SACRUM Flashcards

Question

Left on Right

Answer 1

left on right: left rotation around the right oblique axis This is a posterior torsion and is a non physiological movement, it does not take place normally -due to trauma

Answer 2

Rotate anteriorly around the left oblique axis: rotate towards the left Left rotation around the left oblique axis which is referred to as an ANTERIOR TORSION and it is a normal physiological movement

Answer 3

Right rotation around left oblique axis is a POSTERIOR TORSION, and it is a non physiological movement

Answer 4

unilateral superior sacral shear 1. Hemisacrum slides along side of facet in superior direction 2. Sacral promontory moves posteriorly and superiorly 3. ILA moves superiorly

Answer 5

Inferior Unilateral Sacral Sheer Sacrum sheers in an inferior direction, it slides along the facet joint Sacral base goes forward and inferiorly ILA: moves inferiorly

Answer 6

each innominate rotates anteriorly and posteriorly during the walking cycle

Answer 7

The axis of rotation originates on the side of the weight bearing leg L on L, return to neutral, then R on R, then return to neutral At midstance of gait cycle the axis of rotation of sacrum is on the side of the weight bearing leg and it is always an anterior torsion. i. The axis of rotation originates on the side of the weight bearing leg

Answer 8

when the sacrum rotates to the right, simultaneously it does left side bending When sacrum rotates it also does contralateral side bending

Answer 9

When sacrum rotates, the lumbar spine rotates to the opposite side/ when sacrum sidebends, lumbar spine sidebends to the opposite side

Answer 10

1/3 of the way down on the diagonal that goes between ASIS and the pubic symphysis Gives more a superior part of the SI joint

Answer 11

2 inches from umbilicus (more medially) between umbilicus to ASIS Gives you more inferior part of joint

Answer 12

Space between sacral base and PSIS: | tells us about relationship between innominate and sacrum

Answer 13

Attaches from the anterior inferolateral aspect of the sacrum to greater trochanter Trace along length to palpate Piriformis is over the sciatic nerve (15% of population, sciatic nerve goes through but most of the time is goes under) You will only feel it if it is in spasm

Answer 14

Travel down sacrum and in area of S5 there is an indentation before the coccyx S5 – feel an indentation

Answer 15

Classic SI complaints

Answer 16

1. Pain centered over the SI joint One finger test i 2. Pseudo S1 pattern 3. Diffuse pain from buttock radiating to posterior LE [Rarely see pain go below knee joint, usually jus buttock and if it does radiate it goes down posterior aspect of thigh]

Answer 17

One finger test in literature

Answer 18

1. Standing - asymmetry - forward flexion test - backwards bending test - marching test - weight bearing provocation - lumbar movement 2. Sitting -asymmetry in static siting -seated forward flexion test - R/O fx 3. Supine: PUBIC SYMPHYSIS DYSFUNCTION - iliac crests - pubic symphysis - inguinal ligament - SI provocation test 4. prone: SACRAL DYSFUNCTION - sacral position - ILA - LLD - gluteal tone - ITs - tension sacrotuberous ligament - palpate PSIS - evaluate lumbar curve - spring lumbar curve - spring sacrum 5. supine: IS DYSFUNCTION - ASIS - LLD - long sitting test

Answer 19

Supine: PUBIC SYMPHYSIS DYSFUNCTION - iliac crests - pubic symphysis - inguinal ligament - SI provocation test

Answer 20

prone: SACRAL DYSFUNCTION - sacral position - ILA - LLD - gluteal tone - ITs - tension sacrotuberous ligament - palpate PSIS - evaluate lumbar curve - spring lumbar curve - spring sacrum

Answer 21

Supine: IS DYSFUNCTION (position of the innominate bone) - ASIS - LLD - long sitting test

Answer 22

innominate rotation round the sacrum and it is an IS problem. - eyes level with PSIS, do not stabilize pelvis because we want it to move: , fingers must be under the PSISs - pt stands knees extended: roll down as though going to touch your toes - normal: both PSIS rise forward simultaneously and equally -Positive finding: one side (PSIS) moves first and further (innominate bone grabbed by sacrum + pulled up faster while other side taking up slack between sacrum and innominate bone as normal)

