Midterm

Question 1

SUPINE – SACROILIAC JOINT MOBILITY

Answer 1

NORMAL: Anterior to posterior (A-P) shearing motion should occur at the sacroiliac joint.

POSITIVE: Restricted or reduced anterior to posterior (A-P) shearing motion of the sacroiliac joint.

Question 2

Standing Step test (Gillet’s Test)

Answer 2

Part 1:
Dr’s RIGHT thumb on patient’s RIGHT PSIS
Dr’s LEFT thumb on patient’s LEFT S2 (2nd sacral tubercle) 
RIGHT side: The thumbs Approximate. 
LEFT side: The thumbs Separate.

Part 2:
Dr’s LEFT thumb on patient’s LEFT PSIS
Dr’s RIGHT thumb on patient’s RIGHT S2 (2nd sacral tubercle)
LEFT side: The thumbs approximate.
RIGHT side: Thumbs (distract) move further apart in an oblique direction.

Question 3

Standing Step test (Gillet’s Test)- “Positive test”

Answer 3

POSITIVE TEST: Normal sacroiliac motion is present when the thumbs either move towards each other (Part 1) or away from each other (Part 2) in an oblique direction. With either part 1 or part 2 if the thumbs move at the same time and in the same direction, this indicates restriction (lack of motion) of the sacroiliac joint. The side on which the thumb does NOT move is the side of the lesion (restriction).

Question 4

STANDING Flexion test

Answer 4

Dr Contacts:
Dr’s RIGHT thumb on RIGHT PSIS
LEFT thumb on LEFT PSIS.

Procedure: The patient is asked to bend at the waist

NORMAL: Both thumbs MOVE AT THE SAME TIME.

POSITIVE: One thumb MOVES FIRST. The side of first movement is the side of the LESION (restriction).

Question 5

SEATED Flexion test

Answer 5

Dr Contacts: Dr’s RIGHT thumb on RIGHT PSIS
LEFT thumb on LEFT PSIS.

Procedure: The patient is asked to bend at the waist

NORMAL: Both thumbs MOVE AT THE SAME TIME.
POSITIVE: One thumb MOVES FIRST. The side of first movement is the side of the LESION (restriction).

Question 6

TESTING GLUTEAL STRENGTH:

Answer 6

Procedure:Stabilize the upper buttock (Iliolumbar) area with the superior hand while pressing straight downward on the thigh with the inferior hand. Grade gluteus maximus muscle strength on a 5/5 scale.

NORMAL: Strong muscle strength (4-5/5) that locks in the contraction without muscle shaking or fading.
POSITIVE: The muscle gives way with resistance and either drops to the table top or shakes or fades with resistance.

Question 7

GLUTEUS MEDIUS STRENGTH:

Answer 7

Procedure: Stabilize the pelvis with the superior hand to prevent twisting while pressing straight downward on the thigh with the inferior hand. Grade gluteus medius muscle strength on a 5/5 scale.

NORMAL: Strong muscle strength (4-5/5) that locks in the contraction without muscle shaking or fading.

POSITIVE: The muscle gives way with resistance and either drops to the table top or shakes or fades with resistance.

Question 8

BELT TEST

Answer 8

Part 1. No doctor contact while bends forward (flexes)
Part 2. The doctor stabilizes

NORMAL: The patient fully bends over in both test phases without pain.

POSITIVE: Pain provoked by Part 1 and Part 2 indicates lumbar origin.
Pain with part 1 only indicates sacroiliac origin.

Question 9

ACTIVE STRAIGHT LEG RAISE TEST (aSLR)

Answer 9

Procedure: Part 1. The patient is instructed alternately lift each leg 8 inches (20 cm) off the table. Palpate the patient’s pelvis for torsion instability or difficulty lifting the leg.

Part 2. Additional information can be ascertained by repeating the test with one of the following:
manual compression of the sacroiliac joint
a sacroiliac belt to compress the sacroiliac joint
active abdominal bracing by the patient

NORMAL: The patient raises each leg alternately without lumbar or pelvic pain and without twisting (rotation) of their pelvis (instability).

