Innominate and Sacral Review (MET)

Question 2

EVALUATION: Reset hips

Answer 2

 Always perform prior to supine evaluation

 Have supine patient bend knees, place feet flat on table, lift hips off the table, place hips back down, and extend knees back to a flat supine position

Question 3

Standing flexion test EVALUATION

Answer 3

 Patient standing, physician behind patient with eyes at level of patient’s PSIS

 Contact the inferior aspect of the PSIS bilaterally. Ask patient to bend forward with hands towards toes, knees straight. Let your thumbs follow the motion of the PSIS

 (+) Test = one PSIS moves farther superiorly

 Indicates SI joint dysfunction on the side that elevates first

Standing flexion may be falsely positive if patient has unequal hamstring length. Therefore, treat the hamstrings and then reassess

Question 4

ASIS Compression test EVALUATION

Answer 4

 Patient supine. Physician stands with dominant eye closest to the patient’s body.

 Contact the ASIS bilaterally. Induce a force through the ASIS, toward the table (posteriorly and medially), alternating between the right and left hands. Note end- feel on each side.

 (+) Test = “hard end-feel” or “restriction of motion” on one side

 Indicates SI joint dysfunction on the side of restricted motion

Question 5

PSIS height EVALUATION

Answer 5

 Patient prone or standing

 Place your thumbs on the inferior aspect of the PSIS bilaterally

 Gently push cephalad and note which PSIS is more superior

Question 6

ASIS height EVALUATION

Answer 6

 Patient supine or standing

 Place your thumbs on the inferior aspect of the ASIS bilaterally

 Gently push cephalad and note which ASIS is more superior

Question 7

Iliac crest EVALUATION

Answer 7

 The physician places his hands on the patient’s iliac crests and evaluates the symmetry of heights of the two crests.

 The physician should begin by placing the edges of his index fingers lateral and below the actual iliac crests. Then the physician slides these fingers upward and medially to come into contact with the superior aspect of the iliac crests.

Question 8

Medial malleoli height EVALUATION

Answer 8

 Patient supine

 Contact inferior aspect of medial malleoli bilaterally

 Note which side is more superior

Question 9

ASIS to midline EVALUATION

Answer 9

 Patient supine

 Measure the distance from the ASIS to the xyphoid or umbilicus

 Note which side has an increase in distance

Question 10

Pubic tubercle EVALUATION

Answer 10

 Patient supine

 Heel of hand starts at the suprapubic area.Palpate inferiorly until pubic tubercles felt on superior aspect of pubic bones. Use thumbs or index fingers to contact each pubic tubercle.

 Note asymmetry (right vs left) and/or pain to palpation, assess for superior or inferior tubercle

Question 11

Anterior Innominate rotation

Answer 11

 Standing flexion/pelvic compression + on side of dysfunction

 PSIS heights: superior on side of dysfunction

 ASIS heights: inferior on side of dysfunction

 Malleoli: inferior (long) on side of dysfunction

 Iliac crest heights: even

Question 12

Posterior Innominate rotation SD

Answer 12

 Standing flexion/pelvic compression + on side of dysfunction

 PSIS heights: inferior on side of dysfunction

 ASIS heights: superior on side of dysfunction

 Malleoli: superior (short) on side of dysfunction

 Iliac crest heights: even

Question 13

Superior inominate shear SD

Answer 13

 Standing flexion/pelvic compression + on side of dysfunction

 PSIS heights: superior on side of dysfunction

 ASIS heights: superior on side of dysfunction

 Malleoli: superior (short) on side of dysfunction

 Iliac crest heights: superior on side of dysfunction

 Pubic tubercle heights: superior on side of dysfunction

Question 14

Inferior Innominate shear SD

Answer 14

 Standing flexion/pelvic compression + on side of dysfunction

 PSIS heights: inferior on side of dysfunction

 ASIS heights: inferior on side of dysfunction

 Malleoli: inferior (long) on side of dysfunction

 Iliac crest heights: inferior on side of dysfunction

 Pubic tubercle heights: inferior on side of dysfunction

Question 15

Outflare of innominate

Answer 15

 Standing flexion/pelvic compression + on side of dysfunction

 ASIS to midline distance: longer on side of dysfunction

Question 16

Inflare of innominate SD

Answer 16

 Standing flexion/pelvic compression + on side of dysfunction

 ASIS to midline distance: shorter on side of dysfunction

Question 17

Superior pubic shear SD

Answer 17

 Standing flexion/pelvic compression + on side of dysfunction

 Pubic tubercle: superior on side of dysfunction

Question 18

Inferior Pubic Shear

Answer 18

 Standing flexion/pelvic compression + on side of dysfunction

 Pubic tubercle: inferior on side of dysfunction

Question 19

Anterior Innominate Rotation SUPINE

Answer 19

Supine Technique:

 Patient supine. Physician standing on side of dysfunction.

 Physician passively flexes the patient’s hip and knee until a restrictive barrier is reached.

 Patient is instructed to push their knee into the physician’s hand while the physician provides an equal counterforce for 3-5 seconds. The patient is instructed to relax and the physician flexes the patient’s hip until a new restrictive barrier is reached. Continue until no new barriers are met.

 Reassess

 Modification: have the patient fully extend their knee and flex their leg at the hip.

