What causes a lateral pelvic tilt and how do you fix it?

The simple answer is that a lateral pelvic tilt is caused by an underlying neuromuscular pattern that leads to tight muscles on one or both sides of the pelvis. These tight muscles hold the pelvis in a tilted position.

I realize that “neuromuscular pattern” is a scary word, but in reality it simply means “brain-muscle habit”. All movement is controlled by your brain, and it just so happens that we humans develop a habit of overusing the right side of our body. The reasons for this habit will be explained shortly.

It is this “habit” that results in a laterally tilted position, where one side appears higher than the other.

Some people will refer to it as a “twisted pelvis” or “rotated pelvis” because along with one side being higher, their pelvis may feel twisted. In fact they are correct, their pelvis is twisted and tilted.

So while the simple answer is technically true, it’s only a partial answer to a more complicated situation.

The more complicated answer, and one that virtually no one realizes, is that a lateral pelvic tilt IS NOT a pelvis and muscle issue.

At its core, a lateral pelvic tilt is a symptom of a larger pattern found inside the body and its origin resides in the asymmetric organization of the human body that leads to habitual dysfunctional breathing.

 

The Origin of the Lateral Pelvic Tilt: Human Asymmetry

Look at the picture below. You’ll see the human lumbar (lower) spine, and attached to that lumbar spine are the right and left diaphragms. The diaphragms are our primary breathing muscles.

Interestingly, virtually all sources of information refer to the diaphragm in the singular, giving the mistaken impression that we have just one diaphragm.

In reality, the diaphragm is two separate muscles, and they aren’t even remotely close to being equal! The right diaphragm is larger with a thicker attachment site on the lumbar spine. A larger and thicker muscle is a stronger muscle.

With every breath you take, as the diaphragms contract during inhalation, the right diaphragm exerts a stronger pull on the lumbar spine than the left side does. 

Overall, humans are designed to be better at centering our bodyweight more to the right because it allows us to use our bigger right diaphragm to breathe. It allows us to have a dominant side (regardless of handedness). This asymmetry is normal.

However, the stress and tensions of life often cause our normal asymmetry to become abnormal asymmetry. It is this abnormal asymmetry that is the origin of lateral pelvic tilts, back pain, and so much other bodily dysfunction.

The respiratory diaphragm is the underlying cause of lateral pelvic tilt

Lateral Pelvic Tilt: My Struggle

The traditional thinking of a lateral pelvic tilt is that there is one or two muscles that can be identified as being tight, and that the tilt is a result of these tight muscles pulling the pelvis in one direction or another.

For a long time I believed this, too.

After all, this is the paradigm through which much of physical therapy operates: stretch tight muscles and strengthen weak ones.

Unfortunately, this understanding of a lateral pelvic tilt, while completely understandable, is seriously flawed and generally leads people on a wild goose chase.

We search in vain for a tight muscle to stretch or massage that will release the tilt and return the pelvis back to its normal resting state. Sometimes we have a little success, and feel some relief, but then the tilt returns.

I went through this for years!

The two pictures above were both taken in 2011 after a particularly vicious lower back spasm that kept me from straightening my back for two entire days. The pain was horrendous.

I could not get up off the floor. Trying to straighten my back would just result in more spasm. So I stayed on the ground for two days.

Once the spasm resolved, I remained with a tilt as seen in the picture on the right. From my notes (I started taking extensive notes of my physical experiences during this time) I got out of the first tilt by stretching my right QL.

Unfortunately, I spasmed again into the position on the left.

It’s like my body was playing ping-pong with my pelvis.

Still in pain, I started researching every possible solution.

I tried physical therapy, which did nothing. Strengthening the core is often nothing more than a cruel joke.

Stretching and massage gave me a bit of relief, but nothing lasting.

After many months of pain and confusion, much of my tilt had gone away because the muscles had finally relaxed, but my left SI joint was still killing me.

Also, oddly, I realized I had one leg shorter than the other and this was tilting my pelvis and stressing out my SI joints. Was I born with a leg length discrepancy?

More confusion!

I put some paper towels in my shoe to make my right leg longer, effectively leveling out my pelvis, and the pain would go away.