Answer 23

SI Issues= sacrum moving on the innominate bone PT hands on sacral base: Drop of medially on both sides to PSIS pt hands on butt. pt backward bend, should have increase in lordosis (sacrum moves in opposite direction of the lumbar spine, sacral base will drop forward into kyphosis Normal: should feel both of PT’s thumbs dip forward simultaneously and symmetrically Positive: problem of movement btwn innominate bone and sacrum on one side, sacrum will not be able to drop forward because it is caught on innominate, and on that side the sacral base will remain back and not drop forward - one side will drop forward, the other side will not - PT will feel one side relatively posterior: involved side

Answer 24

innominate rotation round the sacrum (IS problem) On NWB side: PT has one thumb on PSIS and other thumb on ipsilateral sacral base --Must have thumb underneath PSIS and it must stay underneath to follow the PSIS and not let it slip from your finger. Instruct patient to march in place: 90-90 hip-knee flexion Normal: expect to feel innominate bone rotating posteriorly in relation to the sacrum: =should feel PSIS drop down and back under PT thumb as the pt comes up into hip and knee flexion. As put foot back down should come back into normal alignment. Positive finding: = one side does not have appropriate mobility, innominate bone will not drop back and the whole pelvis will shear up and PT feel a stiffness in pelvis and finding will be that PSIS grabbed cranially and will not drop down and whole unit will come up because innominate cannot rotate normally around the sacrum [it almost looks like a hip hike]

Answer 25

Patient stand centered with equal distribution of weight on both LE’s Ask patient to shift weight over one LE and go back to neutral and shift weight over to opposite LE Caution: no lumbar side bending or rotation which can cause pain i. If they sideband and get pain = problem distinguishing between lumbar and SI – so keep in neutral to r/o lumbar spine Don’t allow lumber spine to move in order to rule out lumbar spine, it is a pure weight shift, discomfort is coming from the pelvis if reproduction of the symptoms on a particular side Positive finding: reproduction of pain

Answer 26

1. Already done this as a part of lumbar exam 2. Flexion, extension, sidebending, rotation 3. Incorporate findings into differential diagnosis to figure out patient problem

Answer 27

innominate rotating around sacrum When looking at forward bending test and a marching test we are looking at innominate rotation around the sacrum and it is an IS problem.

Answer 28

sacrum moving on the innominate bone When we’re looking at backward bending in standing we are looking at sacrum, either moving forward or its inability to move forward and its an SI problem.

Answer 29

indicative of issues in the SI JOINT seated with feet supported, roll fingers underneath PSISs, PSIS eye level sitting on ITs: movement first in lumbar spine as it reverses lordosis/ then sacrum: innominate bone will move simultaneously if there is an equal amount of slack on both sides for the two SI joints Normal Finding: PSIS will rise in a cranial direction simultaneously – same finding as the standing forward bending test Positive: one PSIS will move first and further dysfunction on one side: sacrum stuck on the side with the innominate bone

Answer 30

Sitting position: positive finding is indicative of issues in the SI Joint (sacrum moving on the innominate bone) Standing position: positive findings in standing are indicative of ilium moving on the sacrum (innominate rotating around sacrum)

Answer 31

This is a mobility test for the ilium moving on the sacrum. Instruct the patient to stand with the feet approximately 6 in. apart. Stand behind the patient to observe the movement. Remember to use your domi- nant eye. Locate the PSISs and place your thumbs under them. Maintain contact with the PSISs throughout the movement. Ask the patient to bend as far forward as he or she can. Observe the movement of the PSISs in relation to each other. They should move equally. If there is a restriction, the side that moves first and furthest is considered to be hypomobile (Figure 6.33). If the patient presents with tight hamstrings, a false- positive finding can occur (Greenman, 2003; Isaacs et al., 2002).

Answer 32

This is a mobility test for the ilium moving on the sacrum. Instruct the patient to stand with the feet ap- proximately 6 in. apart. Stand behind the patient to observe the movement. Remember to use your dom- inant eye. Locate the PSIS on the side that you are testing and place one thumb under it. Place your other thumb just medial to the PSIS, on the sacral base. Ask the patient to raise the lower extremity on the side being tested so that the hip and knee are flexed to 90 degrees. Note the movement of the PSIS in rela- tion to the sacrum. This test should be repeated on the contralateral side. Compare the amount of move- ment from one side to the other. If the PSIS does not drop down into your thumb on one side, the ilium is considered to be hypomobile (Greenman, 2003) (Figure 6.34).