POSITIVE: Part 1. If any of the following are present.

• The leg can’t be raised off the table.
• There is heaviness of the legs.
• Decreased strength when downward overpressure is applied to leg.
• There’s significant ipsilateral trunk rotation or twisting (instability).

Part 2. If manual compression, a sacroiliac belt or active abdominal bracing by the patient causes a decrease in symptoms after a positive initial active straight leg raise, there is a loss of neuromuscular control and instability of the pelvis.

Question 10

HIP EXTENSION TEST – IPSILATERAL PRONE KINETIC TEST

Assessment of Hip Motion

Answer 10

Dr Contacts:
Superior hand: Thumb placed on apex of PSIS.
Inferior hand: Thumb on the sacrum parallel to the other thumb.

Procedure: The patient is asked to lift up their leg, extending the hip.
Palpate for superior (upward) and lateral motion of the PSIS.

Note: this test is usually performed with active hip extension, however, if the patient is too weak to perform active hip extension or if active hip extension causes pain, this test can be performed passively whereby the doctor lifts the leg into hip extension to assess hip joint mobility.

NORMAL: The PSIS does not move before the hip is extended approximately 10o.
Testing in the prone position places the hip in a neutral (0o) position.
Normal hip extension is 10o-30o.

POSITIVE: The PSIS and the sacrum moves superiorly and laterally as the hip is extended.

Question 11

(PI) PIR Stretch Ipsilateral Hamstrings (Hip Extensors)

Answer 11

(leg on shoulder)
Action:
Fully extend ipsilateral knee with ankle and foot relaxed
Gently stretch hip extensors (hamstrings) by gradually increasing hip flexion while avoiding knee flexion
Deep inhalation and hold breath
Eyes look up (without head movement)
Have patient isometrically contract ipsilateral hip extensors by pushing straight leg into doctor’s HC for 7-10 seconds at 20-75% max contraction.
Rule: “as little force as possible or as much as necessary”
Avoid Valsalva.
Let breath out and eyes release
Relax - wait for muscle resistance to let go (1-3 seconds)
Increase hamstring stretch within comfort zone (should move smoothly).
Repeat PIR stretch 3-5 times total.

Question 12

(PI) Tighten Iliopsoas (Hip Flexors)

Answer 12

Action: Isometric contraction of ipsilateral hip flexors for 7-10 seconds at 50-75% max contraction. Avoid Valsalva. Repeat 3-5 times

(Pt. foot on Dr’s hip, straight leg on bench, Dr. pushes down on straight leg.)

Question 13

(AS) PIR Stretch Ipsilateral Psoas (Hip Flexors)

Answer 13

Action:
Contralateral knee to chest; ipsilateral hip extended with the knee relaxed
in extension
Gently stretch hip flexors submaximally into hip extension
Deep inhalation and hold breath
Eyes look up (without head movement)
Have patient isometrically contract hip flexors at end range by pushing up into
doctor’s hand contact for 7-10 seconds at 20-75% maximal contraction.
Rule: “as little force as possible or as much as necessary”
Avoid Valsalva.
Let breath out and eyes release
Relax - wait for muscle resistance to let go (1-3 seconds)
Slowly increase hip flexor stretch within comfort zone (should move smoothly).
Repeat PIR stretch 3-5 times total

Question 14

(AS) Tighten Hamstrings (Hip Extensors)

Answer 14

Action:
Isometric contraction (50-75% max) of ipsilateral hamstrings for 7-10 seconds.
Avoid Valsalva.
Repeat 3-5 times.

