Patho: Pelvic Girdle Flashcards
1
Q
The Functional Pelvic Girdle: 11 joints sharing 1 purpose of load transmission
A
- L4-L5 intervert.
- L5-S1 intervert.
- L4-L5 Facet joints
- L5-S1 Facet joints
- Right and Left SIJ
- Pubic-symphasis
- 2 hip joints
2
Q
The True Pelvic Girdle
A
- 2 SIJs
- 1 PS
3
Q
Osteology
A
- Innominate: formed by the fusion of the Ilium, Ischium, and Pubis
- Iliac Crests
- ASIS: Sartorius attaches here
- AIIS
- PSIS: promentory, and inferior margin
- Ischial Tuberosities
- Looking to see if these palpations are at even heights
- Short SI ligament is straight across from the PSIS Promentory, and medial and diagonal inferior to apex of sacrum is the Long SI ligament
4
Q
Posterior Checkings
A
- Short and Long Ligaments help prevent the Ilium from moving too far forward on the sacrum (anterior rotation)
- Ilium anterior rotation is coupled with hip extension
- Sacrotuberous ligament runs from the distal Sacrum to Ischial tuberosity (becomes sore when the innominate goes into excessive posterior rotation).
- Iliolumbar ligament assists the Sacrotuberous in keeping the innominate from going into excessive posterior rotation. Can occur in excessive loaded hip flexion
- Glute Max and Hamstrings tightness can cause excessive posterior rotation
5
Q
Osteology: Sacrum
A
- 5 fused vertebra
- Sacral Base
- Sacral Apex
- Sacral Sulcus
- Sacral ILA (inferior lateral angle)
6
Q
Sacrum: Keystone
A
Keystone: the wedge-shaped piece at the crown of an arch that locks the other pieces in place.
-Keystone’s are load transfer sites, from ground reaction forces and gravity.
7
Q
Biomechanics
A
- Ilial movement on sacrum
- Sacral movement on Ilium
- Pubic mobility
8
Q
Ilial Movement: Anterior Rotation
A
- 5 degrees is normal
- ASIS moves anterior and inferior
- PSIS moves superiorly
- Occurs during hip extension
- Short and Long ligaments limit this.
9
Q
Ilial Movement: Posterior Rotation
A
- 5 degrees is normal
- ASIS moves posterior and superior
- PSIS moves inferior
- Occurs during hip flexion > 90 degrees
- The Sacrotuberous Ligament and the Iliolumbar ligament limit this.
- Normal hip extension is 15-30 degrees. First 15 degrees is pure hip movement, after that pelvic movement is assumed to occur
10
Q
Ilial Movement: Inflare/Outflare
A
Inflare: -ASIS moves anterior and medial -PSIS moves anterior and lateral -Deals with Internal Rotation Outflare: -ASIS moves lateral and posterior -PSIS moves posterior and medial -Deals with External Rotation -Is more likely to occur in sports than inflare; when someone says they have deep SI pain its believed that the anterior SI ligaments are damaged. -Normal for both flares is 5 degrees, past that is BAD
11
Q
Ilial Movement: Upslip and Downslip
A
Ilial Upslip
- Superior Shear
- Normally occurs during heel strike, during the swing phase it slides back into normal.
- Generally when you get an upslip its not just in that one motion its usually coupled with anterior or posterior rotation.
Ilial Downslip
-Inferior Shear, the return from upslip during swing phase of gait.
12
Q
Ilial Upslip, The Injury
A
- When the Ilium is forced into upslip it will move into either:
- Upslip with anterior rotation
- Upslip with posterior rotation
- Manipulate with leg pull to re-align joint.
- When you go to measure the PSIS and they are more than 2 cm apart but the ASIS are pretty even then its likely that there was upslip with anterior rotation.
- Short and long ligaments will be sore
- When you have them do March test PSIS goes up instead of down on Ipsi leg lift
- Upslip is corrected first then you correct the other issues.
- Yank the leg (anterior rotation have them lie prone, posterior rotation have them lie supine)
- Squeeze the flute and activate the hip flexors isometrically
- Then shotgun the adductors.
13
Q
Sacral Movement
A
Sacral Flexion (Nutation) -Base moves anterior and inferior. Occurs during initiation of spinal extension, exhalation, and completion of spinal flexion.
