An unlevel pelvis is a common condition that can cause or contribute to other painful biomechanical issues, such as pain in the low back, groin, knee, or foot. The two sources of an unlevel pelvis are structural and functional.
In the presence of a structurally unlevel pelvis, the bony structure has created asymmetry that affects the positioning of the pelvis. A functionally unlevel pelvis occurs when a pattern of shortened muscles creates asymmetry in the pelvis, often from a chronic compensation pattern.
The pelvis is the functional link between the lumbar spine and the lower extremity. When the pelvis is unlevel, either structurally or functionally, there is increased stress on the lumbar spine, joints in the lower extremity, or both. It is well established that patients with low back pain have poor motor control of their trunk musculature and abnormal gait firing patterns.1-6
Proper alignment of the pelvis can alleviate many symptoms a patient may experience. For some patients, pelvic leveling should be a goal within their chiropractic wellness plan. Having a thorough history and physical examination can help identify the presence of an unlevel pelvis.
Many practitioners use leg length checks or radiographs to identify an unlevel pelvis, though those tests should not be used exclusively. Information gathered through gait analysis, functional assessment, orthopedic examination, and muscle strength testing can give a broader and more comprehensive clinical picture of the presence and root cause of an unlevel pelvis, especially in the presence of a leg length discrepancy or radiographic findings.
When setting goals and expectations for the patient’s wellness plan, a chiropractor should consider pain reduction, pelvic leveling, and improved functional movements based on objective findings. Restoration of pelvic stability will likely improve the patient’s overall organ health, circulation, posture, flexibility, mobility, and mechanical efficiency, which are major components of a chiropractic wellness plan.
Current research supports the utilization of custom foot orthoses in patients who exhibit an unlevel pelvis. Patients who exhibited an unlevel pelvis and asymmetrical pes planus were studied in clinical research done at Logan University.
The average unlevel pelvis measured 10 millimeters in the participants. In this project, 57% of patients who were fitted for custom, flexible orthotics improved their pelvic alignment. With orthotics, there was a 25.7% improvement in pelvic discrepancy.3
In another study, published in the Journal of Athletic Training, researchers found individuals with increased arch height had decreased postural stability, and those with hyperpronated feet displayed delayed activation of core musculature and increased peak forces of the iliopsoas.1-6 A recent study in The Journal of Physical Therapy Science supports the utilization of functional foot orthoses to decrease the distance of medial arch collapse and the pelvic incidence angle, thus improving pelvic stability.5
“The longer the duration of the compensation patterns, the less likely joint manipulation and rehabilitative exercises will be effective.”
An unlevel pelvis can be managed with different interventions, depending on the patient and root causation. Patients with a functionally unlevel pelvis due to acute compensation patterns may respond best to joint manipulation and corrective rehabilitation. The longer the duration of the compensation patterns, the less likely joint manipulation and rehabilitative exercises will be effective.
Other interventions that address the quality and length relationship of the soft tissues can be utilized in conjunction with joint manipulation and rehabilitative exercises to create stability within the pelvis and lumbar spine.2 Special attention should be given to the length, tissue quality, and activation of the iliopsoas and quadratus lumborum because these muscles are often shortened and overactive.
The other structure of relevance is the gluteal musculature because this group is often shorted and underactive with poor endurance.4 If joint manipulation, soft tissue therapies, and rehabilitative exercises are still unsuccessful to level the pelvis, custom-molded, functional orthoses should be utilized singularly or concurrently with the previously discussed therapies.13 6 Utilization of custom orthotics should be implemented after a thorough analysis and understanding of the derangements of the internal force systems on an individual basis.
In a patient with a structurally unlevel pelvis, the bony structure has caused the pelvis to be unlevel. While the anatomy cannot be permanently altered, joint mobilization, soft tissue therapies, rehabilitation, and activity modification will help with symptom management. It is paramount to correct the discrepancy with the initial implementation of custom foot orthoses, coupled with a heel lift.3 With flexible custom orthoses and chiropractic wellness plans, patients will greatly benefit in their pelvis support, and most importantly, their overall health.
Dr. Holly Westbrock, DC, DACBSP, EMT, CSCS, graduated from NWHSU and did her DABCSP training at Palmer. She specializes in diagnosing and treating repetitive strain and stress injuries with associated compensation patterns in elite athletes. To learn more, visit www.footleveler.com/more.
1. Cobb SC, Bazett-Jones DM, Joshi MN, Earl-Boehm JE, James CR. The relationship among foot posture, core and lower extremity muscle function, and postural stability. JAM Train. 2014 Mar-Apr;49(2): 173-80. doi: 10.4085/1062-6050-49.2.02. Epub 2014 Feb 25. PMID: 24568226; PMCID: PMC3975772.
2. Kandil EA, Yamany AAER, Aisaka SSD, El-Azeim ASA. Effect of global postural reeducation on chronic low pain patients with lower cross syndrome. Bull Fac Phys Ther. 2024 Feb; 29(8). doi: 10.1186/ S43161-023-00171-6.
3. Kuhn R, Pappas A, Smasal S. Radiographic evaluation of the effects of orthotics on pelvic unleveling: a pilot project. Logan University. 2007.
4. Mehta TB, Sharma A. Lower cross syndrome: specific treatment protocol versus generalized treatment protocol. A randomized single-blinded trial. Folia medica. 2024;66(5):662-672. doi: 10.3897/ folmed.66.el35838.
5. Park K. Effects of wearing functional foot orthotic on pelvic angle among college students in their 20s with flatfoot. J Phys Ther Sei. 2017 Mar;29(3):438-441. doi: 10.1589/jpts.29.438. Epub 2017 Mar 22. PMID: 28356626; PMCID: PMC5361005.
6. Yazdani F, Razeghi M, Karimi MT, Salimi Bani M, Bahreinizad H. Foot hyperpronation alters lumbopelvic muscle function during the stance phase of gait. Gait Posture. 2019 Oct;74:102-107. doi: 10.1016/j. gaitpost.2019.08.022. Epub 2019 Aug 31. PMID: 31499403.
