Download inferior transverse axis

Pelvis
Stuart Williams D.O.
Chairman & Associate Professor
Osteopathic Manipulative Medicine
Objectives
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04/08/2013
10:00 -11:00 PPC/OMM pelvis
Williams
Recall the structural anatomy of the pelvis
Describe the functional anatomy of the pelvis
Explain the difference between iliosacral and sacroilial motion
Recognize common somatic dysfunctions of the pelvis and how to incorporate
these into a differential diagnosis.
Explain the biomechanics of the pelvis including the axes of motion
Recall the lateralizing tests for pelvic somatic dysfunction. Understand the use of
anterior & posterior landmarks to diagnose pelvic somatic dysfunctions
Name potential diagnoses of pelvic somatic dysfunctions. Understand the
difference between physiologic and non-physiologic somatic dysfunction
Recall anatomy of Pelvis
Reading
Foundations of Osteopathic Medicine, 3rd Ed:
– “Pelvis and Sacrum” P 575-601
The Pelvis
Functionally consists of three bones:
- the innominates
ilium
ischium
pubis
- the sacrum,
And three joints
- the sacroiliac joints (two of them)
- the pubis symphysis  moves on a transverse axis
Sacrum
Base of Sacrum
Sacral
Promontory
Superior Articular
Processes
ALA
Median Sacral Crest
Apex of Sacrum
Sacral
Foramina
Sacral Hiatus
Inferior Lateral Angle
Osteology/Articulations
• Sacrum articulates with
– The 5th lumbar superiorly
– The coccyx inferiorly
– Two pelvic( innominate bones )through the “L”
shaped sacroiliac articulation
Lumbarization
S1
S2
S3
S4
S5
Sacralization
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.
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 Joints
Toward ASIS
Sacroiliac
Joint
Toward Greater
Trochanter
These joints are not present at birththey develop functionally
They are not totally symmetric
Lumbosacral Junction
Ferguson’s Angle as measured from the
horizontal should be about 35 degrees.
35º
Ligaments
Ligamentous Attachments of the Sacrum
• Suspended between the innominates by three true
ligaments:
– Anterior Sacroiliac
– Interosseous Sacroiliac
– Posterior Sacroiliac
• And three accessory ligaments:
– Sacrotuberous
• Goes between the ILA and the ischial tuberosity
– Sacrospinous
– Iliolumbar (L4 and 5, connects to lateral thigh too)
Ligaments
• Iliolumbar ligaments prevent L5 from sliding
anterior.
• 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.
Ligaments
Ligaments- Part II
• 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.
Functional Anatomy
Iliopsoas
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Concentric contraction results in hip
flexion & ext rotation.
Function of this muscle is to
eccentrically & dynamically stabilize
hip extension & internal rotation in
bipedal ambulation.
Dysfunction can lead to innominant
rotations & gluteus inhibition.
Muscular Attachments of the Sacrum
•Muscles:
•Gluteus Maximus
•Longissimus Thoracis
•Iliocostalis Lumborum
•Multifidus
•Ligaments:
•Sacroiliac
•Post. Sacrococcygeus
mulitfidus
Gluteus Maximus
Erector
spinea
Sacrum Anterior Aspect
•Muscles:
• Iliacus
• Piriformis
• Coccygeus
•Ligaments:
• Sacrospinous
• Sacrotuberous
• Ant. Sacrococcygeus
• Anterior Sacroiliac
A-P View
Psoas
Iliacus
P-A View
Quadratus Lumborum
Piriformis
Gemellus Superior
Obturator Internus
Gemellus Inferior
Obturator Externus
Quadratus Femoris
Gluteus Maximus
Gluteus Medius
Tensor Fascia Lata
Semitendinosus
Semimembranosus
Pelvic
Floor
Levator Ani Muscles:
Puborectalis
Pubococcygeus
Iliococcygeus
Coccygeus
Autonomic Innervation: Pelvic Viscera
(T10-L2)
Sympathetic
Parasympathetic
(S2-S4)
Nervous System
Landmarks
Landmarks of the Pelvis
Patient Standing
Iliac crest level
PSIS
Greater trochanters
Patient Supine
ASIS
Pubic symphysis
Pubic tubercles
Medial malleoli
Patient Prone
PSIS
Sacral sulcus
Sacral base
Inferior lateral angle
Sacortuberous lig.
Ischial tuberosity
Iliac crest
Piriformis muscle
Iliolumbar ligament
Sacral
base
Inferior
Lateral
angle
• Multiple axes of
motion:
– Transverse (3)
• Superior S1 (TP)
• Middle S2 (TP)
• Inferior S3 (TP)
– Vertical
– A/P
– Oblique (2)
• Left
• Right
Sacral Axes
SACRAL ANATOMIC AXIS
Transverse axis
• Superior: the cranial primary respiratory mechanism creates motion
around this axis
• Middle: sacral base anterior and posterior (FB/BB) occur around this
axis
• Inferior: the innominates rotate around this axis
•
Reference Foundations p.1136-1137
SACRAL PHYSIOLOGIC AXIS
• Oblique: both left and right oblique axes are named for the superior pole
• 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 MECHANICS
• Physiologic diagnoses
• of the sacrum occur in
• neutral and non-neutral mechanics:
Neutral Mechanics a.k.a.
• Left rotation on a Left Oblique Axis
• Forward Torsion
(all three are equivalent terms!!)
• In neutral mechanics, the sacrum rotates in
the same direction as the oblique axis (left
rotation on a left oblique axis).
Non-neutral Mechanics a.k.a.
