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