Sacrum/Cervical Test 2 Flashcards
1
Q
Cyriax says __% of LBP attributed to SI joint dysfunction
A
Cyriax says
2
Q
Cyriax says __% of LBP attributed to SI joint dysfunction
A
Cyriax says
3
Q
Do we want to SI joint to be hypermobile or hypomobile?
A
We want the SI joint to be hypomobile because the SI Joint is designed to be a stabilizer
Want the joint to be properly aligned—we do not mobilize it to increase mobility
4
Q
When do we want the SI joint to have play?
A
labor and delivery
The pelvis have lateral movement to allow baby’s head and shoulders to come through: females designed to have increased mobility at the joint during labor and delivery
Problems occur postpartum:
PT treat postpartum women, important to look at when looking at back issues and women’s health issues. It has a different connection than any other joint.
5
Q
When is the SI joint identified in development?
A
Early in fetal development
Joint is identified at 4-5 weeks gestational age
10 weeks sacral cartilage is formed
6
Q
How is SI joint Locus for dissipating of energy in bipedal locomotion?
A
-Pelvis needs to rotate during gait: swing to HS, midstance neutral, opposite in push off
(pelvis rotate contralaterally in gait: one side in HS and the other side in pushoff)
- SI joint is the connection between the LE and the spine
- –>connection between the innominate bone (hemipelvis) has its articulation with the sacrum (the sacrum is the bottom part of the spine)
7
Q
How does Lower extremities amplify the movement of the SI Joint?
A
(Can visualize what is happening in pelvis by looking at movement of LE)
Heel strike through swing to push off:
Leg moves through swing the LE amplifies posterior rotation of innominate bone
To neutral
To push off: LE goes into extension as innominate rotates in anterior direction
8
Q
Is the SI under voluntary control?
A
SI is not under volitional control
even though muscles attach there is no activating force to move it –it happens as a secondary passive effect to movement in muscles ie from hip joint
9
Q
Do we want to SI joint to be hypermobile or hypomobile?
A
We want the SI joint to be hypomobile because the SI Joint is designed to be a stabilizer
Want the joint to be properly aligned—we do not mobilize it to increase mobility
10
Q
When do we want the SI joint to have play?
A
labor and delivery
The pelvis have lateral movement to allow baby’s head and shoulders to come through: females designed to have increased mobility at the joint during labor and delivery
Problems occur postpartum:
PT treat postpartum women, important to look at when looking at back issues and women’s health issues. It has a different connection than any other joint.
11
Q
When is the SI joint identified in development?
A
Early in fetal development
Joint is identified at 4-5 weeks gestational age
10 weeks sacral cartilage is formed
12
Q
How is SI joint Locus for dissipating of energy in bipedal locomotion?
A
-Pelvis needs to rotate during gait: swing to HS, midstance neutral, opposite in push off
(pelvis rotate contralaterally in gait: one side in HS and the other side in pushoff)
- SI joint is the connection between the LE and the spine
- –>connection between the innominate bone (hemipelvis) has its articulation with the sacrum (the sacrum is the bottom part of the spine)
13
Q
Pelvis:
Male vs Female
A
Female pelvis is broader, open outwardly with a larger pelvic rim
Male pelvis higher and narrower
14
Q
How does Lower extremities amplify the movement of the SI Joint?
A
(Can visualize what is happening in pelvis by looking at movement of LE)
Heel strike through swing to push off:
Leg moves through swing the LE amplifies posterior rotation of innominate bone
To neutral
To push off: LE goes into extension as innominate rotates in anterior direction
15
Q
Is the SI under voluntary control?
A
SI is not under volitional control
even though muscles attach there is no activating force to move it –it happens as a secondary passive effect to movement in muscles ie from hip joint
16
Q
SI Anatomy
A
Closed osteoarticular ring with three bony parts and three joints
o 3 Bones:
- -2 innominate bones
- -Sacrum
o 3 Joints:
- -2 SI joints
- -Pubic symphysis – between 2 pubic rami: Diarthroidial with symphysis in the front (SIJ)
17
Q
Pelvis: There is complete interdependence of all three joints
what happens if forces not balanced?
