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EVALUATION AND TREATMENT OF PELVIS ANATOMY Bones o Functionally consists of 3 bones Innominates: Ilium, ischium, pubis Sacrum o Three joints SI joints and pubis symphysis Sacrum articulates with o 5th lumbar superiorly, coccyx inferiorly, and two pelvic (innominate bones) through the “L” shaped SI articulation Pubic symphysis o Motion at each pubic ramus is a PHYSIOLOGIC rotation around a transverse axis o SYNARTHROSIS—intrapubic disc that is covered with hyaline Is a fibrocartilagenous joint Lumbosacral junction o Ferguson’s angle as measured from the horizontal should be about 35 degrees o Used on lateral X-ray film to determine hyper-lordosis of lumbar spine LIGAMENTS o Iliiolumbar ligaments prevent L5 from sliding anterior It also blends with anterior SI to integrate SI joint mechanics This allows smooth symmetry of motion Is sensitive to pain in conditions that cause sacral instability o Interosseous ligaments blend the non-articular surfaces of the SI joint o In a weight bearing position the sacral base would move anteriorly if it wasn’t restrained o Sacrotuberous and sacrospinous ligaments restrain anterior motion of the sacrum by resisting posterior rocking of the apex MUSCLES OF THE PELVIS o Pelvic position, and therefore motion, is highly dependent upon muscular control o Can be the hidden cause of repetitive or recalcitrant problems o ILIOPSOAS Concentric contraction results in hip flexion and external rotation Function of this muscle is to eccentrically and dynamically stabilize hip extension and internal rotation in bipedal ambulation Dysfunction can lead to innominate rotations and gluteus inhibition o OBTURATOR INTERNUS AND EXTERNUS Controls internal/external rotation at the hip, in a combination of eccentric and concentric contraction With hip in flexion, the internus also abducts the thigh Can create functional short or long LEs Can be easily confused with piriformis syndromes o PIRIFORMIS Eccentrically stabilizes hip internal rotation, especially at toe-off and pronation Sciatic nerve can pass either through or under the muscle belly o HIP FLEXORS Eccentrically stabilizes hip extension Dysfunction here can also reciprocally inhibit the gluteus musculature Comprised of the iliopsoas, but also rectus femoris and the Sartorius, and in certain situations, the tensor fascia lata and the IT band in combination with the adductors o ADDUCTORS Eccentrically stabilize upper body via tension on the pelvis during stance phase Dysfunction here can result in pubic symphysis shears Includes pectineus, adductor longus, adductor brevis, obturator externus, gracilis, quadratus femoris, adductor magnus o REMEMBER Psoas, iliacus=iliopsoas Passes from the upper lumbar vertebrae, over the pelvic rim, and to the lesser trochanter quadratus lumborum arises from aponeurotic fibers of the iliolumbar ligament, origin from the last rib and inserts on the TP’s of L1-L4, and the posterior third of the iliac crest o EXTERNAL HIP ROTATORS Piriformis, gemellus superior, obturator internus, gemellus inferior, obturator externus, quadratus femoris, gluteus maximus, gluteus medius, tensor fascia lata, semitendonosus, semimembranosus o PELVIC FLOOR MUSCLES--**NEW** Levator ani muscles Puborectalis, pubococcygeus, iliococcygeus Coccygeus These muscles constitute the pelvic diaphragm—they have rhythmic contractions like the respiratory diaphragm, but when relaxed they will contract with the diaphragm In disease states of the pelvis, respiratory mechanics are an important consideration REMEMBER YOUR PELVIC LANDMARKS REMEMBER SACRAL AXES o Sacral physiologic axes 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) REMEMBER SACRAL MARGINS See sacrum outline for sacrum stuff DIAGNOSIS OF THE INNOMINATES AND PUBIC SYMPHYSIS LANDMARKS o Iliac crest o ASIS o Pubic symphysis o Pubic tubercle o Iliolumbar ligament o PSIS o Iliac crest o Sacrotuberous ligament o Ischial tuberosity MOVEMENT OF THE INNOMINATES o Innominates rotate around the inferior transverse axis of the sacrum Located at the inferior limb of the SI joint Once you have lateralized the patient to one side, all other findings are named in relation to what is found on the RESTRICTED side o Lateralize with standing flexion, seated flexion, and ASIS compression tests Thumbs UNDER PSIS! Palms cupping ASIS and force vector is posteromedial SUPINE DIAGNOSIS o Put thumbs horizontally UNDER the ASIS! Are they level? Is lateralized side inferior