Illiosacral/Pelvic ME

Question 1

Non-physiological movements vs physiological movements

Answer 1

Non-physiological movements

• generally induced by trauma
• evidence by joint/muscle and CT elements being in positions that are NOT physiological ROM Or AOM

Include:

• innominate shears (superior/inferior)
• pubic shears (superior/ inferior/compression/ distraction)

Physiological movements

• generally induced by over working
• evidence by joint/muscle and CT elements being in positions that are physiological ROM Or AOM but are dysfunctional since they are not in neutral

Include:

• rotations (anterior/posterior)
• flares (inflare/outflare)

Question 2

Innominate rotation movement

Answer 2

Rotate around the inferior transverse axis of the sacrum located at inferior part of SI joint

Question 3

Anterior innominate rotation

Answer 3

ASIS moves inferiorly and the PSIS moves superiorly around the inferior transverse axis

Question 4

Posterior innominate rotation

Answer 4

ASIS moves superiorly and the PSIS moves inferiorly around the inferior transverse axis

Question 5

Pelvic outflare

Answer 5

Ipsilateral ASIS of the (+) standing flexion side is farther away from the midline, but is still at the same level as the the normal ASIS

Question 6

Pelvic inflare

Answer 6

Ipsilateral ASIS of the (+) standing flexion side is closer to the midline, but is still at the same level as the the normal ASIS

Question 7

Superior innominate shear

Answer 7

Ipsilateral ASIS and PSIS of the (+) standing flexion test side is superior compared to the other side

Question 8

Inferior innominate shear

Answer 8

Ipsilateral ASIS and PSIS off the (+) standing flexion test is inferior compared to the normal side

Question 9

Iliosacral diagnosis steps

Answer 9

1) standing flexion test
- if (+) on one side, that is the side of the dysfunction

2) physician reseats pelvis on supine patient
3) ASIS compression test (optional)
4) measure ASIS levels, pubic rami levels and supine leg length on the supine patient
5) physician reseats pelvis on prone patient
4) measure PSIS, ischial tuberosity is and prone leg lengths on prone patient

Question 10

Standing flexion test

Answer 10

Physicians thumbs are placed on inferior slope of patients PSIS with rest of fingers on supero-lateral surface of iliac crests

Maintain firm pressure and follow bone only

Patient is to actively bend forward at waist slowly to touch toes
- allow pelvis to come back to you, dont resist

Physician keeps their eyes level with PSIS

(+) side is if one PSIS moves more CEPHALAD than the other at the end of range of motion

(-) is if PSIS are symmetrical at end of range of motion

Question 11

Why does the standing flexion test positive side the one that has the superior PSIS?

Answer 11

As patient bends forward, spine and L5 go first, then sacrum, then innominate

If a patient has a iliosacral dysfunction, then the innominate and sacrum will be “glued” so innominate rotates forward quicker and more superior than the normal side

Question 12

Possible reasons for false negatives and positives

Answer 12

Tight hamstrings

Tight Iliopsoas

Leg length discrepancy > 1/2 inch at rest

Unilateral sacral dysfunction

Question 13

How to reseat pelvis supine

Answer 13

Actively

• patient lays supine with knees bent, feet on table and hips on table
• patient lifts hips off table
• patient then slowly returns hips to table
• patient then straightens legs out
• physician pulls legs straight and relaxes traction to measure leg length

Passively
- same steps except step 2 is done by the physician rather than patient

Question 14

ASIS compression test

Answer 14

Stand at level of patients hips

Place palms on thenar eminences on the ASIS

Compress with mild/moderate A->P medial force at 45 degree angle through ASISs

Sequentially induce an impulse to spring the joints

(+) = blocked relative motion

really only used if standing flexion cant be done

Question 15

Reseat the pelvis prone

Answer 15

• must be done passively*
  1) patient lays prone
  2) physician grabs patients legs and lifers patients hips up
  3) physician centers hips over table and returns legs to table

40 physician ensures feet are off table and in neutral and then pulls on legs/relaxes to measure leg length

Question 16

Anatomic long/short leg vs functional long/short leg

Answer 16

Anatomical

• tape measure from ASIS -> medial malleolus shows discrepancies in Leg lengths at least 2 separate occasions
• get ortho xrays if measurements are off to confirm
• treatment = lift therapy or orthopedic shoes + OMT as adjunct

Functional

• positive supine/prone leg length test
• treatment = OMT, if doesnt resolve then lift therapy

Question 17

What are possible OMT dysfunctions for functional long/short legs?

Answer 17

Innominate shear (inferior is most common)

Innominate rotation (anterior is most common)

LE somatic dysfunctions

Sacral somatic dysfunctions

Lumbar somatic dysfunction

Question 18

What are the most common OMT diagnosis for long leg

Answer 18

Anterior innominate rotation (more common)

Inferior innominate shear

Question 19

What is the most common OMT dysfunction assocaited with ischial tuberosity dysfunctions?

