EFFECT OF POSTERIOR PELVIC TILT TAPING IN WOMEN

WITH SACROILIAC JOINT PAIN DURING ACTIVE STRAIGHT

LEG RAISING WHO HABITUALLY WORE HIGH-HEELED
SHOES: A PRELIMINARY STUDY
Jung-hoon Lee, PhD, a Won-gyu Yoo, PhD, b Mi-hyun Kim, PhD, b Jae-seop Oh, PhD, b
Kyung-soon Lee, PhD, c and Jin-tae Han, PhD d

ABSTRACT
Objective: The purpose of this study was to assess whether a 1-day application of posterior pelvic tilt taping (PPTT)
using a kinesiology tape would decrease anterior pelvic tilt and active straight leg raising test scores in women with
sacroiliac joint who habitually wore high-heeled shoes.
Methods: Sixteen women (mean age, 23.63 3.18 years) were enrolled in this study. Anterior pelvic tilt was measured
using a palpation meter before PPTT application, immediately after PPTT application, 1 day after PPTT application, and
immediately after PPTT removal after 1 day of application. Active straight leg raising scores were measured at the same
periods. Posterior pelvic tilt taping was applied in the target position (posterior pelvic tilt position).
Results: The anterior pelvic tilt was decreased during and after 1 day of PPTT application (before and after
kinesiology tape removal) compared with the initial angle (all P b .05). Active straight leg raising scores were
decreased during and 1 day after PPTT application (before and after kinesiology tape removal) compared with the
initial score (all P b .05).
Conclusion: The results of this preliminary study suggests that PPTT may temporarily decrease anterior pelvic tilt
and active straight leg raising score in women with sacroiliac joint pain who habitually wear high-heeled shoes. (J
Manipulative Physiol Ther 2014;xx:1-9)
Key Indexing Terms: Joint Pain; Pelvis; Athletic Tape

n a recent survey on shoe choice, 59% of women chose

to wear high-heeled shoes for 1 to 8 hours per day. 1
Many physicians and therapists consider habitual
wearing of high-heeled shoes as a cause of an increase in
the lumbar lordotic curvature, which could be a source of
pain. 2 Because lumbar spine posture is associated with
pelvic posture, changes in lumbar lordosis are in conjunction with changes in pelvic posture. 3 In a recent study,
prolonged use of high-heeled shoes among adolescents
showed increased lumbar lordosis and pelvic anteversion. 3

Sacroiliac joint (SIJ) pain has many causes including

inflammatory arthritides, ankylosis, 4,5 osteoarthritis, and
posttraumatic arthritis. 6 Although requiring further investigation, the primary source of SIJ pain is thought to be SIJ
dysfunction (SIJD). 7,8 The pain associated with SIJD
suggests that the nociceptive and painful mechanical stress
within the SIJ or acting on the surrounding tissues attached
to the innominate bones is caused by pelvic asymmetry, or
SIJ hypomobility, 9 hypermobility, 10 or instability, 11 with
or without positional abnormalities. In contrast, DonTigny

a
Professor, Department of Physical Therapy, College of
Nursing and Healthcare Sciences, Dong-Eui University, Republic
of Korea.
b
Professor, Department of Physical Therapy, College of
Biomedical Science and Engineering, Inje University, Gimhae,
Republic of Korea.
c
Professor, Department of Physical Therapy, Dong Ju College
University, Busan, Republic of Korea.
d
Professor, Department of Physical Therapy, Kyung-sung
University, Busan, Republic of Korea.

Submit requests for reprints to: Won-gyu Yoo, PhD, Professor,

Department of Physical Therapy, College of Biomedical Science and
Engineering, Inje University, 607 Obang-dong, Gyeongsangnam-do,
Gimhae 621-749, Republic of Korea.
(e-mail: won7y@inje.ac.kr).
Paper submitted June 11, 2013; in revised form November 24,
2013; accepted January 14, 2014.
http://dx.doi.org/10.1016/j.jmpt.2014.01.005
0161-4754/$36.00
Copyright 2014 by National University of Health Sciences.