But unless I wanted to live with paper towels in my shoe for the rest of my life, I had to address the underlying structural dysfunction.

Two years later, the situation hadn’t changed and I wrote this on my blog:

Two years of physical misery and no one could get to the origin of the problem.

Then I took Myokinematic Restoration from the Postural Restoration Institute and discovered the truth about lateral pelvic tilts.

Lateral pelvic tilt is caused by your pelvis being stuck in an asymmetrical position due to the influence of the larger right diaphragm above it. Over time, the pull of the right diaphragm overpowers the pull of its counter-part on the left side and our body’s center of mass shifts to the right. This causes our lower back to become hyper-lordotic (increase lumbar curve, or lordosis) and results in compressive forces through the low back and pelvis that cause pain.

The typical asymmetrical position consists of a left side of the pelvis rotated forward compared to the right side (in Postural Restoration terms, a left AIC pattern). The larger right diaphragm pulls the lumbar spine and sacrum to the right and that’s where we end up stuck, with a pelvis and ribcage that is oriented to the right. 

In this position, some muscles are constantly short and tight and some muscles are constantly stretched and weak. Traditional physical therapy attempts to treat these muscles. But the muscles can’t be treated because they are a symptom of the underlying pattern that has its origin in our asymmetrical design. You have to resolve “the pattern” that is causing those muscles to be tight and painful.

Lateral Pelvic Tilt, the Psoas, and the Quadratus Lumborum

Let me state this clearly: you can not stretch or massage your way out of the underlying pelvic asymmetry that is causing the lateral pelvic tilt.

The “tight” muscle that is identified as holding your pelvis in a tilted position (quite often your right or left quadratus lumborum and psoas) did not just one day decide to get tight.

Muscles do not tighten independent of the rest of the body and certainly not independently of respiration. 

While it is local musculature (such as a left psoas or right QL) that holds the pelvis in a tilted position, that musculature was forced into that situation by the asymmetric resting position of the pelvis that itself was influenced by the respiratory induced pull of the right diaphragm. The QL and psoas are more victims than perpetrators.

As an example, let’s examine the right QL, the position it can be forced into, and it’s role in a pelvic tilt.

The Right QL

 

The quadratus lumborum is not actually considered a back muscle, it’s considered a posterior abdominal muscle and an accessory breathing muscle. 

What is important is the QL’s three attachment sites:

  1. at the top of the pelvis
  2. transverse processes of the lumbar vertebrae L4,L3,L2, and L1.
  3. bottom portion of the last rib.

The QL also has a direct connection and influence on the SI joint because the ilio-lumbar ligament has its embryological origin in the QL, and this ligament plays a vital role in stabilizing the SI joint.

In addition, the ilio-lumbar ligament has a plethora of nociceptors and mechanoreceptors, so it will be quite sensitive to abnormal pelvic mechanics.

When the QL is tight, more often on the right side (in the left AIC pattern, our bodyweight is shifted to the right), it can contribute to abnormal pelvic mechanics (and thus intense pain) in the form of a lateral tilt as it pulls the pelvis and ribcage closer together on that right side. Hence it’s nickname, the “hip hiker”.

But why on earth is that right QL tight?

Out of all the muscles in the body, why does this muscle seem to get tight so often? Doesn’t it seem odd that this lonely right QL just gets tight out of nowhere?

It should seem odd, because that isn’t what happens.

Pelvic Orientation to the RIght

 

The right QL only gets tight because it is forced into that position by the two structures it attaches to, the pelvis and the ribcage (remember it attaches to the 12th rib, so the respiratory action of the ribcage influences the QL, as well.)

The QL’s job is to side-bend, and then stabilize, the pelvis, ribcage, and spine to the same side.

So a right QL will bring the right pelvis and right ribcage closer together by sidebending the spine to the right.

All this sidebending and stabilization produces a pelvis and lumbars spine that are oriented to the right.

If the right QL is tight, it means the entire pelvis is oriented to the right. It will then begin to increase its role as an accessory breathing muscle because the left diaphragm loses its ability to pump as a breathing muscle. 

