Pelvic Obliquity: Understanding Uneven Hips, Causes, Symptoms, and Treatment

What is it called when your hips are uneven?

When your hips appear uneven, it is most commonly referred to as pelvic obliquity or pelvic tilt, which indicates an asymmetry in the position of the pelvis. This condition can stem from structural differences in the bones or, more frequently, from functional issues such as muscle imbalances or postural habits.

Understanding Pelvic Asymmetry

The pelvis, a complex ring of bones comprising the sacrum and the two innominate bones (ilium, ischium, and pubis), serves as the central link between the spine and the lower limbs. Its balanced position is crucial for efficient movement, load distribution, and spinal alignment. When the hips appear uneven, it signifies a deviation from this optimal alignment, potentially leading to a cascade of biomechanical issues throughout the kinetic chain. This asymmetry is not a diagnosis in itself but rather a sign that warrants further investigation into its underlying cause.

Anatomy of the Pelvis and Hips

To appreciate pelvic obliquity, it's essential to understand the foundational anatomy:

• Pelvic Girdle: Formed by the sacrum (at the base of the spine) and the two ilia (hip bones) that articulate at the sacroiliac (SI) joints posteriorly and the pubic symphysis anteriorly.
• Hip Joints: Ball-and-socket joints where the head of the femur (thigh bone) articulates with the acetabulum (socket) of the pelvis.
• Muscles: A vast network of muscles surrounds the pelvis and hips, including the gluteals, hip flexors, adductors, abductors, hamstrings, quadriceps, and core musculature. Imbalances in these muscles are primary contributors to pelvic asymmetry.
• Ligaments: Provide stability to the SI joints and hip joints, ensuring proper alignment and limiting excessive movement.

Common Terminology for Uneven Hips

Several terms are used to describe uneven hips, often reflecting different aspects or causes of the asymmetry:

• Pelvic Obliquity: This is the most general and widely accepted term for an unlevel pelvis. It describes a situation where one side of the pelvis is higher or lower than the other when viewed from the front or back.
• Lateral Pelvic Tilt: Specifically refers to the pelvis tilting sideways, causing one iliac crest (hip bone prominence) to be higher than the other. This can be due to a genuine leg length difference or functional factors like muscle imbalances.
• Pelvic Rotation: Describes the pelvis rotating on its horizontal axis, meaning one side of the pelvis moves forward or backward relative to the other. This often accompanies lateral tilt and can be seen as one ASIS (Anterior Superior Iliac Spine) being more prominent or recessed than the other.
• Leg Length Discrepancy (LLD): Often a direct cause of uneven hips.
  • Structural LLD (True LLD): An actual difference in the length of the bones of the lower limb (femur or tibia). This can be congenital (present from birth) or acquired due to injury (e.g., fracture that healed shorter), surgery, or developmental issues.
  • Functional LLD (Apparent LLD): The legs are actually equal in length, but the pelvis appears uneven due to muscular imbalances, joint restrictions (e.g., in the hip or SI joint), scoliosis, or postural habits. This is far more common than structural LLD.
• Sacral Torsion/Dysfunction: Refers to an abnormal rotation or misalignment of the sacrum relative to the ilia, often leading to a compensatory pelvic obliquity.
• Scoliosis: A lateral curvature of the spine can directly cause or contribute to pelvic obliquity as the body attempts to compensate for the spinal deviation.

Causes of Pelvic Obliquity

Uneven hips can arise from a multitude of factors, broadly categorized as structural or functional:

Structural Causes

• True Leg Length Discrepancy: A measurable difference in the length of the femur or tibia bones.
• Congenital Anomalies: Birth defects affecting the development of the pelvis or lower limbs.
• Previous Injury or Trauma: Fractures that heal with shortening or angulation, or severe joint damage.
• Scoliosis: A primary spinal curve can pull one side of the pelvis higher or lower.

Functional/Acquired Causes

• Muscle Imbalances:
  • Tight Hip Flexors: Can pull the pelvis into an anterior tilt on one side.
  • Weak Gluteal Muscles (especially Gluteus Medius): Can lead to a "Trendelenburg gait" or pelvic drop on the unsupported side during walking.
  • Tight Adductors/Abductors: Imbalances between the inner and outer thigh muscles.
  • Tight Quadratus Lumborum: A deep back muscle that can hike one hip.
  • Core Weakness: Insufficient stability from the abdominal and deep core muscles.
• Postural Habits:
  • Always standing with weight shifted to one leg.
  • Sitting with legs crossed predominantly one way.
  • Carrying heavy bags on one shoulder.
  • Repetitive asymmetrical movements in sports or work.
• Joint Dysfunction:
  • Sacroiliac (SI) Joint Dysfunction: Pain and restricted movement in the joints connecting the sacrum to the ilia.
  • Hip Joint Restrictions: Limited range of motion in the hip due to stiffness, arthritis, or capsular tightness.
  • Foot and Ankle Issues: Pronation (flat feet) or supination in one foot can alter leg mechanics and affect pelvic level.
• Gait Abnormalities: Compensatory walking patterns due to pain or weakness elsewhere in the body.