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Fig 1. Flow diagram for the study. PPTT, posterior pelvic tilt taping. (Color version of figure is available online.)

defined SIJD as the pathological release of the self-bracing

position with an anterior pelvic tilt. 12 In addition to the
bilateral SIJD, lumbar lordosis was increased and the pelvis
was tilted anteriorly. 12 Anterior rotation of the innominates
in the absence of an adequate anterior pelvic support
decreases tension on the sacrotuberous ligaments, releasing
the self-bracing mechanism. 12
The active straight leg raise (ASLR) test has been
described as a clinical test for the assessment of the
neuromuscular system to effectively control load transfer
through the lumbopelvic region 1315 via the form closure
and force closure mechanisms. 16 Form closure describes
the stability of the SIJ to resist shear forces according to its
anatomy and the shape of its bony structure. 1720 Force
closure is a dynamic process performed by the muscular
system, augmented by ligamentous and fascial structures in
the region of the SIJ, to support the pelvis. 21 The ASLR test
has been especially used in studies on pregnancy-related
pelvic pain. 1416,22 Mens et al 23 found that women with
pregnancy-related pelvic pain perceived greater difficulty in
performing the ASLR test. In patients with SIJ pain,
changes in the kinematic data of the pelvic floor and
alterations in respiratory function were found while

performing the ASLR test compared with healthy participants. 21 The change in motor responses during ASLR in
participants with SIJ pain compensates for the lack of load
transfer to the lumbopelvic region by the neuromuscular
system as a result of the form and/or force closure
mechanisms. 21 The methods used to score the ASLR test
were scales of perceived difficulty (patient reported) 24 and
positive (improved performance in the second ASLR test
with manual pelvic compression)/negative (examiner
reported), respectively. 21,23
Kinesiology taping (KT), in combination with other
treatment techniques, is a relatively new therapeutic method
used in orthopedic, 25 neuromuscular rehabilitation, 26,27
and sports medicine 28 to achieve strength in weakened
muscles, 29 control joint instability, assist postural alignment, 30 relieve pain, 25,3133 improve circulation of lymph
and blood flow, 34 and enhance muscular functions. 27,35
No study has been published thus far on the ASLR test
that involves women with SIJ pain who habitually wear
high-heeled shoes. In addition, the mechanical correction
effects of KT application in the short term (eg, 1 day) and
after tape removal in comparison with the mechanical
correction effect of immediate 36 or medium- to long-term

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Table 1. General Characteristics of the Participants

Variable

Female (n = 16),
mean SD

Age (y)
Height (cm)
Weight (kg)
ASLR score of the dominant side from 0 to 5
ASLR score of the nondominant side from 0 to 5

23.63 3.18
159.75 4.10
51.31 5.26
3.00 1.10
2.75 1.18

ASLR, active straight leg raise.

follow-up 37 after KT application have not been sufficiently

studied. Hence, the purpose of this preliminary study was to
assess whether 1-day application of posterior pelvic tilt
taping (PPTT) using a kinesiology tape would decrease
anterior pelvic tilt and ASLR scores in women who
habitually wore high-heeled shoes and experienced SIJ
pain and difficulty performing ASLR. The hypotheses of
this study were as follows: (i) the anterior pelvic tilt could
be decreased immediately after and 1 day after PPTT
(before and after removal of the kinesiology tape),
compared with the initial angle, and (ii) the ASLR score
could be decreased with a decrease in anterior pelvic tilt.

METHODS
Participants
38

For sample size determination, a significance level () of

.05, a desired power (1 ) of 0.90, an effect size of 1.41, 36
and a 20% dropout rate were used. A sample size was
calculated to be 20; thus, 20 women were recruited in this
study, which was conducted at the Inje University laboratory,
to undergo physical therapy in the outpatient department of a
private hospital. In the screening process, 4 women who did
not meet the inclusion criteria were excluded and 16 women
who habitually wore high-heeled shoes (users of high-heeled
shoes at least 4 times a week for 4 consecutive hours and with
at least 1 year of usage time) 3 and had pain in both SIJs during
ASLR were included in the study. Figure 1 shows a flow
diagram illustrating the progress of the participants at each
stage of the study. The general characteristics of the
participants are displayed in Table 1. The inclusion and
exclusion criteria are displayed in Figure 2. Prior to
participation in the testing, all the participants read and signed
an informed consent document that was approved by the
human ethics committee of the National Evidence-based
Healthcare Collaborating Agency (PIRB11-021-1[1]). The
trial was registered under trial registration no. KCT0000913.