A right QL will not be tight if the pelvis is oriented to the left and we can start using our left diaphragm again. This is important to understand, otherwise the remedy won’t make sense.

Muscle Behavior

 

Muscles have attitudes and behaviors just like our personalities do.

Once a muscle’s behavior has become habitual, it doesn’t give up its habit easily. In this case the right QL is thinking “I’m doing exactly what you asked me to do, keep the right hip and ribcage stable”.

If you never shift your weight fully to the left, or something is preventing you from shifting your bodyweight fully to the left, why would the right QL ever turn off?

It will only fully turn off when you fully shift your weight to the left because if your weight is on the left foot, the right QL has no reason to stay on. Your left QL will activate appropriately when you shift your weight to the left and can breathe with the left diaphragm.

Weight on the right foot, right pelvis and ribs closer together, pelvis oriented right. Right QL should be on and right diaphragm pumping.

 

Weight on the left foot, left pelvis and ribs closer together, pelvis oriented to the left. Left QL should be on and left diaphragm pumping.

 

The picture on the left, where I am standing with my body centered over my right leg, is normal “right stance” position. In this position, my right diaphragm is optimally positioned to pump as the primary breathing muscle. This is the position that our brain likes to habitually place us for easier breathing and stabilization. 

The picture on the right, I am standing with my weight centered on the left leg. In this position, my left diaphragm is optimally positioned to pump as the primary breathing muscle.

Over time, this is the position that we struggle to attain because of our brain’s habit of placing us more to the right for easier breathing and stability. Doesn’t it makes sense to make use of the larger and more powerful right diaphragm?

Additionally, whenever there is repetitive overuse, prolonged sitting/computer usage, sedentary lifestyles, general inactivity, injury to the body, or any type of trauma, the right side is our “safe side”, further reinforcing our natural tendency to overuse our right side and underuse the left side. 

 

To fix the situation you have to attain a new pelvic behavior that orients the pelvis to the left when your weight is on the left foot. You have to make the left-weight bearing picture, and thus the left diaphragm, become part of your gait and respiratory cycles.

The Solution

 

The only way to resolve the underlying structural issue that is leading to lateral pelvic tilt is to reposition the pelvis into a more symmetrical resting position via Postural Restoration techniques that use the appropriate hip musculature and also correct dysfunctional breathing, all at the same time!

You can not separate movement from breathing because it involves all the same muscles. The psoas and QL muscles are directly connected to the diaphragms. If diaphragmatic breathing, particularly on the left, can not be restored, nothing you try to do with the hip musculature will work long term because the psoas and QLs won’t relax.

 Once pelvic repositioning has occurred, you then train your body to establish and stabilize itself in left stance.

For people who already understand PRI, this means that you need to strengthen the left hamstring, left IC adductor, left glute medius, and left internal obliques using PRI exercises. All these muscles stabilize our body in left stance.

For starters, You can try the exercises on this page. 

I also offer online coaching via Zoom. The information can be found on the Online Consultations page.

Or just start with the one below. 

Also, I have soooooo many videos on my YouTube channel about lateral pelvic tilts and Postural Restoration in general, including the playlist below.

Some people have both sides of their pelvis rotated forward (PEC pattern) and/or may feel like the right side of their pelvis is rotated forward compared to their left.

While this is probably not what is actually happening, you can try this Postural Restoration technique.  In this technique you should be able to feel both hamstrings. All you have to do is put a small ball between your knees (not a foam roller or yoga block), sense your heels, and lift your hips off the ground. Your lower back should remain flat on the floor so make sure you don’t lift too high. 

Breathe in through your nose and out through your mouth, focusing on getting all your air out! This focus on exhalation positions your ribs properly for diaphragmatic breathing.

 If you can’t feel your hamstrings too easily, you can compare your right and left sides by taking your left foot off the wall while keeping the right foot on the wall.  Take five breaths. Then put the left foot on the wall and the right foot off. Compare the two sides of your body.

 

Do you feel each hamstring equally? Do you feel them at all?

If you don’t feel your hamstrings it means that your hip flexors, low back muscles, and/or neck muscles are overactive and you aren’t able to breathe with your left diaphragm.

This type of situation is what a Postural Restoration program addresses.