basic illustration of your pelvic anatomy.
Now, with some colors added, we can name those parts further. To your left in red is the right innominate, to the middle in blue is the sacrum, and to your right in yellow is the left innominate.
Pelvis Innominates and Sacrum Anatomy
These three separate pieces and their relationships to one another have been discussed extensively in the manual therapy, manual medicine, osteopathic and chiropractic literature dating back to the 19th century (2). The best way I could think to describe how these pieces “move” on one another is through the fairly inaccurate metaphor of a Rubix Cube. (I can’t even begin to explain to you how much more stable your pelvis is than a child’s toy.)
Pelvic Movement and Rubic Cube Analogy For Hip Alignment
I’ve colored the three different columns of our cube here to match our our pelvis illustration above. Generally speaking, it has been theorized that the different parts of the pelvis can “rotate” or “shift” on one another, causing misalignments with hip alignment (2). To conceptualize this, imagine holding the red and blue columns of this rubix cube stable, while you turn the yellow column towards you several degrees (we’d call this left innominate “anterior rotation” or “nutation”). Many clinicians attempt to find these alignments, and restore the rubix cube, or pelvis, back to it’s original anatomy. And thus: normal “alignment restored,” pain resolved and the patient returns to everyday life. Present day, the field is moving away from this train of thought. It’s really not as simple as my metaphor here — but we’ll loop around back to this soon.
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Leg Length Discrepancy & Hip Alignment
Now naturally, you have legs attached to those innominate bones (our red and yellow halves in the illustration above). It is theorized that when you have innominate rotation, that it can create leg length discrepancy (3). Obviously, leg length discrepancies can change your gait, work its way “up the chain” and cause pain at the hip, sacroiliac joint and/or the lumbar spine.
Returning to our Rubix Cube metaphor, imagine holding the red (right innominate) and blue (sacrum) columns stable, while turning the yellow column (left innominate) towards you. Rotating the yellow column towards you would make your left leg appear a bit longer in relation to your right leg (red column). Rotating the yellow column (left innominate) away from you would make your left leg appear a bit short in relation to your right leg (red column). This all being said, if a patient is concerned regarding their leg length, or if a clinician visually observes a leg length discrepancy on an exam table, it’s not uncommon for he/she to work up to the pelvis and check your pelvic alignment.
Sacroiliac Joint / Lumbar Pain & Hip Alignment
Compared to innominate rotation or leg length discrepancy, this category requires a bit less explanation. Many clinicians will often check pelvic alignment whenever a patient complains of sacroiliac joint or lumbar pain. It has been claimed that a large majority of innominate rotations can be made rapidly pain free by quick recognition and subsequent manual correction (4). Many musculoskeletal health care providers continue to follow this model today.
Fortin Finger Sign
A simple and fairly intuitive test is the “Fortin’s Finger Sign” (5). 85% of patients who point to this landmark are said to be struggling with a sacroiliac disorder (5, 6). Generally, if a patient points to this landmark, a clinician will more likely closely examine the sacroiliac joint, which may involve a closer look at hip alignment.
A Cultural Perspective: How did we get here?
Again, the manual therapy literature and culture is littered with books, chapters, and papers on the treatment of the sacroiliac joint. Many of these methods, using the aforementioned three thought processes, are based on the presumptions that these biomechanical faults directly cause sacroiliac joint based pain (2). Physical therapists, chiropractors and osteopaths spend years of graduate school mastering these assessment skills and manual interventions, regularly fine tuning them later through residencies, fellowships, continuing education and tons of repetitions in clinical practice. The bottom line is that we’re proud of these skills, and want to help our patients. When we can find a helpful “quick fix,” such as restoring “normal hip alignment” — we’re absolutely thrilled to take it and provide some results within a single visit. Who wouldn’t be? We want to help!