Procedure
Active straight leg raise scores (for the supine position)
and anterior pelvic tilt measurements (in the standing
position) were obtained from the dominant and nondominant sides (all the participants having right-side dominance)
at 4 time points as follows: before PPTT application,

Inclusion Criteria
The patients have pain in the sacroiliac joint (SIJ) region, but it is not
referred proximally to the lumbar spine7,3941
Symptoms present for longer than 3 months21
SIJ pain provocation tests: at least 3 of 5 positive SIJ pain provocation
test results on both sides
Posterior shear test4244
Pelvic torsion test42,43
Sacral thrust test42,43
Distraction and compression test42,43
Tenderness on palpation of the long dorsal SIJ ligament45
Positive ASLR test21,23
Improved performance in the second ASLR test with manual pelvic
compression
Other tests
Absence of lumbar spine impairment and pain42,43
Negative outcomes of the passive accessory intervertebral motion46
The outcome of neurological screening is negative46
No neural tissue mechanosensitivity (slump test)46
Exclusion criteria
A history of neoplasm and fracture of the lumbar spine, the pelvic
girdle, and hip joint46
Any other musculoskeletal problems in the last 6 months46
Neurological, Inflammatory and Respiratory problems46
Surgery to the lumbar spine and pelvic in the last year46
Active straight leg raising restricted by pain in the lower extremity
A history of current or recent pregnancy (i.e., within the past year)
Physical treatment (whatever technique) undergone some weeks
before the study

Fig 2. Inclusion and exclusion criteria of the participants. ASLR,

active straight leg raise.

immediately after PPTT application, 1 day after PPTT

application, and immediately after PPTT removal after 1
day of application. The participants did not receive any
other therapeutic interventions during the study period.
All assessments were completed by 2 independent
physical therapists, each with 10 years of experience.
Eight women were respectively assigned to a physical
therapist, using allocation card A (physical therapist 1) or B
(physical therapist 2), by an independent assistant who was
not a participant in the study. The same physical therapist
assessed the same participants before and after the PPTT
intervention. In addition, before starting the study, both
physical therapists practiced the assessment methods
(ASLR test and pelvic tilt angle measurement) for 1 day.
The physical therapists examined independently 10 young
female volunteers who participated in the session.

Measures
Pelvic Tilt Measurements. In this study, a palpation meter
(PALM; Performance Attainment Associates, St Paul, MN)
was used to measure pelvic tilt angle. Each side of the
participant was measured 3 times, and the mean measurement was calculated. During the measurement, the
participants removed their shoes and stood in an upright
position with their feet spread apart (approximately 10-12

Lee et al
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Fig 3. The use of the PALM to measure pelvic tilt angle

(ipsilateral ASIS and PSIS). (Color version of figure is available
online.)

cm), leaning the anterior aspect of the thighs against a

stabilizing table. 47 The investigator palpated the ipsilateral
anterior superior iliac spine (ASIS) and posterosuperior
iliac spine (PSIS) and marked them with a black pen. The
anterior pelvic tilt was measured by placement of the caliper
tips of the PALM in contact with the ipsilateral ASIS and
PSIS (Fig 3). 36,4750 PALM consists of 2 caliper arms and
an inclinometer. This is a valid, reliable, and cost-effective
clinical measurement instrument 51,52 for calculating any
discrepancy between landmarks. 47 Intratest reliability of
the PALM was 0.90.
Measurements of ASLR Score. The ASLR test was performed
with the participants in a supine position, with legs straight
and feet 20 cm apart. The participants were requested to
respond to the command, Try to raise your legs one at a
time to 20 cm above the mat without bending the knee.
Each participant was asked to score for disability on a 6point scale defined as follows: not difficult at all, 0;
minimally difficult, 1; somewhat difficult, 2; fairly difficult,
3; very difficult, 4; and unable to perform, 5. 24

