04/30/2025
What is an Intra-Pelvic Torsion?
This is a long post about clinical reasoning of the pelvic girdle. In part to clear up misunderstandings and misinformation about this clinical reasoning tool.
TLDR: An IPT is a positional finding that is helpful for clinical reasoning in patients with nociceptive pain. No assumptions from the finding alone, changing it has to provide a meaningful change to the patient's experience. If it helps, work on structures and strategies that help facilitate alignment change.
Read on if you are interested!
What is an intra-pelvic torsion?
This is a term to describe the biomechanical movement of the pelvis. It describes the relative rotation of the two innominates and sacrum. This is the normal physiological movement of the pelvis. It's easy to feel on yourself. If you are sitting, rest your hands on your illiac crests then twist your body to the left, you'll feel the right side of your pelvis rotate anteriorly and the left side rotate posteriorly. Also notice that your right knee translates forward as a result of this torsion. This is the normal physiological motion of the pelvis and happens for most people without any pain or awareness. This terminology was coined by Diane Lee in her the various editions of her book, the latest: The Pelvic Girdle, an integration of clinical expertise and research. Fourth edition.
Who is this helpful for?
The first step in any clinical reasoning process should be to classify the likely mechanism of pain for that patient (nociceptive, neuropathic or nociplastic are the three agreed upon categories). Assessment of alignment is not usually helpful for people with nociplastic pain since it is mediated centrally and neuropathic pain involves more complex tests so lets exclude both of those. This assessment tool should be used for people with nociceptive pain, the kind that is provoked or relieved with mechanical movements and when people are usually showing you their pain with one finger.
What does it mean?
Alone this finding means nothing, it is no different to the resting position of any other joint, we can't make any assumptions about how it might be contributing to pain or dysfunction. In order to determine if this finding should be included in a treatment plan we first need to have a meaningful task. This is a task that represents a meaningful goal for the patient. The question "what can't you do that you'd like to be able to do?" usually leads us there. For example, 'Putting on my socks without pain' or 'Standing up after sitting without pain'
Once you have a meaningful task you can then determine if a change in the pelvis position (IPT) changes the meaningful task. It's important to understand that the patient decides wether this is meaningful, not the practitioner. If a change in alignment has no effect on the patient's task then that finding is meaningless. If it improves the meaningful task then your next step is to figure out what could facilitate a change in alignment.
Another note on meaning. Be sure to normalize these findings to your patient. Be careful not to give them the impression that their alignment is wrong or dysfunctional. It's just that it could be better with a different strategy.
What should I do about it?
If you have determined that the changing the alignment of the pelvis improves the meaningful task then the question is how can I help facilitate this alignment. We know that the mechanisms of manual therapy are multifactorial so you should consider as many options as possible. For example: Release techniques applied to any tissues that could be maintaining non-optimal alignment. Exploring unhelpful beliefs that could be contributing to bracing eg "I have to keep my pelvis stable". Motor control or movement strategies that could be unhelpful. Habits of sitting or moving that could be contributing to non-optimal alignment.
Is there any evidence for this?
No, but it is still Evidence Based Practice. This clinical reasoning process is unique to each patient so we'll never get population level data (evidence) for this sort of reasoning. Remember that Evidence Based Practice is a synergy of evidence, patient values and clinical expertise. This reasoning process relies on your clinical expertise (reasoning) and patient values (is this better for you?) and it falls inside the best evidence guidelines of reassurance and exercise. So, this clinical reasoning process definitely meets the threshold of Evidence Based Practice.
Summary:
Start with pain mechanism classification. This process is for people with nociceptive dominant pain.
Identify a meaningful task (what can't you do that you want to be able to do?)
Screen for alignment of the pelvis (and other regions).
Determine if a change in alignment changes the patient experience (Is that the same, better or worse?)
Normalise, don't pathologize.
Explore clinical strategies that can improve alignment and control.
Encourage meaningful function (all roads lead to movement).
If you made it this far you might be interested in an in-person course with me. Link in the comments.