These aforementioned skills that many in our profession have worked hard to polish are hard to leave behind. Unfortunately for some clinicians, but fortunately for patients, the field is slowly moving on from these thought processes. Evidence continues to mount that refutes, or generally discourages, viewing pelvic or hip alignment as a major, causative, contributor to sacroiliac pain or lumbar pain. Let’s dive into some of that evidence here next.
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An Evidence-Based Perspective: Innominate Malalignment & Hip Alignment
When a clinician checks your hip or pelvic alignment, they’ll first start by locating some important bony landmarks. Since the pelvis isn’t as easy to visually interpret as jumbled colors on Rubix Cube, these landmarks help your clinician to palpate and interpret the positioning of the innominate bones on the sacrum. Typically the landmarks we use are the “anterior superior iliac spine” (from the front of your hips, pictured on left below) and the “posterior superior iliac spine” (from the back of your hips, pictured on the right below).
Image made by DBCLS (Polgondata is from BodyParts3D) and used via Wikimedia Commons
Funny enough, this was the first very palpation skill I remember learning in physical therapy school. In principle, it makes sense. In practice, it turns out we’re probably missing the mark. A very important piece of literature came out of Canada in 2016 that actually looked deeper into the clinician’s ability to locate the posterior superior iliac spine correctly (7). The authors complied 13 high-quality articles that examined if a clinician could 1.) consistently find the same bony landmarks time and time again reliably (intrarater reliability) or 2.) consistently find the same bony landmarks compared to his/her peers (interrater reliability). When the result were summarized, words used to describe this skill generally included adjectives like “poor” (8,9,10), “difficult” (11), “unreliable” (12, 13), and to do so with accuracy “might be difficult” (11). To make matters even more difficult, this bony landmark varies considerably from patient to patient. In some, this bony protuberance has a “blade-like” feel (7), and in others, it’s much more subtle. At the end of the day, if we can’t reliably identify innominate rotation, how can we possibly provide the correct intervention?
Well, it turns out our interventions don’t hold much weight either. In manual therapy, a clinician can select a variety of different interventions to address the theorized imbalance at hand: manipulation, mobilization or muscle energy (to name a few). In the not so subtlety titled article “Manipulation does not alter the position of the sacroiliac joint,” researchers used roentgen stereophotogrammetric analysis (basically a series of specialized x-ray machines used to create three-dimensional information regarding the pelvic anatomy) to look at how the innominate bones changed on the pelvis pre and post manipulation. In none of the 10 subjects did the manual techniques actually change the positional relations between the sacrum and innominate (14). The researchers then checked their bony landmarks by palpation before and after the intervention. You guessed it: their manual assessment had found that positional faults had been “corrected,” despite the findings of the gold-standard roentgen stereophotogrammetric analysis. Because of these contradictory findings, the authors of this paper went as far to suggest our standard nomenclature of “forward and backward rotated” innominate should be abandoned. That’s a bold statement.
To close this point, Sturesson has stated that the range of motion in the sacroiliac joint is impressively small, allowing for about 4 degrees of motion (imagine the second you try and move the yellow column of our rubix cube towards you that it stops so quickly you have to double check it’s not glued to the blue middle column) and 1.6 mm of translation (15, 16). We could dive even deeper here, but appreciate there’s a substantial amount of evidence that suggests both our examination skills and interventions here at the sacroiliac joint probably don’t work (at least not in the way we typically describe them to a patient). That being said, it’s arguably against best practice to tell our patients their hips are out of alignment.
An Evidence-Based Perspective: Leg Length Discrepancy
No, I’m not doubting that leg length discrepancies don’t exist. It’s very likely that you, and probably I, have small leg length differences even now. However, little agreement exists regarding the degree of limb length inequality that is considered clinically significant and (are you seeing a theme here?) the validity of our assessment methods to determine differences as such (17). Let’s break down some key elements here quick. There are generally two types of leg length differences:
Anatomical Leg Length Discrepancy: This is considered to be a true or a structural limb length difference (17), meaning somewhere between the head of your femur and your ankle there is a literal difference in the length of your bones. Think hip dysplasia, congenital disease, nasty fractures or neurologic conditions.