Taping Intervention Protocol

The PPTT was applied by a single physical therapist
who was well trained in the KT method. The elasticity of
the KT (BB TAPE; WETAPE Inc, Seoul, Korea) is
approximately a 70% to 80% stretch of the original
length. According to the stretch guidelines provided by
Kase et al, 34 the tension for facilitating muscle function is
25% to 50% of the available tension and the tension for
mechanical correction is 50% to 75% of the available
tension. I-type strips with approximately 50% of the
available tension were placed over the rectus abdominis
(RA) and external oblique (EO) muscles, which are
involved in posterior pelvic tilting, 53 and I-type strips

Fig 4. Application of PPTT. A, Application of kinesiology tape for

the EO muscle. B, Application of kinesiology tape from the ASIS to
the PSIS. C, Application of kinesiology tape for both RA muscles.
(Color version of figure is available online.)

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with approximately 75% of the available tension were

applied from the ASIS to the PSIS to provide a mechanical
correction effect (ie, posterior tilt to the pelvis bilaterally).
According to the published PPTT methodology, 37 the first
strip of tape was applied over the EO muscle, originating in
the inguinal region and terminating on the spinous process of
thoracic vertebra 12 (Fig 4A). The second tape strip
originating at the ASIS was pulled over the PSIS (Fig 4B).
The participant was in the side-lying position, and the pelvis
was maintained in the posterior pelvic tilt posture such that the
participant would not experience pain while using the tape.
The third tape strip was applied over the RA, originating near
the pubic symphysis and terminating on the xiphoid process
and fifth to sixth costal cartilages, while the participant was in
the hook-lying position (Fig 4C). The arrow in Figure 3
indicates the direction of the tape application. Participants
were instructed to immediately remove the tape if they
experienced pruritus of the skin beneath it.

Statistical Analysis
Statistical analysis was performed using the PASW
Statistics 18.0 (SPSS Inc, Chicago, IL). Normal distribution of the variables of the anterior pelvic tilt on both
sides was analyzed using the Kolmogorov-Smirnov test
(P b .05). Therefore, the Friedman test was used to
analyze changes in anterior pelvic tilt and ASLR scores
by PPTT application. Post hoc analyses were based on
the Wilcoxon signed rank test results. The level of
statistical significance was set at P b .05.

RESULTS
The results of the pelvic tilt measurements on both sides
are shown in Table 2. The Friedman test detected a
significant effect for time on the dominant ( 2 = 41.962,
df = 3, P b .001) and nondonimant sides ( 2 = 37.374, df =
3, P b .001). The post hoc analyses revealed that the
anterior pelvic tilt of the dominant side was decreased
significantly immediately after PPTT application (P b
.001), 1 day after application (P b .001), and immediately
after PPTT removal after 1 day of application (P = .001),
compared with the initial angle (Fig 5A). Although the
anterior pelvic tilt of the dominant side after PPTT removal
was increased significantly compared with that after PPTT
application (P b .001) and before PPTT removal (P = .001),
it was decreased significantly compared with the initial
angle (P = .001; Fig 5A). The anterior pelvic tilt of the
nondominant side was decreased significantly immediately
after PPTT application (P b .001), 1 day after application
(P b .001), and immediately after PPTT removal after 1 day
of application (P = .001) compared with the initial angle
(Fig 5B). Although the anterior pelvic tilt of the nondominant side after PPTT removal was increased signifi-

Fig 5. Comparison of the pelvic tilt angle of the participants at the

4 different time points. A, Comparison of the dominant pelvic tilt
angle. B, Comparison of the nondominant pelvic tilt angle. The
data are expressed as mean SD values. *P b .05. PPTT,
posterior pelvic tilt taping.
cantly compared with that after PPTT application (P = .003)
and before PPTT removal (P = .001), it was decreased
significantly compared with the initial angle (P = .001;
Fig 5B).
The ASLR scores for both sides are shown in Table 3.
The Friedman test detected a significant effect for time
point on the dominant ( 2 = 41.308, df = 3, P b .001) and
nondominant sides ( 2 = 41.727, df = 3, P b .001). The
post hoc analyses revealed that the ASLR score for the
dominant right side was decreased significantly immediately after PPTT application, 1 day after application, and
immediately after PPTT removal after 1 day of application
compared with the initial score (all P b .001; Fig 6A). The
ASLR score for the nondonimant side was decreased