Sacral Extension (Counternutation)
- Base moves posterior
- Early spinal flexion, inhalation
-Sacrum on Ilium has to do with when the feet are on the ground.
14
Q
Sacral Rotation
A
- Right and left rotation around a right oblique axis
- Right and Left rotation around a left oblique axis
- Lumbar SBR= sacrum rotates left
- SB right= left rotation; right thumb moves forward
- SB Left=right rotation; left thumb moves forward
- SB right, no left rotation then stuck in right rotation (If right side isn’t coming forward, then isometric contraction of the piriformis, if left side isn’t rotating then you are contracting the multifidi isometrically for treatments)
15
Q
Pubic Motion
A
- Walheim (1984)
- Frontal plane
- 1.3mm-2.1mm
- Sagittal Plane
- .4-1.1mm
- Frontal plane
- Pregnancy
- Separation 1-7 mm normal
- Lindsey (1988) case at 4.5 cm.
- If the pubic symphysis becomes hypermobile, then one of the only treatments you can do is the scarring injections (prolotherapy)
16
Q
Role of Ligaments: Anterior Sacroiliac
A
- Run from sacrum to Ilium laterally and inferiorly. Reinforced by Ilio-lumbar ligament.
- Stressed during Ilial outflare, hyper hip external rotation
17
Q
Role of Ligaments: Iliolumbar
A
- Attaches from TP of L4 and L5 to the Ilium.
- Checks posterior Ilial rotation and contralateral lumbar SB and rotation.
- Becomes taut during Ilium posterior rotation and contralateral SB
- Also may have role in prevention a lateral shift
- If shifted to the right then a sprain in the left Iliolumbar ligament.
18
Q
Role of Ligaments: Short Posterior SI
A
- Runs from PSIS promentory to the sacrum. Possibly limits all Ilial motion on sacrum, mainly anterior Ilial rotation.
- Tender much of the time with SI malalignment
- Becomes sore with too much anterior rotation
19
Q
Role of Ligaments: Long Posterior SI
A
- Runs from the inferior margin of PSIS to the lower 1/2 of sacrum.
- It checks anterior Ilial rotation.
20
Q
The Pelvic Girdle’s need for Load Transfer
A
Mobility
- The PG is mobile
- Ilium moves on sacrum with AROM of hip in Open Chain.
- Sacrum moves on Ilium when the spine flexes, extends, SB, and rotates on the Ilia. Closed Chain
Stability
-The PG needs to be stable to effectively transfer loads across its joint surfaces when we are in WB. This requires proper function of the static and dynamic stabilizers.
- Ligament and boney congruency are static stabilizers
- Dynamic stabilizers are motor control (muscles)
21
Q
Self-Locked and Loose-Packed Positions
A
- Self Locked or Closed Pack Position of SIJs
- Full posterior innominate rotation. Ideal position for loading tasks since joint surfaces are most congruent. Example, lifiting in a full squat.
- Sacral (nutation) during active flexion and extension of the spine the sacrum nutates (flexes)
- The Pelvic girdle is not self-locked in spine neutral= lying supine, standing, sitting upright, and during the gait cycle.
- When joint surfaces are closest together and ligaments are shortest is closed packed position.
- Loose-packed position is where the joint has the most play in it.
22
Q
Static Stabilizers and Form Closure
A
- Form Closure: the ability to transfer loads through the PG, while keeping the joint surfaces stable. This depends on the static stabilizers being healthy and doing their job:
- Ligaments
- Bony and joint integrity.
23
Q
Dynamic Stability: Force Closure
A
- Optimal muscle function provides the PG with dynamic stability= force closure.
- Local muscle system
- Pelvic Floor muscles: need to activate for PG stabilization and bladder control. Co-activated with TA contraction
- Diaphragm: the roof, provides stability by increasing intra-abdominal pressure.
- Transverse Abdominus
- Lumbo-sacral multifidi
- The deep multifidi and the TA both put tension on the thoraco-dorsal fascia creating a corset of support for the LB and PG. A “circle of integrity”
- Global Muscle System
- Opposite Latissimus Dorsi and Gluteus Maximus
- Abdominal Obliques and adductors
- Gluteus Medius in weight-bearing.
