Rethinking the Pelvis: Building On Traditional Training
Why the Pelvis is Foundational
In pelvic health, the pelvis is the foundation of our work. Knowing how to assess and treat this structure effectively is critical for clinical success with any pelvic health issue, especially postpartum. Physical therapy school provides a strong base, but when it comes to the pelvis, we need to do more.
The Limits of Traditional Training
Our foundational training includes a number of practices and techniques that are helpful, but when I started to implement these pieces into my own practice, I was often left wanting a better way, a simpler way.
In physical therapy, we use pain provocation tests like the P4, Thigh thrust, Gaenslen’s and FABER which use pain as the indicator that there is something going on in the joint.
We are taught other assessment skills including palpation of the long dorsal ligament, the symphysis pubis and the Stork test, in standing, palpating the PSIS and the sacrum to see if the SIJ is lacking inferior movement during hip flexion.
In every other area of the body we use joint mobilizations to determine if the joint is moving well. The shoulder, the spine, the wrist, knee, all of these joints require mobilization testing to determine if there is a dysfunction in the joint.
In addition, we are taught muscle energy techniques to help make changes to the pelvis. With palpation being our only assessment tool, we determine if the sacrum is positioned in a left on left oblique axis or if the ilium was more anteriorly rotated than the other. Then we have to remember if we used the hip flexors or hip extensors to activate a correction for the rotations.
I used to get so frustrated and tired trying to remember all the different ways to use the muscles to make corrections. I often wondered why we were creating more pain for our clients in order to treat the pain? Wasn’t there a better way? And, I don’t know about you, but I’ve never been effective with the Stork test in determining if there is movement or not, especially on my patients with more adipose tissue in this area.
Why Spring Testing Changed Everything
My own clinical outcomes changed dramatically after training with Jerry Hesch at the Hesch Institute. He introduced me to spring testing for pelvic mobility.
Spring testing simplified the process. The assessment, treatment, and reassessment all use the same technique:
- Test the pelvis for mobility differences side to side.
- Hold the restriction until a release occurs.
- Reassess to confirm balanced mobility.
Simple. Effective. No endless mental gymnastics.
Beyond Traditional Biomechanics
Research and clinical discussions around the pelvis usually focus on ilial rotations (anterior/posterior), inflare/outflare motions, or upslips of the SIJ. But one critical area remains overlooked in practice and in research: the impact of birth on the pelvis and what happens at the pelvic outlet.
The Reality of Birth Mechanics
During childbirth, the sacrum is forced into flexion and the ischiums widen to allow for the baby’s passage. This creates an expansion of the pelvic outlet that goes far beyond typical physiologic motion.
I call this motion ischial splay—an abduction of the ischiums that alters the pelvic position and often needs to be addressed.
The medical community rarely acknowledges the effects of these shifts on the pelvis. It’s as though a huge puzzle piece has fallen on the floor, and the medical community doesn’t even see that it is missing. As pelvic health practitioners, we need to be looking at the impact birth has on the pelvis, especially when baby is occiput posterior or asynclitic and the pelvis has to widen even further to allow baby’s passage. We assume bones return to their original position—but often, they do not.
Birth Position Matters
Understanding a client’s birth story and the position they gave birth in helps provide clues as to what pelvic patterns you may find:
- Side-lying birth: the top ischium often splays more and there is more dysfunction on that top side.
- Hands-and-knees or squat birth: if one leg was bent outward, that side’s ischium is more likely to be splayed.
As with other common birth patterns, the ischium splays rarely resolve on their own and need support to return to their pre-birth position. The pelvis can hold the imprint of birth for years—sometimes decades—creating pain and dysfunction unless treated.
The Common Birth Patterns of the Pelvis
I call these lasting imprints the Common Birth Patterns of the Pelvis.
Through my clinical work, I’ve identified four main patterns, each with distinct signs and symptoms. Addressing them has led to powerful, lasting improvements for my clients regardless of when they gave birth.
I teach how to identify and treat these patterns in my Treating the Postpartum Pelvis online course, where I share step-by-step assessment and treatment techniques for all 4 patterns. To get an overview of these patterns, start with the free online Common Postpartum Patterns course.
Expanding Our Horizons
It’s time to broaden our view of the pelvis. Birth leaves behind patterns that extend beyond the physiologic motions we currently recognize. When you know how to assess and treat these postpartum pelvic patterns, you’ll see faster, more profound results with your clients.
About the Author: Lynn Schulte is a Pelvic Health Therapist and the founder of the Institute for Birth Healing, a pelvic health continuing education organization that specializes in prenatal and postpartum care. For more information, go to https://instituteforbirthhealing.com
Great reporting and synopsis, Detective Schulte! I just pretended my hands were on your hands to help with my own awareness, muscle memory And understanding.