Pelvic Reflections

The pelvis is undoubtedly a divine construction. I’m filled with joy every time I see the surprised and amazed expression on my patients’ faces when I show them the pelvic model I keep in my clinic.

One of my patients is an architect with a great sense of humor, who also happens to suffer from sacroiliac joint (SIJ) pain. During one of her treatments, we observed the pelvis together, especially the junction and angle between vertebrae L5 and S1, and the sacroiliac joints. She exclaimed in shock: “No structural engineer would ever approve such a thing!” It was incredibly amusing to see this marvel of creation through her architectural lens.

One of the key principles of osteopathic philosophy, defined by Andrew Taylor Still, the father of the method in the mid-19th century, is: “Structure affects function, and function affects structure.” I dare to go a step further – “Structure and function are inseparable; they are one.”

For example, in cases of SIJ pain, the root cause may lie in the uterus or ovaries. Alternatively, cases of constipation or menstrual pain may stem from restricted movement of the sacrum and SI joints. I’ve seen many cases in the clinic where, following treatment for lower back pain, a patient casually mentions that their menstrual pain has significantly improved. One case I particularly like to share is of a woman in her thirties who suffered from severe postpartum urinary incontinence. The issue was resolved in a single session through pelvic balancing.

Functionally, the pelvis is home to the digestive, urinary, reproductive, and hormonal systems. In short, these systems are complex, integrated, both voluntary and involuntary, and require mobility and proper organ function. This is reflected in basic actions such as elimination, retention, and sex – not to mention the incredible combination of voluntary and involuntary effort: childbirth.

Structurally, the pelvis serves as a ‘container’ (pregnancy, stool…), a ‘drainage basin’ (urine, menstruation…), and a ‘funnel’. Indeed, the pelvic bones and sacrum form a vessel shaped like a funnel, and the downward movement of a baby through the birth canal is a perfect illustration of this.

The pelvis defines our center, both structurally and on deeper, subconscious levels of release and control. The tone of the pelvic muscles and ligaments (including abdominal muscles), the mobility of the pelvic bones (ilium, pubis, ischium, sacrum), and the tone of internal organs all tell a complete story. From this information, we can tailor our treatments and guide patients to more mindful self-practice of relaxation and/or engagement. For example, I find glute and deep hip rotator strengthening exercises very effective when weakness or looseness in the pelvis is observed, due to their direct connection with the pelvic floor.

In osteopathic treatment, we always examine the pelvis and rarely choose not to treat it. Any restriction in the body, even far from the pelvis, will manifest in the pelvis as a secondary, compensatory restriction. Treating the primary restriction is essential, but adding pelvic balancing enables the most accurate systemic reset. A common example I see in the clinic is old, untreated ankle sprains that trigger a chain reaction up to the pelvis. Treating the ankle and then balancing the pelvis has proven effective and even reduces the likelihood of recurrent sprains.

Osteopathy is a language that defines body movement from gross biomechanics to the most subtle passive movements of the patient. In treatment, we examine the movement of bone within soft tissue, even bone movement within itself. It’s important to know that a traumatized bone becomes harder and heavier, and we can improve its mobility by enhancing blood flow. We also assess movement of tissues not related to the musculoskeletal system.

As osteopaths, we have three ‘windows’ through which we diagnose and treat:

• Structural/biomechanical window: the musculoskeletal system
• Visceral window: the internal organs
• Craniosacral window: the nervous system, focusing on the movement of the dura mater (the membrane of the brain and spinal cord) and cerebrospinal fluid from skull to tailbone

Andrew Taylor Still also defined another key principle: “Our role is to find health in the body, not the disease.” Health is the state of harmony within and between these three systems. The practitioner promotes health by improving blood flow to areas with poor circulation. Hence another of Still’s principles: “The rule of the artery is supreme,” meaning blood flow is the foundation of healing.

Regarding the pelvis, my clinical experience has taught me the importance of examining and releasing blood flow in the abdominal aorta and major pelvic arteries. A touching example happened recently in my clinic when a patient with acute sciatica (sharp radiating pain down the leg) experienced significant relief following release of the deep left internal pelvic artery.

I deeply believe in awareness-based work, helping the patient understand the nature of their limitation and the biomechanical and psychosomatic patterns behind it. This has led to the development of my own therapeutic language, which I call “Osteopathy in Motion,” strongly influenced by contemporary neuro-somatic rehabilitation models. When a patient understands their sitting, driving, breathing, etc. patterns, they can consciously transform faulty movement habits. For example, a patient with severe right groin pain who had tried every therapy and painkiller without success overcame the problem once we connected it to long hours of driving and poor right leg and pelvic mobility while pressing the car pedals.

One of the researchers who has influenced my work is Phillip Beach, a New Zealand osteopath and acupuncturist. He wrote the book Muscles and Meridians, in which he discusses “Archetypal Postures”—the fundamental postures of early human beings: resting on the ground, rising from the ground, running long distances, climbing, hunting, etc.—all essential for survival.

When I work on the pelvis, I think of appropriate movement nutrition, just like regular nutrition. I ask whether the pelvis is receiving its full range of archetypal movements, such as full squats, cross-legged sitting, Japanese sitting, half-kneeling—these are all healing, restorative positions, like movement-based food groups.

In our modern times, it’s sad to see how the pelvis loses its mechanical and functional vitality due to limited movement repertoire and prolonged chair sitting. Without proper movement nourishment, blood flow becomes impaired, affecting joints, muscles, and ligaments—leading to stiffness, calcification, and inflammation. Western medicine labels these conditions as: lower back pain, disc herniation/bulge, spinal canal stenosis, ligamentum flavum calcification, sacroiliac joint inflammation, etc.

Beyond all the functional processes it hosts, the pelvis structurally connects the upper and lower body, balancing weight load and protecting the internal organs. The frequent and extreme shifts between intra-abdominal pressure and relaxation demand coordination across systems.

The pelvis, in its delicacy, reminds me of a tent: it requires a precise balance of tension between the ropes and stakes to remain wide, open, stable. Our job as practitioners is to fine-tune and balance the delicate support network of tendons and ligaments to properly align the bones and allow the organs optimal space to function.

In the pelvis, even a small change in angle or internal structure can have serious consequences: acutely, it may trigger severe lower back pain, or internal organ issues like ovarian torsion, appendicitis, pelvic inflammation, and more.

To end, I want to reflect on the word “osteopathy,” made up of two Latin roots: “osteo” – bone, and “pathy” – disease. Osteopathy reads the body through the movement of bone. Bones are living, ever-changing tissues, connected to all systems – blood, immunity (bone marrow), nervous system (proprioception), and the endocrine system (insulin, testosterone). Thus, working with bones impacts all of these systems.

In Hebrew, the root ע.צ.ם reflects our deepest identity: self (atzmi), independence (atzma’i), strength (otzma), essence (etzem hadavar). Touching bones in treatment connects us to this core sense of self—especially the bones of the pelvis. Many patients say that this touch grounds and calms them, offering a powerful experience of core connection.

By Michal Lerer – Osteopath and Iyengar Yoga Teacher at the Studio