24
Q
Dynamic Stability: Force Closure: Global Muscle System
A
- Posterior Oblique Sling aiding force closure
- Left latissimus with right Gluteus Maximus and the intervening thoracodorsal fascia.
- Anterior Oblique Sling:
- External Oblique and opposite Internal Oblique and opposite adductor of thigh and the intervening abdominal fascia.
- Adductors on one hip and obliques on the other side.
25
Force Closure: The Lateral System/Sling
- Stabilizes body in frontal plane in single limb support.
- Keeps pelvis level, prevents Ilial Upslip.
- Stance leg Glute Med and Adductors, opposite side Quadratus Lumborum.
- Someone with an upslip will need a strengthening program for these muscles, to keep them from going back into the upslip.
26
Lateral Sling Exercise Example
- Global Muscle System
- The role of the Gluteus Medius in single limb support
- Keeps pelvis level, prevents Trendelenberg, when firing properly limits unwanted superior shear or upslip forces of the Ilium on Sacrum.
- Very important to keep the Glute Med strong.
27
Posterior Sling
- Biceps Femoris is coupled with the Erector Spine through the Sacrotuberous Ligament. At the end of swing phase the Hamstrings eccentrically contract to control hip flexion and knee extension.
- Contraction of Biceps Femoris pulls the Sacrotuberous taut, assisting in stabilization of the sacroiliac joint (=force closure of the sacroiliac joint)
28
Motor Control and PG Function
- Research has shown that in a healthy back and PG, the CNS can anticipate when muscles need to activate to handle an oncoming load and the muscles fire before the load or required motion occurs.
- Thus, muscle timing and sequencing of activation is critical for normal LB and PG function.
- PG with LBP and PGP lose this timing!
29
Emotions-Awareness
- Emotional States play an important role in physical function.
- Example:
- Chronic pelvic pain may be tied into chronic stress and negative life experiences. May result in hypertonic muscle firing. Over-activation of pelvic muscles= overly compressed joint surfaces= pain.
30
SIJ MOI Athletes and Performers
- Keep in Mind the relationship that hip motion has on the pelvis.
- Think about how lumbar spine motion impacts sacral position.
31
Mechanisms of Injury to Pelvic Girdle
- Leg Length Discrepancy
- Superior shearing force- causing innominate upslip.
- Cause unhealthy forces aroung the SI Joint
- Long leg side is the short lumbar side.
- In left SB then in right rotation and opening the right facets and closing the left facets.
- Long leg will cause early heel strike and a forceful one, putting the Ilium into more chance of superior shear (upslip)
- Adductors are in a short position and the Glute Med is stretched out. (long muscle is a weak muscle, Short muscles lose range)
32
Mechanism of Injury: Hypers
- Hyperabduction force to the hip
- Separation force to PS
- Hyperflexion force of hip
- Results in excessive posterior Ilial rotation stressing Sacrotuberous and Iliolumbar ligaments
- Hyperextension for of hip
- Results in excessive anterior rotation of Ilium, stressing short and long posterior SI ligaments.
- Hyper External Rotation forces of hip
- Causes possible damage to Anterior SI Ligament and possible PS separation.
33
Mechanism of Injury: Others
- Weal Lateral Sling and jump landing
- Hormonal influences-relaxin
- Affects women at times of pregnancy or still breast feeding.
- Systematic hypermobility
- An athlete who has restricted hip motion may compensate at SI joint by becoming hyper mobile.
34
Common PG Signs and Symptoms
- Local SI Joint pain and tender palpation
- Local Pubic symphysis pain and tender palpation
- Unilateral complaint
- Pain with stair climbing, gait, standing, sitting
- Referred pain buttock to posterior thigh with SI involvement
- Referred pain to adductors with PS involvement.
- Zingy pain below the knee think ridiculopathy or sciatica.
- Painful palpation of one or more SI Ligaments
- Painful palpation of hip adductors and lower rectus abdomens with pubic problem
- Active SLR sign.
- Is a stability test= a good one.
- Leg raise makes the symptoms hurt worse
35
Pelvic Girdle Assessment
- Signs & Symptoms
- Posture/LLD
- Palpate position
- Palpate mobility
- Palpate for Tenderness
- Special tests
- Pain Provocation
- Stability tests
- Core and Sling Function
- Hip Muscle Length
- Correlate Data-no one test proves anything in this area of the body.