or superior relative to the nonlateralized side o INFLARE/OUTFLARE Visualize a line from each ASIS to umbilicus Is lateralized side relatively further (outflare) or closer (inflare) to umbilicus? o 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 Can CONFIRM diagnosis PRONE DIAGNOSIS o Alight the pelvis—operator bends patient’s knees, then returns legs to table o Or you can lift the patient’s hips, then recenter them over the table o Thumbs UNDER PSIS! Are they level? Is the lateralized side inferior or superior relative to the nonlateralized side? There is a dimple under the PSIS: place thumbs horizontally o Test ischial tuberosities POSSIBLE SOMATIC DYSFUNCTIONS OF THE INNOMINATE o Anterior innominate rotation (innominate anterior) Ex) left anterior innominate Left ASIS is relatively inferior Left PSIS is relatively superior o Posterior innominate rotation (innominate posterior) Ex) left posterior innominate Left ASIS is relatively superior Left PSIS is relatively inferior o Upslipped innominate (superior innominate shear) NONPHYSIOLOGIC dysfunction, traumatic etiology Not involved in inferior transverse axis mechanics Ex) left upslipped innominate Left ASIS is relatively superior o o Left PSIS is relatively superior Downslipped innominate (inferior innominate shear) NONPHYSIOLOGIC dysfunction, RARE Not involved in inferior transverse axis mechanics Innominate inflare/innominate outflare Innominates rotate around respective vertical axes INFLARE Lateralized ASIS is closer to the umbilicus than the non-lateralized side Ex) 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 o Ex) with a left outflare, there is a longer distance between the umbilicus and left ASIS that the right ASIS Innominate inflare/outflare somatic dysfunction is not involved in inferior transverse axis mechanics It occurs about a vertical axis PUBIC SYMPHYSIS DIAGNOSIS Patient is supine Explain to your patient what you are going to do—ask males 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 Place your fingers on the SUPERIOR aspect of the pubic symphysis to diagnose superior/inferior Place your fingers on the ANTERIOR aspect of the pubic symphysis to diagnose anterior/posterior PUBIC SYMPHYSIS SOMATIC DYSFUNCTIONS o Pubic symphysis superior/inferior shear May often follow innominate SD, or be SD by itself (rare) Can follow innominate anterior/posterior rotation, up/down slipped innominate Can follow sacral shear Common in obstetrical patients due to RELAXIN o Pubic symphysis anterior/posterior shear Relatively rare, usually caused by trauma COMPRESSION OF THE PUBIC SYMPHYSIS o You find tissue texture changes in the pubic region o The superior margin of the pubic symphysis is level unless associated with a pubic shear o Superior and inferior glides are restricted o Posterior springing of the pubes is bilaterally restricted o ASIS springing test may be positive bilaterally o Tenderness to palpation over the pubic symphysis May have symptoms of frequency and burning on urination even without infection o NOTE: pubic decompression is helpful in preparing innominates for other techniques SUPERIOR PUBIC SHEAR (PHYSIOLOGIC) o Tissue texture changes in pubic region o Superior surface of pubic ramus is superior (STEP OFF SIGN) on the dysfunctional side o ASIS compression test is positive on the dysfunctional side o Usually a positive flexion test on the side of the dysfunction o Superior glide of the pubic ramus is present o Inferior glide of the pubic ramus is restricted o Tenderness to palpation over the pubic symphysis May have symptoms of frequency and burning on urination even w/o infection o May be seen in INNOMINATE POSTERIOR INFERIOR PUBIC SHEAR (PHYSIOLOGIC) o Tissue texture changes in the pubic region o Superior surface of the pubes is inferior (STEP OFF SIGN o Usually a positive flexion test on the side of dysfunction o Inferior glide of the pubic ramus is present o Superior glide of the pubic ramus is restricted o Tenderness to palpation over the pubic symphysis May have symptoms of frequency and burning on urination even without infection o May be seen in INNOMINATE ANTERIOR DO THESE THINGS IN THIS ORDER TO DIAGNOSE AN INNOMINATE o LATERALIZATION OF PELVIS (at least 2/3) Standing/seated flexion test ASIS compression o SUPINE ASIS (superior/inferior) Inflare/outflare Pubic symphysis (superior/inferior, anterior/posterior) Medial malleoli (superior/inferior) o PRONE PSIS (superior/inferior) o DON’T FORGET TO ZERO OUT THE PELVIS EVERY TIME