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Lecture 3 – Treatment and Evaluation of the Pelvis
ADductors  connect to Pubis Symphysis
The Pelvis
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Functionally consists of three bones:
o the innominates (2)
 ilium
 ischium
 pubis
o the sacrum (1)
And three joints
o the sacroiliac joints (2)
o the pubis symphysis (1)
Hiatus- failure of closure of the 5th sacral vertebral lamina
Ganglion Impar- where right and left sympathetic chains join is on the anterior surface of the coccyx
Osteology/Articulations
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Sacrum articulates with
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The 5th lumbar superiorly
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The coccyx inferiorly
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Two pelvic( innominate bones )through the “L” shaped sacroiliac articulation
Pubic Symphysis
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Motion at each pubic ramus is a PHYSIOLOGIC rotation about a transverse axis.
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Synarthrosis- intrapubic disc that is covered with hyaline. Fibrocartilagenous joint.
Sacroiliac Joint
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The SI joint functions to redirect force from the lower extremities to the rest of the body.
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Movement in the SI joints is small, but measurable in both rotation (~1.8°) and translation
(~1mm).
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No muscles are directly responsible for this motion.
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Force is accommodated by the irregular surface of the joint and LARGE posterior ligaments.
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This has treatment implications, we have to use the legs as levers.
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45 degree angle from the AP axis has diagnostic and treatment implications
Lecture 3 – Treatment and Evaluation of the Pelvis
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Upper pole  spring towards greater trochanter
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Lower Pole  ILA toward ASIS
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Final fusion of SI joint not until mid 20s  may not be bilaterally symmetrical
Lumbosacral Junction
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Ferguson’s Angle as measured from the horizontal should be about 35 degrees
Ligamentous Attachments of the Sacrum
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Suspended between the innominates by three true ligaments:
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Anterior Sacroiliac
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Interosseous Sacroiliac
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Posterior Sacroiliac
And three accessory ligaments:
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Sacrotuberous
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Sacrospinous
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Iliolumbar
Ligaments
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Iliolumbar ligaments prevent L5 from sliding anterior.
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Iliolumbar is sensitive to pain in conditions that cause sacral instability
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It also blends with the anterior sacroiliac to INTEGRATE SI joint mechanics. This allows smooth
symmetry of motion.
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Interosseous ligaments blend the non-articular surfaces of the SI joint.
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In a weight bearing position the sacral base would move anteriorly if it wasn’t restrained
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Sacrotuberous and Sacrospinous ligaments restrain anterior motion of the sacrum by
resisting posterior rocking of the apex.
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The sacroiliac and the iliolumbar ligaments prevent the sacral base from rocking anteriorly.
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Posterior, Lateral and Axial Rotation are prevented by a combination of the anterior, posterior
and interosseous ligaments.
Lecture 3 – Treatment and Evaluation of the Pelvis
Muscles
Iliopsoas  hip flexor (attaches lesser trochanter)
Piriformis  internal rotator (att. Greater trochanter)
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Sciatic nerve  passes through or under
Obturator internus & externus  int/ext rotation at the hip
Hip Flexors
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iliopsoas, but also the rectus femoris & the Sartorius (ITB and TFL sometimes)
Dysfunction here can also reciprocally inhibit the gluteus musculature
Adductors
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Dysfunction here can result in pubic symphysis shears & other SD.
Quadratus Lumborum  12th rib attachment
Levator Ani Muscles:
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Puborectalis
Pubococcygeus
Iliococcygeus
- And Coccygeus constitute the pelvic diaphragm
Autonomic Innervation: Pelvic Viscera
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T12 – L2  sympathetic
S2 – S4  parasympathetic
- Note: Inneveration of lower extremity  sympathetic  T11 – L2
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Close relationships between the nerves and the sacrum.
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Pain can be secondary to m/s involvement or visceral or BOTH!
