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Is Pelvic Upslip possible

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Apr 5, 2014.

  1. David Smith

    David Smith Well-Known Member

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    Hi Guys

    Been looking at improving assessment for leg length dicrepancy (LLD). In particular I'm investigating so called Pelvic Upslip (PU). PU being defined as where there is a change in the relative positions of the left and right pelvic innominates due to a translation movement at the sacro-iliac joint on one side (there can be down slip as well but this seems to be reported as less common)

    My Question is 'does this really exist in the general population'?

    There's much written about PU and many suggest that many LLD that show as one of the pelvic inomminates being higher than the other at the ASIS are actually the result of Pelvic Upslip.

    For me this seems very unlikely since the structure of the pelvis strongly resists any slip between the sacrum and the pelvis at the sacro-iliac joint.

    I think I've seen this discussed on PA before with some sceptisism but I cant find and threads by searching here or via google.

    I'd appreciate a good discussion if you have any thoughts or experience and particularly hard research evidence of PU.

    Cheers Dave
  2. Dananberg

    Dananberg Active Member


    Can't give you hard study data, but can contribute this.

    When ankle equinus is present, the fibula does not translate. Since the biceps femoris inserts into the fibula head, and originates according to Vleeming from the sacrotuberous ligament which inserts directly to the sacrum, then sacral position can be impacted. When the fibula translates, it relaxes the sacrum and lets it nutate. When the fibula is fixed, the "connection" tightens, and the fibula becomes counter nutated. When this occurs unilaterally, then the rotation imparted can give the appearance of a pelvic upslip.

    While PU can create some considerable LLD, my experience was that there was a far smaller amount of actual LLD which co-existed. This is why patients who see chiros and osteos regularly for care, seem to always have the same chronic rotations. The underlying LLD (albeit small) changed gait style and created the motion patter which then maximized the LLD appearance.

  3. Stanley

    Stanley Well-Known Member

    Hi Dave,

    I have seen it just a few times over the years. If I remember correctly, there was an association with unilateral gluteus medius weakness.
    In the physical exam, there would have to be a discontinuity of the pubic ridge in addition to a high pubic tubercle with an ipsilateral high ASIS and PSIS. An anatomic shortage would not have the discontinuity of the pubic ridge.

  4. Only time I've allegedly come across it was in a post-natal female. The explanation she'd been given was that the high levels of relaxin had allowed distraction of the sacro-iliac joint which had "popped" back in the wrong place after a particularly difficult labour. Take from that what you will, I never saw any diagnostic imaging.
  5. kevin miller

    kevin miller Active Member


    I see an upslip a couple of times a year, maybe less. The parameters I use for confirming the DX include prone short leg in knee extension and flexion on the side of higher iliac crest with ipsilateral lower lumbar spinous rotation.....sometimes with weight bearing scoliosis. The mechanism of injury is important as well. Most occur secondary to a pelvic sprain of some sort. E.g., a tired triple jumper who hits his last phase with his foot in external rotation, or a soccer player who is injured while kicking one direction and cutting in the other. My last case was a few weeks ago....rugby player who pulled a big fellow down on his pelvis, spraining both SIJ and pubic symph...... then got hit in the low back/hip while cutting opposite of his planted/involved foot. In other words, having the illium externally rotated at the time of injury seems to make it more likely that the upslip will develop. The problem with a true upslip, as opposed to the "apparent" upslip that Howard mentions, is that they are often very difficult to treat because a true hypermobility is involved. Most end up needing and SIJ belt and very specific rehab to resolve.

  6. Blaise Dubois

    Blaise Dubois Active Member

    I don't believe that... invention of chiro/physio. Myofascial tension "fixing" the joint (decrease ROM) = OK.
    Blaise (PT)
  7. David Smith

    David Smith Well-Known Member

    Thanks all

    You seem to be confirming what I thought i.e. that upslip, if it actually is possible, is rare and if present will include displacement of the pubic symphysis joint, which i cannot see in any x rays that purport to show upslip. Many non research literature propose that this is a common finding and I have a physio who has asked me to review my findings of LLD on a mutual customer as he thought it was pelvic uplift. So I'm taking this opportunity to revise and prepare a more robust pelvic alignment protocol for daily use in my clinic.


    Yes I regularly notice that after mobilising the ankle joint the pelvic levels change, usually the low innominate becomes level with the the contralateral one. But sometimes when they start level they end up uneven after mobs.