36
Special Tests
- Stability Test:
- Stork Standing/Trendelenberg's.
- Shows instability, looking for any sign of shaking
- March Test
- One thumb on the PSIS and the other thumb on the sacrum. Use a firm hand hold the crest, usually do 2-3 passes to get a good grasp of what's going on.
- Thumb on the sacrum straight on the midline, when you ask them to raise that knee past 90 degrees, the PSIS should travel inferiorly 2-3 cm.
- PSIS doesn't move or travels superiorly then its bad, travels superiorly then you probably have an upslip. Second part of the test is raising the opposite leg and the thumb on PSIS should look like its traveling superiorly. ( if when moving the opposite leg the PSIS doesn't travel superiorly then you would think that the Ilium is stuck in posterior rotation.
- 1st part checking for the Ilium to move posteriorly
- 2nd part checking for the Ilium to move anteriorly.
37
Classify the Problem: Hypo vs. Hypermobility: Hypermobile Pubic Symphysis
Hypermobile Pubic Symphysis
- MOI-childbirth of forced hip abduction or ER
- Systemic Hypermobility
- Hormonal Influences
- Poor tolerance to sitting, standing, walking
- "+" pain over pubic tubercle
- "+" pain/spasm of adductors or RA
- "+" ASIS gapping test
- "+" FABER test.
38
Classify the Problem: Hypo vs. Hypermobility; Hypermobile SIJ
- Hx of systemic hyper mobility
- Hormonal Influences
- Local SIJ pain and referred pain buttock and thigh
- Local Ligament tenderness
- Difficulty holding stable pelvic posture in stork stand
- "+" pain on Squish test, ASIS gapping and or FABER's
- "+" Active SLR sign
- "+" Sidelying posterior Ilial translation test
- Bilateral Hip ROM Asymmetry
- Finding that a joint you assigned as restricted and then treated with mobilization continues to come out of alignment
39
Treatment of Pelvic Girdle Position and Motion Dysfunction
- Direct mobilization- upslip correction (leg pull)
- Isometric mobilization "muscle energy"
- Soft Tissue mobilization- massage hypertonic muscles
- Lumbopelvic taping/strapping
- Core Stabilization-improve force closure!!!!
- Strengthen the local muscle system
- Strengthen the global muscle system
- Improve motor control-sequencing of muscle firing
- Deal with emotional component-Chronic pain
- Prolotherapy
- Upslip with Posterior Rotation
- supine leg pull-manipulation
- Upslip with Anterior Rotation
- Prone leg pull-manipulation
40
Treatment of Pelvic Girdle Position and Motion Dysfunction: Rotations/Flares
- Anterior Ilial Rotation
- DIrect mobilization into posterior rotation
- Isometric contraction of glute max or RA; opposite limb gives a counterforce
- Posterior Ilial Rotation
- Direct mobilization into anterior rotation.
- Isometric contraction of hip flexors, or hip adductors; opposite limb gives a counterforce.
- Ilial Inflare
- Isometric mobilization using gluteus medius and minims
- Ilial Outflare
- Isometric mobilization using Iliacus
41
Treatment of Rotated Sacrum
- Stuck in right rotation= unable to left rotate. Sacral sulcus test reveals that the right joint is not moving. Treat by using isometric contract of right piriformis.
- Stuck in right rotation= unable to rotate left. Sacral sulcus test reveals that the left joint isn't movin. Treat by contracting the left multifidi.
42
Prolotherapy
- Prolotherapy is the intraligamentous or intratendinous injection at a fibro-osseous junction (The SI or PS) of a solution that induces a temporary inflammatory reaction. This causes an influx of fibroblasts that synthesize collagen at the injection site leading to the formation of new ligament and tendon tissue.
- Take Prolo over wire for gross instability.
- When going through injections don't do rehab after injections are done then slowly work them to return to normal
- Most patients receive a total of 6-10 treatment session spaced at 1-2 week intervals (4-6 month process)
- Activity is limited during treatment period.
- Patients with disabling joint pain and instability that has lasted greater than 6 months.
- Patient needs to demonstrate significant joint instability.
- Who is not a candidate?
- Discogenic pain
- Chronic pain patients post fusion surgery
- Patients who have been bedridden due to chronic low back pain.