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Table 2. Comparison of the Pelvic Tilt Angle Before, During, and After PPTT Application (n = 16)
Mean SD (deg)
Pelvic Tilt Angle

Before PPTT

After PPTT

After 1 d

On removal

Dominant side
Nondominant side

11.97 2.81
12.68 2.76

6.73 3.17
7.10 2.79

7.16 2.87
7.25 2.45

8.69 2.98
8.80 2.45

.000
.000

P, adjusted for post hoc comparisons; PPTT, posterior pelvic tilt taping.

Table 3. Comparison of the ASLR Scores Before, During, and After PPTT Application (n = 16)
Mean SD
ASLR Score

Before PPTT

After PPTT

After 1 d

On removal

Dominant side
Nondominant side

3.00 1.10
2.75 1.18

1.69 1.30
1.05 1.27

1.38 1.08
1.25 1.13

1.38 1.08
1.25 1.13

.000
.000

P, adjusted for post hoc comparisons; PPTT, posterior pelvic tilt taping.

significantly immediately after PPTT application, 1 day

after application, and immediately after PPTT removal after
1 day of application compared with the initial score (all P b
.001; Fig 6B). No significant differences were noted
between the ASLR scores at the 3 postbaseline time points.

DISCUSSION
This preliminary study aimed to assess any change in
ASLR performance and a decrease in anterior pelvic tilt
rather than on a decrease in overall SIJ pain immediately
after PPTT application. The present study shows that the
anterior pelvic tilt on both sides was significantly decreased
immediately after PPTT application and 1 day after PPTT
application (before and after KT removal) compared
with the initial scores. Although the effects of KT, such
as increased muscle strength and activity, remain
controversial, 5458 findings of previous studies suggest
that KT may assist muscular functioning. 27,35,59 In this
study, the KT applied on the RA muscle originated from the
pubic crest and symphysis pubis and was inserted at the
xiphoid process and cartilages of ribs 5 to 7, 53 tilting the
pelvis posteriorly. 53,60 The bilateral activation of the lateral
fibers of the EO muscle, on which KT was applied in this
study, flexed the vertebral column, permitting a posterior
pelvic tilt. 53 According to recent similar studies on KT
application on muscles around the pelvis, the application of
KT on the muscles involved in anterior pelvic tilting
immediately increased the anterior pelvic tilt in healthy
participants. 36 In women with SIJ painrelated low back
pain, the PPTT application for 2 weeks (6 times per week
for a mean of 9 hours each time) gradually decreased
anterior pelvic tilt. 37 Therefore, KT may assist the functions
of the RA and EO muscles and may contribute to the
decrease in anterior pelvic tilt. However, determining the
underlying mechanism of KT regarding muscle activity is
beyond the scope of this study, and the electromyographic
activity of the RA and EO muscles during ASLR were not

