Assessing the hips in the transverse plane (why your lower back hurts)

Posted on January 11, 2019

(Last Updated On: January 11, 2019)

When referencing hip alignment the sagittal plane (forward and backwards) is predominantly mentioned.

This normally revolves around anterior pelvic tilt:

Simplistically, this is a sign of tight hip flexors and lumbar spinal erectors, and weak abdominals and glutes.

However, often times an anterior pelvic tilt -or too much lumbar extension- is accompanied by issues in the transverse plane –or too much lumbar rotation– as well.

-> Or, APT isn’t even a problem!

This can be much harder to assess only looking at someone’s standing alignment. And even harder to assess if you’re trying to look at yourself. While you can simply look at your belt line from the side in the mirror to assess anterior pelvic tilt (if your belt line is pointing down, you have an APT), you can’t really do this with rotation.

Instead, you need to determine if you’re hips are pointing left or right.

Here’s a quick method I’ve been playing around with to assess pelvic alignment in the transverse plane (rotational):

Take two pencils (or pens), place the tip of each pen on the top of each of your hip bones. You know, the pointy part. Like where you would have a hip pointer. (The anterior superior iliac spines for the anatomy inclined.)

Where the green is.

Ideally, the pens will point straight ahead. Not down, and not to a side. But straight ahead.

Realistically, they won’t point straight. For a lot of people they will be pointed downward (APT) and to one side. Typically that one side is to the left.

Now this won’t always manifest itself as much. The hips may only point a few degrees to the side.

-> Frankly, doing this assessment yourself is rife with opportunity to fool yourself. Another pair of eyes is always advantageous.

But a few degrees coupled with thousands and thousands of reps can make a difference. Especially in a joint that doesn’t deal well with rotation. (More on this later.)

Another way to assess rotation is to look at the shoulders. Is one shoulder lower than the other? If so, the shoulders are likely rotated to one side and the hips the opposite side. (This isn’t always true, especially for young athletes, but for the general population it often is.) For example, look at this person’s shoulders and hips as they walk:

You can clearly see the right shoulder is hanging much lower than the left. Then, looking closer, you can see the shoulders turn to the right (clockwise) more so than the left. Then, looking very close, you can see when the shoulders turn right (when the right leg comes forward), the hips turn quite a bit to the left.

Again, these methods of assessing aren’t the best. It’s just something I’ve been messing around with as a self-assessment method. There are other ways to look at the rotational elements of the spine and hips (see below), but they can be harder to spot without someone helping you.

Why will the hips point to the side?

The general reason is people are constantly performing an activity where their hips point to one side.

For instance, people often drive with their left arm up in front of them, thus they turn their shoulders to the right. Think your left hand on the steering wheel and your right arm resting on the console.

Notice how the right shoulder is hanging lower than the left just like the video of the man walking above. And no, this does not make you hood rich.

When the shoulders turn to the right the hips reciprocate with a turn to the left.  This is despite the fact the hips may appear to still be facing straight ahead. In other words, relative to the shoulders, the hips are now turned to the left.

Note: While we are talking about the shoulders turning to the right and the hips turning to the left, the opposite holds true as well: If the shoulders turn to the left, the hips then turn to the right.

This turning often takes place in people with desk jobs i.e. everyone nowadays. They often arrange their desk where they are always only turning from their shoulders (rather than including the hips) a certain direction. Think reaching for your phone, which is always on one side of the desk.

Or it can be just the mere act of sitting. In fact, you may be reading this like so:

Sitting lower back pain

Note how the hips and knees are turned to the left of the shoulders. The shoulders are facing straight ahead and down (to the laptop), while the knees and hips are facing to the left of it.

This sitting often translates to home activities too. Laying down like this:

Shoulders are facing straight up towards the ceiling while the hips are facing to the person’s left some.

Or sleeping like this:

This one is a bit more subtle, but it’s there. The shoulders are turned back some (to the right), and the hips are turned down some (to the left).

Next, people will stand crooked. Their shoulders will be facing, say, the person they are talking to, BUT, their hips will not be.

Notice if the person faced me more, like to talk to me, they would likely turn their shoulders (to the right) towards me but their hips would still be turned to the left.

A lot of times people who do this are standing with the majority of their weight on one leg as well. You can see this above.

Tons of people do this! This is a significant factor for those with knee, hip, and lower back issues.

Honestly, for some people it’s literally everything they do they are crooked. Everything.

And then sometimes you see people who have a throwing or overhead sport history with this alignment. Notice how the wind-up of a right-handed person throwing looks familiar to the position of someone driving or turning to the right in their desk chair:

See how the right shoulder is behind the right hip?

Why is this important?

Lower back pain:

This could be a long, long post in itself. To be brief though, while we always talk about correcting anterior pelvic tilt with respect to back pain, we never talk about correcting the rotational alignment of the pelvis. This is just as important!

The lumbar spine is not designed well for, and does not like, rotation. Just think about all those discs sitting in your lower back and then think about twisting them. Painful, no?

Therefore, we want to minimize rotation at the lumbar spine.  We can do this by improving our pelvic alignment in the transverse plane. Specifically making sure the pelvis is not rotated to one side but is pointing straight ahead.

The above examples of how people sit, stand, drive are BY FAR the most common causes of lower back pain. So stop sitting, standing, driving, etc. like a contortionist.

For more on this click here: Example of impaired movement causing lower back pain.

Knee pain:

The knee is another joint that does not like rotation. Notice what happens to the knees as the pelvis rotates here:

You’ll see in this instance it is the right knee that is primarily rotating / caving inward. And this is what I see most often.

That is, most people’s shoulders tend to rotate to the right (clockwise), their hips tend to rotate to the left (counterclockwise), and their right knee tends to rotate / cave inward.

This is why I see people with more right knee issues than left. I’d venture to say this would be true for nearly anyone dealing with the general population. The fact of the matter is most people are right handed, most people use their right hand more than their left, thus most people rotate their shoulders to the right more, eventually causing issues down the chain.

Neck pain:

Here’s a less obvious one. So let’s take a person who is standing with good alignment. They are upright, their head, shoulders, hips, are all facing forward. Then, let’s have their shoulders turn to the right; hips to the left.

You’ll notice what the person has to do in order to still be looking straight ahead…they have to turn their neck to the left. Otherwise they will be looking to the right (in line with their shoulders).

Or, if the person tends to always stand on one leg, their neck is always going to be turned in one direction also. Using the above example of the person having their shoulders turned to the right, their neck is going to be excessively turned to right quite often as well:

A neck always turned in one direction is a potentially unhappy neck.

I could really go on forever about the importance of the hips and their influence on other joints. I could make a case rotated hips affect everything -> The neck, the shoulders, lower back, hips, knees, feet, etc.

The point of this is to illustrate the importance of hip alignment in the rarely talked about transverse plane (rotational), to give some simple ways for assessing alignment, and to elucidate some of the more common daily posture flaws that can cause rotated hips and pain.

Give it a shot.

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