Answer 19

Innominate shears

• inferior = ischial tuberosity on (+) side is lower
• superior = ischial tuberosity on (+) side is higher

Question 20

Area of greatest restriction (AGR) and Muscle energy treatment of pelvis

Answer 20

Find the AGR from the screening examination
- treat AGR first and then work down the remaining restrictions after initial AGR treatment (pick the next most restricted)

If you cant determine AGR, use “HIPLSIT” order

Hip long restrictions 
Innominate and sacral shears 
Pubic dysfunctions 
Lumbar (non-compensated L5) 
Sacral Torsions 
Innominate rotations/flares 
Thoracic dysfunctions

Question 21

Anterior and inferior innominate rotations

Answer 21

1) are right or left depending on (+) flexion test (same side)
2) anterior = PSIS superior, ASIS inferior
3) posterior = PSIS inferior, ASIS superior
* on both, ischial tuberosity are the same level*

** rotation is along an inferior and transverse axis **

Question 22

Anterior innominate rotation ME

Answer 22

1) patient supine, physician is standing at the side to be treated
2) patients hips and knees are flexed up (similar to how both are blacked when curling into a ball)
3) physicians caudad hand resets on the patients knees and the cephalad hand grabs the PSIS on the dysfunctional side
4) physicians caudad hand will flex the patients hips and knees up to disengage the sacroiliac joint (may also need to add mild abduction and external rotation to fully disengage)
5) patient tries to extend knee against force for 3-5 seconds while physician applies a inferior force on the PSIS with cephalad hand
6) after 3-5 seconds, patient relaxes and physician further flexes and traction’s the PSIS inferiorly
7) recheck after 3-5 cycles

Question 23

Posterior innominate rotation ME

Answer 23

1) Patient prone, physician on side of dysfunction
2) patient is brought to the edge of the table so the dysfunction side leg can hang freely, disengaging the dysfunctional SI joint
3) physicians cephalad hand stabilizes the contralateral innominate, allowing pelvis to rotate anteriorly
4) physicians caudad hand grabs the ipsilateral hanging leg on the thigh, just above the knee and passively extends the patients hip to the feather edge of the barrier
5) patient flexes hip against physician counter force for 3-5 seconds
6) patient relaxes and physician extends towards new barrier
7) repeat 3-5 times and recheck

Question 24

Innominate flares

Answer 24

1) right or left is dependent on (+) standing flexion side (same side)
2) out-flare: ASIS = lateral, PSIS = medial
3) in flare: ASIS = medial, PSIS = lateral
* for both, ischial tuberosities are on the same level*

Question 25

Innominate outflare ME

Answer 25

1) patient supine, physician on contralateral side of the dysfunctional hip 2) patient flexes their hip and knee, crossing the leg on the dysfunctional side over the unaffected side 3) physician places cephalad hand over the dysfunctional ASIS to monitor ONLY 4) physician slowly adducts the femer and internally rotates the hip to the barrier. 5) patient abducts the femer and externally rotates the hip against the physcian for 3-5 seconds 6) patient relaxes and physician takes up slack by further addicting and internally rotating hip to new barrier 7) repeat 3-5 times and then recheck * Can also monitor PSIS instead as well, which requires physician to be on ipsilateral side. Still adduct and internally rotate the hip though. *

Question 26

Innominate inflare ME

Answer 26

1) Patient supine with physician standing at side of dysfunction 2) patient flexes ipsilateral hip and knee and places ipsilateral foot just above or just below the opposite knee. This externally rotates the dysfunctional hip 3) physician places cephalad hand over the contralateral innominate to stabilize the pelvis and caudad hand on the medial aspect of the dysfunctional knee 4) physician externally rotates hip until barrier is engaged. 5) patient internally rotates hip against physician force for 3-5 seocnds 6) patient relaxes and physician places patient into further external rotation to new barrier 7) repeat 3-5 times and then recheck

Question 27

Inferior and superior innominate shears

Answer 27

1) right or left is dependent on (+) standing flexion side (same side) 2) superior: ASIS = superior, PSIS = superior, ischial tuberosity on the dysfunctional side = superior 3) inferior: ASIS = inferior, PSIS = inferior, ischial tuberosity on the dysfunctional side = inferior

Question 28

Superior innominate shear ME

Answer 28

1) Patient is supine with physician at the end of the table near the feet. - patients feet are off table 2) Physician places thigh against contralateral foot to the dysfunction to stabilize the pelvis 3) physician places cephalad hand on inferior hamstrings (just above popliteal region) and caudad hand on the distal tibia (just above ankle) 4) physician abducts dysfunctional leg 10-15 degrees and internally rotate the to loosen the SI joint and tighten the hip joint respectively. 5) the physcian then applies inferior traction (towards them) 6) patient pulls hip superiorly (towards them) for 3-5 seconds against the physicians force. 7) patient relaxes and the physician resists any superior motion 8) repeat 3-5 times, increasing tractional force each time, then retest.