measured exactly because their surface electrodes overlapped with the position of the PPTT. Further research is
thus needed to ascertain the results of this study.
The elasticity of kinesiology tape makes free movement
possible within the desired range of elasticity 32 and recoils
back to its original length. 61 To achieve an additional
mechanical effect on posterior pelvic tilt, 37 an I-type strip
with approximately 75% of the available tension 34 was
applied from the ASIS to the PSIS in the posterior pelvic tilt
position. 37 When the pelvis anteriorly tilts after PPTT
application, the kinesiology tape is stretched and under
increased tension, creating forces that might cause resistance to the anterior pelvic tilt posture, which subsequently
induces the pelvis to return rapidly into a posterior pelvic
tilt posture. Therefore, application from the ASIS to the
PSIS may induce a decrease in anterior pelvic tilt. 37
According to the KT methodology, 34 the muscle on
which the tape was to be applied should be placed in a
stretched position. However, in this study, the patient was in
the side- or hook-lying position during tape application 37
because stretched positions would provoke SIJ pain. In
addition, in previous studies on the mechanical correction
effect of KT, KT was applied in the target positions for the
pelvis 37 and shoulder. 62
The stability of the SIJ through the form and/or force
closure mechanisms 63 was proposed to facilitate load
transfer to the pelvis. 21 Deficit in the form or force closure
mechanism may be related to pain disorders of the
lumbopelvic region. 17,23,64 If the lumbosacral area is stable,
ASLR may be easily performed. 23 The wearing of highheeled shoes moves the center of gravity anteriorly,
resulting in anterior rotation of the ilium, 3 which may
lessen the stability of the SIJ 12 and lead to failure of a safe
load transfer to the lumbopelvic region. 17,22 Therefore, a
decrease in anterior pelvic tilt by PPTT may decrease the
ASLR score. This proposal may be inferred from observed
results. Although the mechanical effect and assisted muscle
function disappeared after PPTT removal, a decrease in
anterior pelvic tilt after 1 day of PPTT application from the

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findings. The number of participants was small and thus

limits generalizability. Standardizing the changes in pelvic
tilt and ASLR scores was difficult because the sample size
was small and the participants were all women. The effect
of natural history and the placebo effect on the results could
not be established because of the lack of a control group.
Various clinical outcomes (eg, pain and disability) aside
from ASLR score and pelvic tilt angle were not used. The
increase in anterior pelvic tilt angle in comparison with that
before wearing high heels was not analyzed. No follow-up
examination was performed, except for the 1-day treatment.
It is unknown if there were any lasting findings.

Future Studies
Future studies with additional outcomes, more participants, and longer treatment and follow-up should be
considered. The results of this study might serve as a
basis for future clinical studies on the use of PPTT for SIJD
related to wearing high-heeled shoes. Further research is
required regarding clinical outcomes of PPTT application,
such as pain, disability, and alterations of kinematic data of
the pelvic floor and breathing pattern during performance of
the ASLR test, in comparison with controls or other
intervention groups.

CONCLUSIONS

Fig 6. Comparison of ASLR scores of the participants at the 4

different time points. A, Comparison of the dominant ASLR scores. B,
Comparison of the nondominant ASLR scores. The data are
expressed as mean SD values. *P b .05. PPTT, posterior pelvic
tilt taping.

The results of this preliminary study suggest that a 1-day

PPTT application using the KT contributed to the decrease
in anterior pelvic tilt and ASLR scores in the women who
habitually wore high-heeled shoes and experienced SIJ pain
and difficulty performing ASLR. Kinesiology taping
application in the target position may produce a temporary
mechanical correction effect.

Practical Applications
initial angle may help to prevent an increase in ASLR score.
However, further research studies are needed for mediumto long-term follow-up on continuous maintenance of
decreased anterior pelvic tilt after PPTT removal and
determining the underlying mechanism of action of PPTT
regarding pelvic stability and external compression force
during ASLR through an assessment of changes in
kinematic data of the pelvic floor and alterations in
respiratory function.

The 1-day PPTT application using KT may

decrease anterior pelvic tilt.
A decrease in anterior pelvic tilt by PPTT
application may decrease the ASLR scores in
women with SIJ pain who habitually wear highheeled shoes.
KT application in the target position may produce
a mechanical corrective effect.

Limitations

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST

This preliminary study had several limitations that

impact the clinical importance and generalizability of the

No funding sources or conflicts of interest were reported

for this study.

Lee et al
Taping for Saeroiliac Joint Pain

CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
J-HL, W-GY
Design (planned the methods to generate the results):
J-HL, K-SL
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript):
W-GY, M-HK, JS-O
Data collection/processing (responsible for experiments, patient management, organization, or reporting
data): J-HL
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): J-HL,
J-TH
Literature search (performed the literature search):
J-HL, M-HK, JS-O
Writing (responsible for writing a substantive part of the
manuscript): J-HL
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): K-SL, J-TH

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