Functional Leg Length Discrepancy: This type of leg length discrepancy is when there is an apparent difference in leg length without shortening of the bony anatomy. This can occur anywhere from the pelvis all the way down to the bottom of the foot. Things like foot mechanics, shortening of soft tissues, joint contractures, ligamentous laxity and “innominate rotations” are said to play a role here (17).
An anatomical leg length discrepancy is more literal. It’s objective. The majority of leg length discrepancies that we see in the clinic are not anatomical. Generally, they’re functional and extremely interpretational. And if you do have an anatomical leg length discrepancy, manipulating the innominate bones at your pelvis won’t correct this.
I spent my life watching my poor dad limp around the house and yard due to his anatomical leg length difference. He grew up with a type of congenital hip pathology called Legg-Calve-Perthes disease. This is where the blood supply to your hip is poor and the femoral head can die away. Back in the 1950’s, treatment options weren’t as strong as these are now a days. If I had to guess, he had a 2 to 3 inch leg length difference, and would commonly walk on his left toes to balance out. This is an example of meaningful leg length difference.
I know his left leg is trailing behind him in this picture, but you can still appreciate my dad’s left leg was about 2-3 inches shorter than his right due to Legg-Calve-Perthes disease. And no — you can’t rock an Elmo tank top like me.
There are a few ways a clinician may practically assess for leg length differences in clinic. One involves taking a tape measure from the anterior superior iliac spine (reference the little red tips of your pelvic anatomy, shown on the left, two pictures above) down to the inside of your ankle (medial malleolus). Dr. Freiberg and researchers wanted to look deeper at the reliability of this method across multiple patients. The examiners measured 21 subjects with this tape measurer method twice over the course of 3 months, totaling 196 different measures. They compared their tape measurements to measurements done with x-ray (their gold-standard). When the data was collected, the team found repeated measurements by the same examiners on the same patients conflicted 28% of the time regarding which leg was the shorter leg (18)! This was even the case when large differences were found by x-ray imaging of up to 25 mm! One examiner identified one leg as being 10 mm shorter than the other limb at the beginning of the study. 3 months later, he identified the previously “short” leg as being 15 mm “longer” (18). Freiberg also found that small limb length differences by x-ray measurements of 5 mm or less were measured incorrectly 88% of the time, with overestimations of up to 20 mm (19).
Another common in-clinic technique is to visualize the alignment of the malleoli (your bony bumps on the inside and outside of your ankles) while in supine and long-sitting positions on a plinth table. If you recall, we talked about a scenario earlier with our rubix cube metaphor that when an innominate is rotated forward, the leg attached to that side is typically longer. In traditional manual therapy education, this has generally been the common understanding. However, Dr. Cooperstein and Dr. Lew reviewed some of the most pertinent literature on this thought process in a great systematic review. Contrary to what we’ve been traditionally taught in manual therapy practice, these researchers found the exact opposite of what we believe — they found consistently that the innominate actually rotates forward (anteriorly) on the side of a shorter leg and backwards (posteriorly) on the side of a longer leg (3).
In short, the water is so muddy. In fact, it’s probably not even water, it’s just mud. There are so many different factors in play here, but the largest is probably that these traditional manual therapy beliefs continue to be passed down from generation to generation, despite that research consistently tells what we’ve believed for years is wrong.
To put a bow on top of this section here, another large review of the literature regarding leg length was published in 2005 by Knutson. Knutson states that 90% of the population has some leg-length inequality; and that the average was found to be 5.2 mm. In closing, anatomic leg-length is near universal (we all have it) but the average magnitude is small and not likely to be clinically significant (19).
Exercises For Hip Alignment & Pelvic Drop
An Evidence-Based Perspective: Sacroiliac Joint / Lumbar Pain
This section is a bit more straight forward: sacroiliac and lumbar pain are very much real, and it sucks. It is thought that 13% of patients with chronic low back pain have an origin of pain that truly originates from the sacroiliac joint (2). If you’re here reading this article due to your sacroiliac or lumbar pain — I’m sorry. It’s a rough and often long road.