Question 29

Inferior innominate shear ME

Answer 29

1) Patient is prone with physician on ipsilateral side of dysfunction 2) patients sacrum is at edge of table, with dysfunctional side leg hanging off the table and the sky’s functional side hand and arm gripping the table and flexed respectively. 3) patients ipsilateral foot is placed against the physicians thigh, flexing the knee (approx. 90 degrees) and hip (approx. 60 degrees) 4) physician places caudad hand on the ankle of dysfunctional foot and abducts the leg 10-15 degrees to loosen the SI joint 5) physician places cephalad hand on the ipsilateral ischial tuberosity and applies a cephalad and slightly lateral tractional force (roughly 10 o’clock) 6) during inhalation, patient straightens ipsilateral arm that is holding the side of table (caudad force moves through the trunk), while physician holds applied force and resists caudad motion. 7) during exhalation, patient stops moving arm and physician further induces cephalad and lateral tractional force on the ipsilateral ischial tuberosity. 8) this is repeated 3-5 times and then recheck.

Question 30

Superior and inferior pubic shears

Answer 30

1) right or left is dependent on (+) standing flexion side (same side) 2) superior: ASIS = superior, PSIS = superior, pubic bone itself = superior 3) inferior: ASIS = inferior, PSIS = inferior, pubic bone itself = superior * note that in both superior and inferior, the ischial tuberosities are the same level* **dysfunctional pubic bone side may be tense/tender or have a prominent inguinal ligament**

Question 31

Superior pubic shear ME

Answer 31

1) patient is supine and physician is standing on ipsilateral side of dysfunction 2) patients pelvis is shifted to the edge the table so the dysfunctional leg is a hanging off the table 3) physician holds freely hanging leg with their legs, while placing caudad hand on the contralateral innominate (after setting barrier) and cephalad hand on the ipsilateral distal femur (just above patella) 4) mild hip extension and abduction is applied to the respective barriers. 5) patient flexes and adducts hip for 3-5 seconds against physician force 6) patient relaxes, physician takes up slack by further placing the patient into th new restrictive barriers of hip abduction and hip extension 7) repeat 3-5 times and then recheck

Question 32

Inferior pubic shear ME

Answer 32

1) patient is supine with physician standing on the ipsilateral side of the dysfunction 2) patient flexes dysfunctional hip and knee 3) physician places cephalad hand on the ipsilateral PSIS and caudad hand on the ipsilateral knee, applying a slight internal rotational force (forcing pelvis to opposite side) 4) physician relaxes and allows pelvis to sit back on the table, and then moves then cephalad hand to the ipsilateral ischial tuberosity. 5) physician applies a superior and medial force against the dysfunctional ischial tuberosity (3 o’clock position) 6) patient straightens leg (pushes caudad on leg) for 3-5 seconds with physician resisting this force 7) patient relaxes and the physician applies more superior and medial tractional force on dysfunctional ischial tuberosity 8) this is repeated 3-5 times and then recheck

Question 33

Pubic compression (adduction) and distraction (abduction)

Answer 33

1) side of dysfunction is not 100% dependent on the standing flexion test (if positive though, likely that side) 2) ASIS and PSIS will be level with normal side 3) compression = pubic rami is bilaterally tender and bulging 4) distraction = pubic rami is bilaterally tender and sinking in

Question 34

Pubic symphysis reset ME

Answer 34

* Note: this can be done for superior/inferior pubic shear or pubic compression* 1) patient supine with physician at any side of the table (most comfortable) 2) patients hips and knees are flexed and feet are flat on the table and together 3) physician sits on table and grabs both knees compressing them 4) patient abducts both knees against physician force for 3-5 seconds 5) patient relaxes and the physcian slightly abducts( externally rotates ) both hips. 6) steps 4-5 are repeated 3-5 times, each time allowing slightly more external rotation 7) afterwards, physician now abducts patients knees to barrier and patient adducts knees against physician force for 3-5 seconds. 8) patients relaxers and the physician then slightly adducts (internally rotates) both hips 9) steps 7-8 are repeated 3-5 times and then recheck

Question 35

Why does one reseat the pelvis when conducting a pelvis exam?

Answer 35

To ensure the spine is straight and the pelvis is not twisted (help prevent false positives)

Question 36

What two tests can be used to determine the side of a pelvic somatic dysfunction?

Answer 36

ASIS compression and standing flexion test - Both show ipsilateral somatic dysfunction to the (+) side ( i.e: (+) ASIS compression on right = right pelvic somatic dysfunction)