Question 15

MET FOR LESIONS OF THE PUBIC SYMPHYSIS

Answer 15

PP: Supine, knees flexed at 45o, knees separated, and feet flat and parallel on the table.
DP: Hand contact medial aspects of both of the patient’s knees.
Procedure: The patient gently actively adducts their knees isometrically
The position is held against patient resistance for 7-10 seconds
Repeat 3 times and re-assess
Alternately: Gently pull against the patient, trying to separate their knees

Question 16

PELVIC BLOCKING; PRONE POSITION

“Right AS Innominate or Left PI Innominate”

Answer 16

Block #1 Right side:
Iliac crest at 45° and place it under the Right ASIS

Block #2 Left side:
Horizontally (90°) under the Left greater trochanter

Adjust both blocks to assure pelvis is level (check PSISs)

After at least 5 minutes, remove the blocks slowly and simultaneously

Question 17

PELVIC BLOCKING; PRONE POSITION

“Left AS Innominate or Right PI Innominate”

Answer 17

Block #1 Right side:
Iliac crest at 45° and place it under the Left ASIS.

Block #2 Left side:
Horizontally (90°) across the femur under the Right greater trochanter.

Question 18

PELVIC BLOCKING; SUPINE POSITION

“Right AS Innominate or Left PI Innominate”

Answer 18

Block #1 Right side:
iliac crest at 45° and place it under the Left PSIS

Block #2 Left side:
Horizontally (90°) across the femur under the Right greater trochanter.

Question 19

PELVIC BLOCKING; SUPINE POSITION

Left AS Innominate or Right PI Innominate

Answer 19

Block #1 Left side:
Iliac crest at 45° and place it under the Right PSIS

Block #2 Right side:
Horizontally (90°) across the femur under the Left greater
trochanter.

Question 20

PIR-

Tensor Fasciae Latae (TFL)

Answer 20

Patient Position: Side lying with target (involved) muscle up.
Patient’s posterior trunk positioned close to the edge of the table.
Upside leg (target muscle): the hip and knee are extended and the leg is lowered over the edge of the table until the barrier of resistance is palpated.
Downside leg: hip and knee flexed on the table for stability.

Question 21

PIR-

Piriformis

Answer 21

Patient Position: Supine
Contralateral leg (target muscle): knee flexed. Hip flexed, adducted and internally rotated to the position where the “barrier of resistance” is palpated
Ipsilateral leg: extended and relaxed on the table

Question 22

PIR-

Iliopsoas

Answer 22

Patient Position: Sitting on the edge of the foot of the table.
Ipsilateral leg: patient pulls their knee-to-chest (flexion) and reclines the upper trunk backwards onto the table, leaving the contralateral leg (target muscle) hanging off the foot of the table.
The doctor places his/her lateral hip against the sole of patient’s foot to help stabilize the leg in flexion.
Contralateral leg (target muscle): allowed to hang over the foot of the table with the thigh resting as close as possible to the table top and the knee passively flexed as much as possible over the edge of the table.

Question 23

PIR-

Rectus Femoris

Answer 23

Procedure:
Place the superior (cephalad) hand on the patient’s ipsilateral knee to stabilize it.
With the inferior (caudal) hand push on the contralateral tibia to induce knee flexion.
Stretch the rectus femoris (quadriceps) until the “barrier of resistance” can be palpated.
Ask the patient to breathe in and look up with both eyes.
Direct the patient to push their lower leg against your contact hand as you apply isometric resistance to the patient’s knee extension (20-75%).

Question 24

Quadratus Lumborum

Answer 24

Patient Position: Sidelying with target (involved) muscle up
Patient’s trunk is positioned close to the edge of the table.
Upside leg (target muscle): the knee is straight (extended) and the hip is either flexed or extended (anterior vs. posterior divisions) with the leg lowered over the edge of the table.
Downside leg: hip and knee are flexed on the table for stability.
The patient’s upside arm reaches overhead and grasps the top of the table.
A roll may be placed on the table under the patient’s waist.

Doctor Position: Ipsilateral to dysfunction; standing behind the patient to stretch the posterior division or in front of the patient to stretch the anterior division.

Question 25

Erector Spinae

Answer 25

Patient Position: Sidelying with a pillow or roll under their waist. The patient’s upper trunk is placed in a pronated position (hugging the table) and their downside hip and knee is flexed.