A landmark paper by Mark Laslett, “Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint,” largely provided the framework for this piece you’re reading here today. Laslett (and a large growing body of musculoskeletal health care providers) believes that small pelvic alignment issues and limb length differences don’t make a significant difference regarding your back pain (in the overwhelming majority of cases). However, sacroiliac joint pain may develop secondary to a variety of situations, two of the most common being:
- An inflammatory condition within the joint may be causing or may be associated with sacroiliac joint pain
- The joint has become unstable through ligamentous laxity or tearing of the capsule (2).
Both of these scenarios are much more realistic and can be targeted with thought processes and interventions that are direct and accepted. Stabilizing exercises prescribed by a physical therapist (21), a compression/pelvic belt in those with hypermobility diagnoses or post-pregnancy related pelvic girdle pain (22) or injections (23, 24, 25) are immensely impactful when used skillfully by a thoughtful and attentive healthcare provider. Lean towards these interventions, and clinicians who do as well, rather than those that remain hyper-focused on your malalignments or leg length discrepancies.
A Psychosocial Perspective
Let me be clear: none of this isn’t to say your manual therapist or chiropractor or osteopath isn’t skilled. I’m sure they have years and years of training under their belts, and they’ve trained their hands with the entire goal of helping you. Manual therapy is a powerful thing — but probably doesn’t work in the ways that techniques were literally designed (pop this to realign that, push on this to put that hip alignment back in place, etc).
Ever hear of placebo analgesia (26)? You’re most likely already familiar with the placebo effect, which occurs when a patient experiences a beneficial effect, although the effect can’t be attributed to the intervention itself. Instead, the benefit is most likely derived from the patient’s belief in that treatment. Analgesia is just a fancy word to describe the “inability to feel pain.” If something provides an “analgesic effect,” it means that it’s helping to blunt or minimize pain levels.
Placebo analgesia is a placebo effect that results from numerous psychosocial contexts surrounding the clinical encounter with your healthcare provider. Placebo analgesia is much larger when an intervention is provided with instruction beforehand, significantly enhancing expectations. This type of placebo is said to be maximized when patients (27):
- Believe they’ve received an analgesic treatment or agent.
- Conditioned to think the treatment is going to be effective.
- Conditioned with an effective treatment and given a placebo treatment afterwards.
- Have had previous successful experiences and/or when the environment includes other patients benefiting from the experience.
Think about it. The clinician gives you a very detailed exam checking hip alignment and leg length. His/her hands feel confident and skilled — and those degrees on the wall speak for themselves. The clinician gave you a great explanation using words like “nutation,” or “posteriorly-rotated innominate” and told you that you have a leg length difference. They even measured with a tape measure! It makes total sense. You’ve heard this was the best physical therapy/chiropractic clinic in town, and it shows. Finally, when you were “adjusted”, you felt a “pop” and the provider was really pleased with the end result. Now years later, every time you feel a similar pain, you know it’s because your hips are out of alignment again — and you return to have them adjusted.
All of these considerations contribute to a positive or negative experience with a healthcare provider. It doesn’t mean that your treatment did or didn’t work. Who cares if it’s placebo, but you’re feeling better? There are many studies examining clinical interventions like these that report true clinical improvements with pain reduction. It’s hypothesized that these interventions normalize musculoskeletal function, but likely not bone positions (7). The problem is that the false explanation behind your initial pain, and how it was resolved, conjure really negative beliefs. These false explanations breed dependence on interventions that probably don’t provide the literal product that’s being promised. But at the end of the day, it’s our opinion that patients shouldn’t become reliant on us as healthcare providers, especially with fictitious malalignments or insignificant leg-length differences.
- Your hips probably aren’t out of alignment. In fact, the amount of rotation at your hips/pelvis is generally so small, we literally can’t pick this up reliably on exam.