A
Balance of force from ground and force from top: there needs to be an interdependence between the three components of the osteoarticular ring
–ie inferior: LLD: imbalance of forces entering pelvis
–ie superior: scoliosis, lateral shift, hemivertebrae (triangulated shape of vertebra creates scoliosis)
18
Q
SI Anatomy: # of Joints
A
3 Joints:
- -2 SI joints
- -Pubic symphysis – between 2 pubic rami
19
Q
What type of joint is the pubic symphysis?
A
Diarthroidial with symphysis in the front (SIJ)
20
Q
Iliac Bone:
- shape
- concave/convex
- what cartilage
A
- Crescent shaped, very irregular with a crest lying between two furrows
(crest between furrows = tubercle sticking in the middle)—it is irregular shape (it is not flat) - Concave posterior-superiorly direction
- Lined with fibrocartilage
21
Q
Pelvis: Function of the pelvis:
A
–Bony pelvis transmits forces from the vertebral column to the lower limb:
(Bony pelvis is center point for transmitting forces)
–There is a ground reaction transmitted to the acetabulum by the head and neck of the femur
(Force comes down from the trunk–trunk that is loaded down entire vertebral column—dissipated at the top of the 2 innominate bones
2 legs equally placed on the leg, force comes up both legs and dispersed around pelvis rim)
–There is complete interdependence of all three joints
22
Q
Pelvis: How Bony pelvis transmits forces from the vertebral column to the lower limb?
A
Bony pelvis is center point for transmitting forces
23
Q
Sacrum
- shape
- cartilage
- concave/convex rule
A
has a corresponding articular facet to the part that is on the iliac/innominate bone
- Corresponds in shape with a furrow bordered by two crests: TWO crests and ONE furrow so they can interlock one top of the other—this prevents sliding of innominate on sacrum
- Lined with hyaline cartilage which is 2-3x thicker than the fibrocartilage cartilage on innominate bone
Does not truly follow the concave/convex rule
There is a depression on the sacrum that articulates with crest on innominate
24
Q
Pelvis: There is complete interdependence of all three joints
what happens if forces not balanced?
A
Balance of force from ground and force from top: there needs to be an interdependence between the three components of the osteoarticular ring
–ie inferior: LLD: imbalance of forces entering pelvis
–ie superior: scoliosis, lateral shift, hemivertebrae (triangulated shape of vertebra creates scoliosis)
25
How an issue in pelvis can be created when imbalance of muscle:
Weakness--ie gluteus medius
Tightness --ie illiopsoas
• Weakness: If there is significant atrophy or weakness on one side there will be a change in alignment
ie gluteus medius will change gait, the pull, and balance.
• Tightness: if I have tight illiopsoas on one side, it will pull anteriorly on anterior innominate on one side and not other side. If innominate is pulled on right by illiopsoas or hamstring it will passively change the alignment.
26
Pelvis: why have to evaluate strength, flexibility and structural assessment bilaterally?
o all of these can alter the joint alignment
27
Iliac Bone:
- shape
- concave/convex
- what cartilage
1. Crescent shaped, very irregular with a crest lying between two furrows (crest between furrows = tubercle sticking in the middle)—it is irregular shape (it is not flat)
2. Concave posterior-superiorly direction
3. Lined with fibrocartilage
28
Iliolumbar ligaments:
1. where does it attach (origin and insertion)
2. with what ligament does it blend
3, when does it develop
Start from TP at L4-5 levels and attach down to iliac crest
The Iliolumbar ligaments blend with the anterior SI ligament (anterior SI ligament)
Iliolumbar develops in second decade of life.
29
Which ligament only in bipedal animals?
iliolumbar ligaments in bipedal animals
– because it’s the connection from the lumbar spine to the pelvis
--It is thought that ligament itself is an out sprouting of QL: QL in the same location as the iliolumbar ligament.
30
Sacrum articular facet corresponds to what?
has a corresponding articular facet to the part that is on the iliac/innominate bone
31
Does the sacrum follow the concave/convex rule?