Doctor Position: Standing behind the patient near the patient’s pelvis.

Procedure:
Doctor’s hand position:
Reach over to the patient’s posterior trunk and contact the iliac crest/ASIS with the superior hand. With the inferior hand contact the lower thoracic or upper lumbar erector spinae muscles.

Question 26

INNOMINATE MANIPULATIONS
POSTERIOR – INFERIOR INNOMINATE (P- I)
Side posture or Knee-to-knee.

Answer 26

SC: Inferior aspect of the upside PSIS for the side posture contact
Medial aspect of the upside PSIS for the knee-to-knee contact

HC: Side posture contact: Hypothenar eminence of inferior hand
Knee-to-knee contact: Pads of inferior hand’s index and middle fingers
The superior hand induces traction and posterior rotation of the thoracolumbar spine.

Thrust: Side posture: P-A and I-S on the PSIS, while inducing pelvic rotation with your torso
contact (grade I-V).
Note: The direction of thrust is on the innominate in the sagittal plane (oblique)
of the sacroiliac joint (gliding).
Knee-to-knee: M-L on the PSIS, while inducing pelvic rotation with your knee contact
(grade l-V).
Note: The direction of thrust is on the innominate in a lateral vector which causes gapping (joint surface separation) of the sacroiliac joint.

Question 27

INNOMINATE MANIPULATIONS
ANTERIOR – SUPERIOR INNOMINATE (A-S)
Side posture or Knee-to-knee

Answer 27

SC: Posterior aspect of the upside ischial tuberosity for the side posture contact
Superior aspect of the upside PSIS for the knee-to-knee contact.

HC: Side posture contact: Hypothenar eminence of inferior hand
Knee-to-knee contact: Pads of inferior hand’s index and middle fingers
The superior hand induces traction and posterior rotation of the thoracolumbar spine.

Thrust: Side posture: P-A on the ischial tuberosity. The best vector is along the patient’s femoral shaft (grade I-V).
Knee-to-knee: S-I and M-L on the PSIS, while inducing pelvic rotation with your knee
contact (grade l-V).

Question 28

SACRAL TORSION – sacral base push (LEFT SIDE)

Answer 28

Left Sacrum is posterior
LEFT side is UP
LEFT side is contacted
on the sacral base inside the iliac crest

DP: Side posture.

SC: The upside sacral base just medial to the iliac crest.

HC: The hypothenar of the inferior hand contacts the sacral base. Avoid contact on the innominate. Superior hand induces traction and posterior rotation of the thoracolumbar spine.

TP: Inferior to Superior

Thrust: Push P-A on the sacral base while inducing pelvic rotation with your torso (grade I-V).

Question 29

SACRAL TORSION – sacral APEX puLL (AFFECTED SIDE UP)

Answer 29

DP: Side posture.

SC: Broad soft contact on the posterior sacrum and sacral apex.

HC: The hypothenar of the inferior hand contacts the posterior sacrum and sacral apex.
Superior hand induces traction and posterior rotation of the thoracolumbar spine.

TP: Superior to inferior

Thrust: Slowly drop your torso on the patient’s pelvis and bring the soft tissues to tension.
Pull inferiorly on the posterior sacrum and sacral apex and drop your body weight on the patient’s pelvis/thigh to deliver a thrust cephalically (toward the patient’s head).

Question 30

COCCYX MANIPULATION (PILLOW UNDER HIP)

Answer 30

DP: Standing at the side of the table and facing 45° cephalically.

SC: The base of the coccyx.

HC: The pad of the superior (cephalad) thumb is placed on the base of the coccyx (on skin)
A pisiform-hypothenar contact of the inferior (caudal) hand is placed over the thumbnail of the contact hand with the fingers lying loosely over the dorsum of the contact hand.

TP: Inferior to Superior

Thrust: Take the tissue to tension in a cephalad direction with both hands. At the end of tension, deliver a cephalad and slightly P-A impulse thrust over the coccygeal base, producing a mixture of tissue pull and osseous thrust.