- You probably have a leg length discrepancy. I probably do too. However, this is normal throughout the public. It’s likely so insignificant, it doesn’t mean much, so don’t worry. Anatomical leg length differences are due to significant health issues (neurologic disease, congenital disease, etc.) and have much more of an impact in these situations.
- Your physical therapist, chiropractor or osteopath isn’t good at assessing your pelvic malalignments or leg length discrepancies. This is generally regardless of years of experience. The palpation skills we use in this area just aren’t reliable.
- For those with sacroiliac pain — it’s challenging. Your pain is real. However, there are other explanations and interventions that carry much more clout. The field is evolving; find a clinician who is too.
- Manual therapy can work and provide real benefit, but likely not through the mechanisms on which it was originally developed. We aren’t putting anything back in place or restoring any types of alignment. Despite the claims your well-intentioned practitioner may tell you.
- Marcon AR, Murdoch B, Caulfield T. The “subluxation” issue: an analysis of chiropractic clinic websites. Archives of Physiotherapy. 2019; 9(11).
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- Cooperstein R, Lew M. The relationships between pelvic torsion and anatomical leg length inequality: a review of the literature. Journal of Chiropractic Medicine. 2009; 8: 107-118.
- DonTigny RL. 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 and Stoeckart R, eds, 2nd edition. Movement, Stability and Lumbopelvic Pain: Integration of Research and Therapy. Philadelphia, PA: Churchill Livingstone, 2007.
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- Murakami, E. Diagnosis of Sacroiliac Joint Disorder. Singapore: Springer, 2019.
- Cooperstein R, Hickey M. The reliability of palpating the posterior superior iliac spine: a systematic review. Journal of Canadian Chiropractic Association. 2016; 60(1): 36-46.
- van Kessel-Cobelens AM, Verhagen AP, Mens JM, Snijders CJ, Koes BW. Pregnancy-related pelvic girdle pain: intertester reliability of 3 tests to determine asymmetric mobility of the sacroiliac joints. Journal of Manipulative Physiol Therapy. 2008; 31(2): 130-136.
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- Kim HW, Ko YJ, Rhee WI, Lee JS, Lim JE, Lee SJ, et al. Interexaminer reliability and accuracy of posterior superior iliac spine and iliac crest palpation for spinal level estimations. J Manipulative Physiol Ther. 2007; 30(5): 386- 389.
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- Tycho T, Blomberg S, Bjorn B, Ragnar J. Manipulation does not alter the position of the sacroiliac joint: A roentgen stereophotogrammetric analysis. Mobilization. 1998; 23(10): 1124-1128.
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- Brady RJ, Dean JB, Skinner TM, Gross MT. Limb length inequality: Clinical implications for assessment and intervention. JOSPT. 2003; 33(4): 221-234.
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- Pereira PL, Gunaydin I, Trubenbach J, et al. Interventional MR imaging for injection of sacroiliac joints in patients with sacroiliitis. AJR Am J Roentgenol. 2000; 175: 265– 266.
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About The Author
[P]Rehab Writer & Content Creator
Originally from Reading, Pennsylvania, Chris graduated with his bachelor’s degree in exercise science and a doctorate of physical therapy from Slippery Rock University. He afterwards completed a sports physical therapy residency at the Memorial Hermann IRONMAN Sports Medicine Institute. He later completed a division 1 sports physical therapy fellowship at Duke University where he worked closely with Duke football, basketball and lacrosse. He then returned to Houston afterwards with Memorial Hermann to help develop an emerging division 1 sports physical therapy fellowship. Present day, he practices with the sports medicine team at the United States Olympic and Paralympic Committee in Colorado Springs, CO. Chris is board certified sports clinical specialist (SCS), certified strength and conditioning specialist (CSCS) and certified in dry needling. He has a particular interest in post-operative rehabilitation of the athletic knee, shoulder, hip and elbow.