**Does not truly follow the concave/convex rule**
32
Ligaments
| 6
1. articular capsule
2. illiolumbar ligaments
3. sacrospinous ligament
4. sacrotuberous ligament
5. anterior SI ligament
6. Posterior SI ligament: short interosseous ligament, intermediate ligament, long posterior SI ligament
33
Can sacrotuberous ligament be palpated?
Palpable at distal attach on IT (not as deep as sacrospinous ligament)
34
What type of joint is the SI joint?
Synovial joint, Large joint – large capsule surrounds the joint
35
Iliolumbar ligaments:
Start from TP at L4-5 levels and attach down to iliac crest
The Iliolumbar ligaments blend with the anterior SI ligament (anterior SI ligament)
36
Posterior SI ligament
3 Layers: what are they
1. Short Interosseous Ligament
2. Intermediate
3. Long Posterior SI Ligament
37
Short Interosseous Ligament
- what is it
- attach
- direction of fibers
Deepest Layer of Posterior SI Ligament
Sacrum --> Ilium
HORIZONTAL FIBERS
(Interosseous SI Ligament)
(online: ilium to S1-S2)
38
Intermediate Ligament
- what is it
- attach
- direction of fibers
Layer of Posterior SI Ligament
middle of ilium to sacrum:
and occupy most of the space of the joint
HORIZONTAL FIBERS
(overlies the whole back of the joint)
39
Long Posterior SI Ligament
- what is it
- attach
- direction of fibers
- purpose
Layer of Posterior SI Ligament
VERTICAL FIBERS
[blend in combination with sacrotuberus and sacrospinous ligaments]
* increases integrity of the SI joint
(online: long posterior sacroiliac ligament from PSIS to transverse tubercle of S3-S4. It is continuous laterally within medial edge of sacrotuberous ligament.)
40
Pubic Symphysis
1. type of joint
2. disc
3. ligaments
1) Secondary cartilaginous joint – Amphiarthrosis
Symphysis (one of the few symphysis joints that we deal with
2) Interosseous Ligament-Fibrocartilaginous Disc
Maintained with an interosseous ligament with a small fibrocartilaginous disc that sits between it
3) Ligaments go form one side of the symphysis to the other
Anterior, Posterior, Superior
41
Anterior SI ligament
1) where is it?
2) structure?
3) purpose?
4) pathology?
1) Anterior surface of SI Joint
2) Thin and broad
3) Supports the sacrum between 2 innominate bones (like a sling)--
* has connections to multifidus muscle
4) Pathology
- -can be injured when joint is displaced
- pain fibers
42
what muscle does anterior SI ligament have connections to?
multifidus muscle
43
Posterior SI ligament
3 Layers
1. Short Interosseous Ligament
2. Intermediate
3. Long Posterior SI Ligament
44
Short Interosseous Ligament
Deepest Layer of Posterior SI Ligament
Sacrum --> Ilium
HORIZONTAL FIBERS
(Interosseous SI Ligament)
45
Intermediate Ligament
Layer of Posterior SI Ligament
middle of ilium to sacrum:
and occupy most of the space of the joint
HORIZONTAL FIBERS
(overlies the whole back of the joint)
46
What does sacrum function as compared to lumbar vertebrae?
Sacrum functions as atypical lumbar vertebrae
--Lowest point of the spine
---Don’t work like a traditional lumbar vertebra but similar function to what we see happening in the lumbar spine
47
Pubic Symphysis
1. type of joint
2. disc
3. ligaments
1) Secondary cartilaginous joint – Amphiarthrosis
Symphysis (one of the few symphysis joints that we deal with
2) Interosseous Ligament-Fibrocartilaginous Disc
Maintained with an interosseous ligament with a small fibrocartilaginous disc that sits between it
3) Ligaments go form one side of the symphysis to the other
Anterior, Posterior, Superior
48
what type of movement occurs at the SI joint?
Movement of SI Joint is passive in response to muscle activity from both above and below
49
ILA
- what it is considered to be
- what it tells us
Inferior lateral angle
--have a dip going down into center to the coccyx, inferior lateral angle (ILA): considered to be atypical TP
--Can look at direction of movement of sacrum, use ILA as markers to tell us what is happening in terms of movement and function of sacrum
50
What causes movement at the SI joint
Movement of SI joint is passive in response to muscle activity from both above and below
-->movement in SI joint is related to a passive function that occurs secondary to LE muscle or abdominal muscle movement
51
How do we strengthen the SI joint?
