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Pelvis Stuart Williams D.O. Chairman & Associate Professor Osteopathic Manipulative Medicine Objectives • • • • • • • • • 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 • • • 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 • Anterior Innominate Rotation( Innominate Anterior) • Posterior Innominate Rotation(Innominate Posterior) • Upslipped Innominate (Superior Innominate Shear) – – • Downslipped Innominate (Inferior Innominate Shear) – – • 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 – 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 • • 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 – – – – 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 • • • 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: 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