Download EVALUATION AND TREATMENT OF PELVIS ANATOMY Bones Functionally

EVALUATION AND TREATMENT OF PELVIS
ANATOMY
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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
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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**
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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
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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
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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
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 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
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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
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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