Greg Knight

Yes, the outflare you are seeing could be an inflare on the opposite side. First, I’d start by looking at the pelvis as a unit, one segment, to see if it is tilted to one side or another or twisted. Is what you are seeing perhaps not an intrasegmental problem with biomechanical components, but rather a tilting of the pelvis as a whole? Are there large patterns above or below to help see in relation to, e.g. sidebent thorax, etc.?

Intrasegmentally, assuming you accurately check the bony landmarks and you are certain one ilium is flared out compared to the other, you will want to check the mobility of each to determine which is the most restricted, the outflare or inflare. A good rule of thumb is to first determine a particular object’s position which you have done, then determine which ways it cannot move within its normal anatomical limitations, then move it through its barrier of motion. For this part of the body, spring tests on the ilium, standing flexion tests, stork tests, feeling for changes in inherent motion, and manually pushing the ilium around will all give a sense of where the restrictions are and which side.

Also, almost always an outflare is part of a posteriorly-rotated ilium (and likewise an inflare goes with an anterior rotation). I tend to correct for these first, and the outflares resolve on their own.

The sacrum is certainly affected; you have an iliosacral dysfunction, along most likely with the pubes being off. How the sacrum and the joint are specifically compromised depends on other factors including what restrictions if any does the sacrum have relative to the ilium. Also, definitely check L4 and L5 and the iliolumbar ligaments. In general, one can say that with an outflare, there is usually a lack of mobility in the SI joint, with the ilium slightly inferior (from its posterior rotation) on the sacrum at the Si.

Besides the joint and ligament issues, muscularly with an outflare you can have structures that pull the ilium out and likely back into posterior rotation. The posterior aspect of the IT band with fibers into posterior gluteus maximus, posterior aspects of gluteus medius, deep rotators, thoracolumbar fascia and lower quadratus lumborum fibers. These specific muscle groups as well as their fascial components can all be involved in an outflare.

Also, an outflare with posterior ilium means narrow ramus, so check the coccyx and pelvic floor.

I rarely have pure up slips in my practice – not my client population. If I suspect that, I usually check again, and again, and find torsions to address. Because a true upslip is such an abnormal dysfunction, I would treat as it is, adjusting vectors of pressure to most accurately stack my treatment. After, I would see what else, if anything, needs to be done with the ilium or its surrounding tissues.

Ed Toal

Your description of ilial flare coupled with A/P rotation differs from my understanding. I am no biomechanical authority, so I’ll quote one.

On page 329 of the second edition of Principles of Manual Medicine, Philip Greenman, D.O., says:

“As an innominate rotates anteriorly during the walking cycle and with an anteriorly rotated dysfunction, it also rotates somewhat laterally (outflare). The reverse is true with the posteriorly rotated innominate as it medially rotates both during the walking cycle and when dysfunctional.”

This seems to be the opposite of the idea I got during training, that narrow ischial tubes went with posterior tilt (apple butt) and wide tubes were a sign of anterior tilt (pear butt). Who’s got it right, Greenman or the Rolfing Faculty?

Greg Knight

I don’t have that quote in my Greenman, which I think is a first edition. I’d want to read the whole context from which you quote the paragraph, but from how it reads in your quote, I’d say Greenman’s wrong.

This is why in my mind: first thinking it through logically, the innominate has two points at which it is “fixed” or attached, the SI joint and the pubes. Rocking it between those two points you can narrow the ASIS as you widen the tubes (inflare) or widen the ASIS as you narrow the pubes (outflare). In an outflare or inflare, you cannot have symmetrical width or narrowness at these two places.

In striding forward, the hip flexes, the ilium rotates posteriorly and slightly externally. Try to make the ilium rotate internally as you step forward – basically it is impossible, unless you are extremely pigeon-toed.

Here is a quote from a website about SI dysfunctions athttp:/ /www.kalindra.com/hesch.htm:

“We will use the example of Anterior Ilium movement dysfunction to illustrate the problem of hypomobility and hypermobility. Anterior Ilium is defined as an excursion of the Ilium on the sacrum. In supine the Anterior Iliac Spine (ASIS) will be anterior, inferior, and medial in comparison to the opposite side. In prone the Posterior Iliac Spine (PSIS) will be superior, lateral and anterior.”

Maybe Greenman or his editors got the words backwards.

When I think of things being stuck and I needing to move, I think about them as being able to be stuck in almost any possible pattern but with very strong biases to certain patterns based on functional anatomy. In other words, when assessing and treating, I look for common patterns of holding while knowing anything could be there. It is possible, I imagine, to have an inflare with posterior rotation, but that is one messed up situation. The functional anatomy, the natural grooves of movement we all share, make that particular situation very awkward to create.