Symptoms and Associated Conditions

While uneven hips might be asymptomatic for some, they often contribute to a range of symptoms and conditions due to altered biomechanics:

• Pain:
  • Lower back pain (most common)
  • Hip pain (on one or both sides)
  • Knee pain
  • Ankle and foot pain
  • Neck and shoulder pain (due to compensatory upper body adjustments)
• Postural Deviations:
  • One shoulder appearing higher than the other.
  • Head tilt.
  • Lateral spinal curvature (functional scoliosis).
• Movement Limitations:
  • Reduced range of motion in the hips or spine.
  • Difficulty with certain exercises or daily activities.
• Gait Changes:
  • Limping.
  • Asymmetrical stride.
  • Increased energy expenditure during walking.
• Muscle Stiffness or Spasms: Especially in the lower back, glutes, and hamstrings.

Assessment and Diagnosis

A thorough assessment by a qualified healthcare professional (such as a physical therapist, chiropractor, or orthopedic specialist) is crucial to identify the cause of uneven hips:

• Visual Observation: Observing posture, spinal alignment, shoulder height, and hip level in standing, sitting, and during movement.
• Palpation: Feeling for bony landmarks (iliac crests, ASIS, PSIS) to assess their relative positions.
• Leg Length Measurement:
  • Tape Measure Method: Measuring from the ASIS to the medial malleolus (inner ankle bone) to check for true LLD.
  • Block Test: Placing blocks under the shorter leg to level the pelvis.
• Range of Motion and Muscle Strength Testing: Identifying specific muscle imbalances or joint restrictions.
• Gait Analysis: Observing walking patterns to identify compensatory movements.
• Imaging (X-ray, MRI): May be used to confirm true leg length discrepancy, assess spinal alignment (scoliosis), or rule out other structural pathologies.

Management and Treatment Strategies

Treatment for uneven hips focuses on addressing the underlying cause and alleviating symptoms. A multidisciplinary approach is often most effective:

Corrective Exercise and Physical Therapy

• Stretching: Targeting tight muscles (e.g., hip flexors, piriformis, adductors, quadratus lumborum, hamstrings).
• Strengthening: Focusing on weak muscles (e.g., gluteus medius, gluteus maximus, core stabilizers, hip abductors).
• Motor Control and Proprioception: Re-educating the body to move with better alignment and awareness.
• Postural Retraining: Learning to maintain neutral pelvic alignment in daily activities.

Manual Therapy

• Joint Mobilization/Manipulation: Performed by physical therapists, chiropractors, or osteopaths to restore normal movement to restricted joints (e.g., SI joint, hip joint, spinal segments).
• Soft Tissue Release: Techniques like massage, myofascial release, or dry needling to address muscle tightness and trigger points.

Orthotics and Shoe Lifts

• Shoe Lifts/Heel Lifts: Prescribed for individuals with a confirmed true leg length discrepancy to level the pelvis and reduce compensatory strain.
• Custom Orthotics: May be used to correct foot mechanics that contribute to pelvic asymmetry.

Lifestyle Modifications

• Ergonomics: Adjusting workstations, seating, and sleeping positions to promote neutral alignment.
• Activity Modification: Avoiding or modifying activities that exacerbate asymmetry (e.g., habitually standing on one leg, carrying bags on one side).
• Regular Movement: Incorporating varied movement patterns into daily life to prevent stiffness.

Surgical Intervention

• Rarely necessary: Surgical correction for uneven hips is typically reserved for severe structural leg length discrepancies or complex spinal deformities (e.g., severe scoliosis) that are unresponsive to conservative measures.

When to Seek Professional Help

If you suspect your hips are uneven or are experiencing persistent pain or discomfort, it is advisable to consult a healthcare professional. Seek professional guidance if you experience:

• Chronic or worsening pain in the lower back, hips, knees, or other areas.
• Noticeable changes in your posture or gait.
• Difficulty performing daily activities or exercises.
• Symptoms that do not improve with self-care or general exercise.

An expert assessment can determine the exact cause of your pelvic asymmetry and guide you toward the most appropriate and effective management strategy, helping you to move with greater balance, efficiency, and comfort.