Answer 33

Instruct the patient to stand with the feet approxi- mately 6 in. apart. Stand behind the patient to observe the movement. Remember to use your dominant eye. Place your thumbs medial to the PSISs bilaterally on the sacral base. Instruct the patient to bend backward. Observe as your thumbs move in an anterior direc- tion. An inability to move anteriorly demonstrates hy- pomobility of the sacrum moving on the ilium (Green- man, 2003; Isaacs and Bookhout 1992) (Figure 6.35).

Answer 34

This is a mobility test for the sacrum moving on the ilium. This test eliminates the influence of the lower extremities. Instruct the patient to sit on a stool with the feet firmly on the ground for support. Stand be- hind the patient to observe the movement. Remember to use your dominant eye. Locate the PSISs and place your thumbs under them. Maintain contact with the PSISs throughout the movement. Ask the patient to bend as far forward as he or she can with their arms between their knees. Observe the movement of the PSISs in relation to each other. The side that moves first and furthest is considered to be hypomobile (Greenman, 2003; Isaacs and Bookhout 1992) (Figure 6.36).

Answer 35

This a test for posterior to anterior mobility of the sacrum. Place the patient in the prone position with the neck in neutral rotation. Stand on the side of the patient that is on the side of your dominant eye, with your body turned so that you are facing the patient’s head. Place your hands over the central aspect of the posterior sacrum using the palm as the contact point. Press directly over the sacrum in an anterior direction until all the slack has been taken up (Paris, 1991) (Figure 6.37).

Answer 36

positive finding: localized point tenderness send for xray

Answer 37

PUBIC SYMPHYSIS DYSFUNCTION - iliac crests - pubic symphysis - inguinal ligament - SI provocation test

Answer 38

SACRAL DYSFUNCTION - sacral position - ILA - LLD - gluteal tone - ITs - tension sacrotuberous ligament - palpate PSIS - evaluate lumbar curve - spring lumbar curve - spring sacrum

Answer 39

IS DYSFUNCTION - ASIS - LLD - long sitting test

Answer 40

for pubic symphysis dysfunction upslip will have a change in iliac crest height in an unweighted position --If upslip where the innominate travels up and when lying down it does not go away and see a high crest in NWB: Get a suspicion that the problem is pelvis (not LLD) Occasionally you will find muscle contraction /muscle spasm that pull innominate bone upward: not an upslip, just secondary stuff going on. (QL in spasm can pull the crest up )

Answer 41

for pubic symphysis dysfunction Pay attention to symmetry from one side to the other Rest hand on symphysis, take two thumbs/index/middle fingers and compare the height from one side to the other from a superior- inferior direction

Answer 42

for pubic symphysis dysfunction In groin line, looking for tenderness/tension between sides May also feel tension from one side to the other but remember the ligament is from two points that don’t change-can have a change in the joint but don’t have a change in the length relationship from the origin and insertion, so wont expect such a tension difference but will find tenderness differences so note which side/ both sides

Answer 43

for pubic symphysis dysfunction Anterior/Posterior SI joint Stress Test look to see if discomfort at the SI joint . Can be done 2 different ways: Compression component: separate ASIS anteriorly to create compression at the SI: cross my arms to push ASIS laterally to compress SI Distraction component: patient supine, my hands lateral ASIS and press medially on anterior aspect to distract at SI: my elbows are out and push ASIS in medially

Answer 44

sacral dysfunction Evaluate the sacral base: take fingers PSISs and place fingers on the base itself (not the sulcus, the sacral base—two thumbs on the base of the sacrum): compare depth from one side to the other side.

Answer 45

sacral dysfunction Look for hiatus and move laterally Fingers under ILA: posterior to anterior and inferior to superior Fingers behind ILA to see if rotated posterior to anterior Put fingers under ILA to see relationship inferior to superior Rotation on oblique axis: - -. If right oblique axis and rotated to right around right oblique axis: the right ILA will move posterior - --If there is a unilateral sheer on right and the sacrum goes into flexion on right, ILA will move inferiorly

Answer 46

sacral dysfunction Pelvis responds differently in different positions In prone: pelvis is secured, trunk is an influence on the sacrum on position (stabilized the pelvis): prone LLD is a function of how the sacrum is located between the two innominate bones may see a different LLD in supine: - supine LLD as a function of innominate bone and as a function of anatomical leg length they don’t have to be the same.