• Right rotation on a Left Oblique Axis
• Backward Torsion
(all three are equivalent terms!!)
• In non-neutral mechanics, the sacrum rotates in the
opposite direction of the oblique axis (right rotation on a
left oblique axis).
Walking Cycle and the Pelvis
Double
support
Double
support
Single limb support
Single limb support
(opposite side)
Heel strike
Flat foot
Mid-stance Heel off
Toe off
Mid swing
Heel strike
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.
• It also causes posterior rotation of the weight bearing ilium and
anterior rotation of the non-weight bearing ilium.
 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.
Right hamstrings contract.
Hamstrings pull right innominate into a relative posterior position.
Pubic sympyhsis provides a transverse axis.
Heel strikes the ground.
Left leg thrusts body forward.
Center of gravity shifts forward & to the right.
Gait Cycle
Walking Cycle
Anterior Anatomical Landmarks
Posterior Anatomical Landmarks
Movement of the Innominates
• Innominates rotate
around the inferior
transverse axis of the
sacrum
– Located at inferior limb of
sacroiliac joint
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
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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Downslipped Innominate (Inferior Innominate Shear)
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Non-physiologic SD, traumatic etiology
Not involved in inferior transverse axis mechanics
Non-physiologic SD, Rare
Not involved in inferior transverse axis mechanics
Innominate Inflare/ Innominate Outflare
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Innominates rotate around respective vertical axes
Once you have lateralized the patient to one side, all other
findings are named in relation to what is found on the
restricted side
Mark your diagnostic worksheet accordingly
Lateralization of the Pelvis
Seated Flexion
ASIS Compression
Standing Flexion
Thumbs under PSIS!
Don’t forget to reset the pelvis!
Palms cupping ASISs, force
vector is posteromedial
Supine Diagnosis
• Put thumbs horizontally under the ASIS’s
– Are they level? Is the lateralized side inferior or superior relative to
the non-lateralized side?
correct
incorrect
Supine Diagnosis
visualize & palpate: do they agree?
L
Supine Diagnosis - Inflare/Outflare
• Visualize a line from each ASIS to
umbilicus
– Is lateralized side relatively further (outflare)
or closer (inflare) to umbilicus?
R
L
Supine Diagnosis
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Place thumbs under medial malleoli
Apply slight inferior traction
– Is the lateralized side inferior or superior relative to
the non-lateralized side?
– Malleoli are mixed landmarks,
but can alert the operator to
stresses placed on pelvis, leg,
and ankle, or to
functional/anatomical short leg
L
correct
• Can be used to help confirm
diagnosis
incorrect
Prone Diagnosis
• Place thumbs horizontally under the PSIS’s
– Are they level? Is the lateralized side inferior or superior relative to
the non-lateralized side?
– There is a “dimple” under the PSIS: place thumbs horizontally
Correct
Incorrect
Prone Diagnosis
L
Prone Diagnosis
• Ischiotuberosity
L
Innominate Diagnoses:
Left Anterior Rotation
• Findings
– Left ASIS relatively
inferior
– Left PSIS relatively
superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Innominate Diagnoses:
Left Posterior Rotation
• Findings
– Left ASIS relatively
superior
– Left PSIS relatively
inferior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Pubic Symphysis Diagnosis
•
•
Patient is supine
Explain to your patient what
you are going to do
– Ask male patients if they need to
adjust
•
Using the heel of your hand,
start at the umbilicus and
slide inferiorly with gentle
pressure until you reach the
pubic symphysis
Pubic Symphysis Diagnosis
• Place your fingers on the superior
aspect of the pubic symphysis to
diagnose sup./inf.
• Place your fingers on the anterior
aspect of the pubic symphysis to
diagnose ant./post.
L
L
Pubic Symphysis
Somatic Dysfunctions
• Pubic Symphysis Superior/Inferior Shear
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May often follow innominate SD, or be SD by itself (rare)
Can follow innom ant/post rotation, up/down slipped innom.
Can follow sacral shear
Common in obstetrical patients due to relaxin
• Pubic Symphysis Anterior/Posterior Shear
– Relatively rare, usually caused by trauma
Innominate Diagnoses:
Left Inferior Pubic Shear
• Findings
– Left ASIS relatively
inferior
– Left PSIS relatively
superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Innominate Diagnoses:
Left Superior Pubic Shear
• Findings
– Left ASIS relatively
superior
– Left PSIS relatively
inferior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Innominate Diagnoses:
Left Upslipped Innominate
• Findings
– Left ASIS relatively
superior
– Left PSIS relatively
superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis
Innominate Inflare/Outflare
Somatic Dysfunction
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Inflare:
– Lateralized ASIS is closer to the umbilicus than the nonlateralized side
• i.e., with a left inflare, there is a shorter
distance between the umbilicus and left ASIS
than the right ASIS
Outflare:
– Lateralized ASIS is further away from the umbilicus than the nonlateralized side
• i.e., with a left outflare, there is a longer
distance between the umbilicus and left ASIS
than the right ASIS
Innominate inflare/outflare somatic dysfunction is not involved
in inferior transverse axis mechanics
– It occurs about a vertical axis
Left Outflare
Innominate Diagnosis Checklist
 Lateralization of Pelvis (at least 2/3)
 Standing/Seated Flexion Test
 ASIS Compression
 Supine:
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ASIS (superior/inferior)
Inflare/Outflare
Pubic Symphysis (superior/inferior, anterior/posterior)
Medial Malleoli (superior/inferior)
 Prone:
 PSIS (superior/inferior)
Right Anterior Innominate
Right Posterior Innominate
Left Superior Pubic Shear
Right Upslipped