Sacral Axes
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Multiple axes of motion:
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Transverse (3)  Sacral Anatomic Axis
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Superior S1 (TP)  “respiratory axis”  posterior as we breathe
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Middle S2 (TP)  sacral flexion (anterior) & extension (posterior)
Lecture 3 – Treatment and Evaluation of the Pelvis
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Inferior S3 (TP)  anterior & posterior innominate rotation
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Vertical
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A/P  sidebending
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Oblique (2)  named for superior pole  physologic
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Left
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Right
Physiologic axis also includes:
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Sagittal: includes both mid-sagittal and an infinite number of parasagittal axes
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Horizontal: functional axis of sacral flexion/extension occur around this axis
(analogous to the middle transverse axis above)
Sacral Margins
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Sacral margins run the length of the Sacro-Iliac Articulation.
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They will rotate about a vertical midline or parasagittal axis
SACRAL MECHANICS
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Physiologic diagnoses of the sacrum occur in neutral and non-neutral mechanics:
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Neutral Mechanics (L on LOA, Forward Torsion)
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sacrum rotates in the same direction as the oblique axis (left rotation on a left
oblique axis).
Non-neutral Mechanics (R on LOA, Backward Torsion)
o sacrum rotates in the opposite direction of the oblique axis (right rotation on a
left oblique axis).
Pelvic Mechanics During the Walking Cycle
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Walking induces (reversible) neutral oblique axis mechanics in the sacrum with every step e.g.,
right rotation on right oblique axis, then left on left oblique axis.
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It induces side bending of the lumbar spine towards the side of the weight bearing leg.
rotation will be AWAY from the side of the weight bearing cycle
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It also causes posterior rotation of the weight bearing ilium and anterior rotation of the nonweight bearing ilium.
Lecture 3 – Treatment and Evaluation of the Pelvis
To move the right foot - the body must shift to the left.
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A N SLRR motion occurs in the L spine
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A left oblique axis occurs at sacrum.
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Sacrum rotates left on oblique axis.
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Right quadriceps tighten and the right innominate rotates anteriorly.
Movement of the Innominates
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Innominates rotate around the inferior transverse axis of the sacrum
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Possible Somatic Dysfunctions of Innominates
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Anterior Innominate Rotation( Innominate Anterior)
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Posterior Innominate Rotation(Innominate Posterior)
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Upslipped Innominate (Superior Innominate Shear)
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Non-physiologic SD, traumatic etiology
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Not involved in inferior transverse axis mechanics
Downslipped Innominate (Inferior Innominate Shear)
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Non-physiologic SD, Rare
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Not involved in inferior transverse axis mechanics
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Innominate Inflare/ Innominate Outflare
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Innominates rotate around respective vertical axes
Neurologic Examination L4
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M  Foot inversion (Tibialis anterior)
R  Patellar reflex
S  Medial aspect of foot sensation
Neurologic Examination L5
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M  Great toe extension (Extensor Hallicus longus)
R  No reflex
S  Dorsum of foot sensation
Neurologic Examination S1
Lecture 3 – Treatment and Evaluation of the Pelvis
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M  Foot eversion (Peroneus longus and brevis)
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R  Achilles tendon reflex
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S  Lateral foot sensation
Malleoli are mixed landmarks, but can alert the operator to stresses placed on pelvis, leg, and ankle,
or to functional/anatomical short leg
Innominate Diagnoses:
Left Anterior Rotation
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Left ASIS relatively inferior
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Left PSIS relatively superior
Left Posterior Rotation
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Left ASIS relatively superior
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Left PSIS relatively inferior
Pubic Symphysis Somatic Dysfunctions
Left Inferior Pubic Shear (w/ anterior innominate)
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Left ASIS relatively inferior
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Left PSIS relatively superior
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Left Inferior pubic symphysis
Left Superior Pubic Shear (w/ posterior innominate)
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Left ASIS relatively superior
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Left PSIS relatively inferior
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Left Superior pubic symphysis
Anterior/Posterior Pubic Shear  Rare
Lecture 3 – Treatment and Evaluation of the Pelvis