Answer 47

sacral dysfunction If have a rotation in the innominate bone or a change in sacral alignment there will be a tone difference May be squishier on one side, fuller on one side, or see atrophy on one side

Answer 48

sacral dysfunction Slide medially off IT and feel the ligament next to your hand If there is an upslip on the side the IT is elevated the sacrutuberous ligament will feel mushy: note the side that is softer and see if it correlates to the height change in the Its Correlated often with upslip because attach form IT to the sacrum—if there is an upslip more slack on the ligament and perceive it as a mush

Answer 49

sacral dysfunction Look at the alignment, is one side higher than the other Don’t know if higher or lower is the significant finding so just note it at this point

Answer 50

sacral dysfunction look at the lateral view should see a lordosis Some people may have a flattening due to spasm or bony alignment changes

Answer 51

sacral dysfunction a. Hand on, spring from L5-L1 vertebrae by vertebrae b. If increase or normal lordosis should feel nice springing c. If flattened lordosis feel decrease springing and it feels stiff

Answer 52

sacral dysfunction Do the same movement to spring the sacrum: now the hand is sitting over the sacrum Note: PAIN and if it moves symmetrically on both sides, is there give

Answer 53

sacral dysfunction Fingers underneath ITs and note a height difference from one side to the other If somebody as a true upslip and half of the pelvis has actually slid up: would find IT higher on the side of the upslip Note: IT that is elevated

Answer 54

position of the innominate bone, IS dysfunction

Answer 55

position of the innominate bone, IS dysfunction 1. If you have an anterior rotation innominate will push the femur inferiorly: functional LLD: LONGER 2. If posterior innominate: functional LLD: leg shorter It is a functional change to accommodate for a true anatomical change: 3. True LLD: Ie right leg is longer, then find a posterior innominate on that side to try to compensate for the longer anatomical leg to make it functionally shorter so it is not as long from one side to the other So can see combination of anatomical and functional leg length discrepancy on the same side

Answer 56

position of the innominate bone, IS dysfunction 1) Patient in a supine position, patient is told to level pelvis: bend knees in hooklying lift pelvis and drop back down to table, allow to straighten out legs. Look at LLD: 2---fingers by mediall malleolus and inspect 3---Then ask the patient to longsit from supine Compare LLD supine to longsit 4. False negatives/positives: Weak abdominals, uneven hamstring length 5. Normal : leg length equal in supine and remains equal in long sitting position - -->Could also be a normal finding if one leg is longer in supine and stays the same amount longer in long sitting (there is NO CHANGE from one side to the other) 6. Positive: one leg that is either equal or shorter in supine: and then when patient goes into long sitting, the short leg becomes much LONGER 7. WHY? If you have a patient who starts out with a posterior innominate which creates a functionally short leg, the acetabulum will be cephalically displaced--Then as you go into long sit pelvis evens out and the relative position of acetabulum goes from superiorly displaced position to a more normal neutral position (evens out because the whole thing rotates together )

Answer 57

In prone: pelvis is secured by having the _ resting on the table, trunk is an influence on the sacrum on position (stabilized the pelvis): prone LLD is a function of how the sacrum is located between the two innominate bones may see a different LLD in supine: supine LLD as a function of innominate bone and as a function of anatomical leg length they don’t have to be the same.

Answer 58

If you have a patient who starts out with a posterior innominate which creates a functionally short leg, the acetabulum will be cephalically displaced--Then as you go into long sit pelvis evens out and the relative position of acetabulum goes from superiorly displaced position to a more normal neutral position (evens out because the whole thing rotates together )

Answer 59

Rationale: differentiate between hip joint and sacroiliac joint pain Patient is put into a figure of four position, Place one hand on the pelvis and the other hand on the distal femur and create an opening If figure of four hurts we suspect the hip If one hand on the pelvis with the other on the knee, putting pressure on the pelvis makes the pain more intense we suspect the SI joint

Answer 60

Patient is in prone, flex the patient knee so heel approach buttock Pain on anterior part of thigh is rectus femoris tightness Classic Test used for L3: - reproduction of symptoms radiation down front of thigh to knee (medial knee) - and/or back pain this is correlated with L3 diagnosis. - Can also get pain around iliac crest, - pain can start at L3 NR in the back. If patient has very hypomobile SI on ipsilateral side or tight anterior structures---> iliac rim will start to move because it doesn’t tolerate this and get ASIS rotating forward as it gets pulled.