Question 20

Anterior Innominate Rotation PRONE

Answer 20

 Patient prone with the dysfunctional innominate off the table. Physician stands on side of dysfunction.

 Physician places one hand on the patient’s sacrum and pelvis to stabilize, and uses the other hand to place the patient’s foot against their thigh. Physician passively flexes the patient’s hip until a restrictive barrier is reached. Apply principles of muscle energy.

Question 21

Posterior Innominate Rotation Supine Treatment

Answer 21

Supine Technique:

 Patient supine, lying near the side of table so the SI joint is off the table. Physician stands on the side of dysfunction.

 Physician places cephalad hand over the patient’s contralateral ASIS and uses their caudal hand to extend the patient’s ipsilateral hip off the table until a restrictive barrier is reached.

 Patient is instructed to push their leg toward the ceiling while the physician provides equal counterforce for 3-5 seconds. The patient is instructed to relax and the physician extends the patient’s hip until a new restrictive barrier is reached. Continue until no new barriers are met.

 Reassess

Question 22

Posterior Innominate Rotation Prone Treatment

Answer 22

Prone Technique:

 Patient prone. Physician stands on either side of the dysfunction

 Physician places cephalad hand on the patient’s PSIS on the dysfunctional side. With caudal hand, physician passively extends the patient’s hip until a restrictive barrier is reached. Apply principles of muscle energy.

Question 23

Superior Innominate Shear Treatment

Answer 23

 Patient supine with feet off the end of the table. Physician stands at foot of the table.

 Physician grasps the patient’s tibia and fibula above the ankle. The physician internally rotates and abducts the patient’s leg to gap the SI joint.

 Physician leans back to maintain axial traction and instructs the patient to pull ipsilateral hip toward ipsilateral shoulder for 3-5 seconds. The patient is instructed to relax and the physician provides more traction until a new restrictive barrier is reached. Continue until no new barriers are met.

 Reassess

 Modification: May also use respiration.

Maintain force on inhalation and increase force on exhalation.

Question 24

Inferior Innominate Shear Treatment

Answer 24

 Patient supine with feet off the end of the table. Physician stands at foot of the table.

 Physician grasps the patient’s tibia and fibula above the ankle. The physician internally rotates and abducts the patient’s leg to gap the SI joint. The patient’s ipsilateral foot is placed on the physician’s thigh.

 Physician provides cephalad compression of the foot toward the ipsilateral hip. The patient is instructed to push their foot into the physician’s leg for 3-5 seconds. The patient is instructed to relax and the physician provides more compression until a new restrictive barrier is reached. Continue until no new barriers are met.

 Reassess

Question 25

Inflare of Innominate treatment

Answer 25

 Patient supine. Physician stands opposite the dysfunction. Patient’s dysfunctional side’s hip and knee are flexed and their foot is placed on the lateral side of the opposite knee.

 The physician places their cephalad hand on the patient’s ASIS (opposite side of dysfunction) and their caudal hand is placed on the patient’s knee (side of dysfunction).

 Patient’s hip is abducted/externally rotated (FABER position) until a restrictive barrier is reached.

 Physician instructs the patient to adduct/internally rotate their hip, by pushing their knee into the physician’s hand while the physician provides equal counterforce for 3-5 seconds. The patient is instructed to relax and a new restrictive barrier is engaged. Continue until no new barriers are met.

 Reassess

Question 26

Outflare of innominate

Answer 26

 Patient supine. Physician stands opposite thedysfunction. Patient’s dysfunctional side’s hip and knee are flexed and their foot is placed on the lateral side of the opposite knee.

 The physician places their cephalad hand on thepatient’s PSIS (side of dysfunction) and their caudal hand is placed on the patient’s lateral knee (side of dysfunction)

 Patient’s hip is adducted/internally rotated until a restrictive barrier is reached.

 The patient is instructed to abduct/externally rotate the flexed hip while the physician provides equal counterforce for 3-5 seconds. The patient is instructed to relax and the physician engages a new restrictive barrier. Continue until no new barriers are met.

 Reassess

Question 27

Pubic Dysfunction Shotgun

Answer 27

 Patient: supine, hips are flexed to 45°and knees are flexed to 90°with feet flat on table

 Physician: standing on side of table

 While having the patient use isometric contractions alternate between adduction and abduction, holding for 3-5 seconds, repeating 3- 5 times

 Alternative method: start with knees together and progressively get wider between contractions

Question 28

Superior Pubic Shear MET

Answer 28

 Patient: Supine

 Doctor: Stand on side of dysfunction

 Doctor stabilizes opposite ASIS with one handand holds dysfunctional side’s leg, abduct and slightly extend dysfunctional side off table

 Using an isometric contraction, have patient flex hip medially and toward ceiling to activate adductor muscles, hold 3-5 seconds, repeat 3-5 times using proper MET

Question 29

Inferior Pubic Shear MET

Answer 29

 Patient: Supine

 Doctor: Standing same side as dysfunction

 Place superior hand on dysfunctional side’s ischial tuberosity to monitor and guide rotation

 Flex patient’s hip until restrictive barrier adding significant adduction to target pubic dysfunction

 Using an isometric contraction have patient try to abduct and extend hip for 3-5 seconds, repeat 3-5 times using proper MET