    Also I find time and time again where there is weakness in the hip abductors they return to full strength after mobilising the ankles.

    Dr Stanley Beekman (my favourite PA uncle ;)) instructed me in releasing the hamstrings with massage of the insertions into the pelvis and iliac cresst and this also enhances and improves the results found with ankle mobilisation.

    I think that good robust pelvic alignment assessment is vital in enhancing the outcome for treatment of lower limb biomechanical dysfunction and especially when using FFO's as an intervention.

    Its great to see Kevin Miller and Stanley Beekman contributing to PA again.

    Blaise can you expand further, I dont quite get what you're trying to say?

    Regards Dave
  8. Blaise Dubois

    Blaise Dubois Active Member

    I never see a real upslip in 15 y of practice. It's over diagnose. it's always clinical... no radiological confirmation. It's maybe possible in some car accident. I discuss many time with orthopaedic surgeon about that and they are all thinking the same.

    I believe we focus to much on "good" alignement... (for the foot AND for the rest of the body)

    Asymmetry is a norm... not a problem in many case. Level of the iliac crest have a lot of inequality (the bone... not the SIJ)

    When you say : after mobilising the ankle joint the pelvic levels change, usually the low innominate becomes level with the the contralateral one"... that's the secret of neurophysiological effect of myofascial mobs... so maybe we need to do the difference between 'upslip' (structural displacement) and uneven pelvis (cause by myofascial tension)... not the same

  9. David Smith

    David Smith Well-Known Member

    I agree pretty much!
  10. kevin miller

    kevin miller Active Member

    Dr. Dubois,

    Can you explain what you meant in your post? On one hand you seem to be saying you don't "believe" that an upslip can happen, but then you follow by suggesting that the upslip phenomenon is produced by myofascial tension.

    The term upslip refers to a set of clinical symptoms/signs that can be documented......and can have fascial origin from the tension in/around the joint.

    I don't think anyone would suggest that an illium just randomly rides high. I have never seen one that was not linked with tremendous force applied to the SIJ when it is in less than a maximally stable position. Furthermore, treatment specific to the pathomechanics seen in clinic almost always reverse they signs/symptoms.

    Can you help me understand what you think is made up when you identify one mechanism for the phenomenon. BY the way you can see the malposition on a standing film, PA Pelvis, put feet equidistant from the center of mass, feet pointed straight, not externally rotated.

  11. kevin miller

    kevin miller Active Member

    I don't disagree with much you are saying here....asymmetry IS normal, and "good" alignment is what makes patient motion efficient and pain-free. But why do you think a TCJ mob changes pelvic obliquity via fascial tension alone? Consider the rearfoot...calcaneus and talus. When they are sitting in apposition where the CCJ and TNJ are congruent and parallel, the apex of the talar dome sits in the TCJ and the and the curve of the calcaneus makes contact at it apex as well. If there is enough midfoot laxity for the rearfoot to plantarflex against the forefoot, not only does the plantar angle of the foot decrease (shortening the leg functionally), the talus and calcaneus make contact is such a way as to shorten the distance between its two contact points. (Take your trusty foot model, measure the rearfoot height from apex to apex, talus and calcaneus, from "12 o'clock to 6 o'clock.) ....then tilt the complex forward and measure the apex again. (When plantar flexed, the "clock" rotates counter clockwise so that the apex is now 1 o'clock and 7 o'clock......or maybe even 2 o'clock and 8 o'clock.) Note the function height change. Add to that the functional leg length lost as the sagittal plane arches collapse, and functional LLD can become significant.

    All that said, usually you only get a run of the mill pelvic obliquity from that mechanism. The upslip usually requires a trauma sufficient to sprain the SIJ and alter muscle firing patterns, negatively affecting the SIJ's ability to protect itself. I.E., if you don't get the upslip immediately, the tone loss makes the joint susceptible to later injury, only to be picked up after the patient has seen multiple docs and had his/her motives questioned....oh, and they finally run across a clinician that know how to test for it. In other words, t is not a clinical diagnosis like ADD or Fibromyalgia. There are measurements that can be take for and upslip. Most telling, however, is that pain/symptoms are not corrected via a "standard" lumbopelvic adjustment protocol, but require some sort of long traction on the involved limb.


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