Answer 61

--Flex the leg that you’re not testing to 90 degrees, hold it there-have them hold it from posterior aspect of thigh --Then extend and abduct the contralateral side that is off the side of the table --This stresses SI joint, if it is painful probably has sacroiliac joint dysfunction or pathology. (looks like Thomas but you’re not stabilizing half of the pelvis—in Thomas test at end of table and pelvis flat on table, but in this test half of pelvis on table. Position looks the same )

Answer 62

1) SI dysfunction 2) Pubic symphysis instability (creating a hemipelvic rotation so if unstable in pubis this would be uncomfortable) 3) Hip pathology (asking the patients hip to hyperextend and in capsular pattern hip hyperextension is limited) 4) L4 nerve root irritation because of the input into the femoral nerve and you’re hyperextending the anterior structures (can get some stretch on the front, can also reproduce some of the radicular complaints that the patient might have from L4 nerve root)

Answer 63

Thrust (POSH test – posterior sheer test): confirm side but ilium pubis vs sacrum 1. pt: Place patient in supine, Flex painful hip to 90 degrees 2. PT: Stand on the UNAFFECTED side and lean across, Place my hand under the sacrum - -->Slide hand under the patients sacrum to allow space for the innominate to move around the sacrum, this creates a bridging effect 3. Force: Press towards the table along the line of the femur thorugh SI on that side don’t compress the patella 4. Positive finding: reproduction of symptoms (creating a posterior shear of the innominate bone through the femur)

Answer 64

To determine side of dysfunction and also reproduce patients symptoms Hands on ASIS and push posterior and medial force: apply downward and medial force (adduction and posterior) Another way to do it is to do one side at a time: so that also a rotational force on the innominate bone on a side to side, to differentiate one side to the other: will probably feel a difference in movement if its positive on one side Direction of force is towards sacrum and back Positive finding: reproduction of pain

Answer 65

Look for symmetry between sides

Answer 66

Hip flexors --Sit at edge of table and table up to buttocks and upper thigh and lie back down. --Take both knees to their chest. Person holds their R knee, bring the left leg down and see if it can make contact with the table. 1--If it doesn’t come down: there is tightness in the ILLIOPSOAS 2--Now we straighten the knee. If the extended knee is able to drop down then we know there is tightness in the RECTUS FEMORIS because there is now less stretch on the rectus femoris and so the hip was able to drop down when it is cancelled out. (If the hip stays up then it is only the illiopsoas that is tight.) 3. If he abducts hip then tight TFL

Answer 67

Rectus femoris tightness --Patient in supine and legs hang off the table. The good leg is flexed to the chest while the other leg hangs off the table. If the knee extends it is a sign of tightness in the rec fem. (because flexion of the opposite leg rotates the pelvis posteriorly pulling the rectus femoris) (some people do a prone knee bend test) rectus vs psoas

Answer 68

--Patient lays on their side and flexes the bottom leg for stability: Abduct and extend the upper leg with knee flexed to 90, Stabilize pelvis from anteriorly tilting, Slowly lower the upper limb. Cradle leg that you’re testing, abduct and extend bring it back to a neutral position or slightly extended. Want to see that person goes further than neutral position. ---Positive: TFL tight if they do not adduct to neutral or if drift into hip flexion when you do it.

Answer 69

Large insertion/attachment onto sacrum big player in sacral alignment Relationship with sciatic nerve it is a causative factor for buttock and leg pain Option 1: (AIF Test= adduction, IR, flexion) Supine: flex hip 90 degrees, with combined adduction and internal rotation -->Normal: at 90 degrees hip flexion expect: 20 degrees adduction; 20 degrees internal rotation Option 2: Prone: knee flexion 90 degrees, bilateral internal rotation Note symmetry of IR, pay attention to what happens to sacral alignment as you allow the legs to come out