There is no way to do strengthening for this joint: cannot do something that isolates function for this joint because there is nothing that exists
The programs we do for strengthening (to reinforce pelvis girdle, pelvic floor) – the only way to reinforce pelvic girdle or pelvic floor is to do abdominal stabilization—same program you do for lumbar spine
Balance hip – length and strength
52
SI Joint: Passive Reaction to which 7 groups of hip muscles?
1. Abdominals
2. Gluteus maximus
3. Iliacus
4. Piriformis
5. Erecti Spinae
6. Multifidus
7. Coccygeus
53
What does sacrum function as compared to lumbar vertebrae?
Sacrum functions as atypical lumbar vertebrae
--Lowest point of the spine
---Don’t work like a traditional lumbar vertebra but similar function to what we see happening in the lumbar spine
54
Biomechanics of SI joint (5)
1. Sacrum functions as an atypical lumbar vertebrae
2. SI joints function as atypical facet joints
3. Functionally innominate bone viewed as LE bone
4. SI joint is the junction between vertebral axis and LE
5. Movement of SI Joint is passive in response to muscle activity from both above and below
55
what type of movement occurs at the SI joint?
Movement of SI Joint is passive in response to muscle activity from both above and below
56
ILA
- what it is considered to be
- what it tells us
Inferior lateral angle
--have a dip going down into center to the coccyx, inferior lateral angle (ILA): considered to be atypical TP
--Can look at direction of movement of sacrum, use ILA as markers to tell us what is happening in terms of movement and function of sacrum
57
What causes movement at the SI joint
Movement of SI joint is passive in response to muscle activity from both above and below
-->movement in SI joint is related to a passive function that occurs secondary to LE muscle or abdominal muscle movement
58
How do we strengthen the SI joint?
There is no way to do strengthening for this joint: cannot do something that isolates function for this joint because there is nothing that exists
The programs we do for strengthening (to reinforce pelvis girdle, pelvic floor) – the only way to reinforce pelvic girdle or pelvic floor is to do abdominal stabilization—same program you do for lumbar spine
Balance hip – length and strength
59
SI Joint: Passive Reaction to which 7 groups of hip muscles?
1. Abdominals
2. Gluteus maximus
3. Iliacus
4. Piriformis
5. Erecti Spinae
6. Multifidus
7. Coccygeus
60
SI Joint: Passive Reaction to which 7 groups of hip muscles?
1. Hip Flexors attach to crest of ilium (AIIS) – rectus, illiopsoas
2. Hip Abductors – glut medius attach under crest, gluteus max top of crest posteriorly
3. Hip Adductors – pubic ramus
4. Rotators – sacrum
5. Rectus Abdominus – superior pubic ramus
6. Long Erector Spinae – sacrum
7. Small rotators – (l5-S1, L4-S1) rotators, multifidus – sacrum
Pelvis floor – inferior pubic ramus, around and underneath to IT, inferior part that stabilizes the most inferior section of the pubis
61
SI Joint: Passive Reaction to
| Pelvic FLoor
inferior pubic ramus, around and underneath to IT, inferior part that stabilizes the most inferior section of the pubis
62
SI Joint: Passive Reaction to
| Hip Adductors
pubic ramus
63
SI Joint: Passive Reaction to
| Hip Abductors
glut medius attach under crest
gluteus max top of crest posteriorly
64
Effect of Piriformis on SI Joint
1. attachments
2. important things about it
1. lateral inferior side of sacrum-->
to greater trochanter
* **connection to sciatic nerve
* **large piece related to alignment of sacrum
---attachment takes up half of sacrum
65
SI Joint: Passive Reaction to
| Rectus Abdominus
superior pubic ramus
66
SI Joint: Passive Reaction to
| Long Erector Spinae
attach sacrum
67
SI Joint: Passive Reaction to
| Small Rotators
(l5-S1, L4-S1) rotators, multifidus – sacrum
68
Sacral Cornu
1. what is it?
2. what articulates here?
3. what part of the triangle is it?
4. what joint it forms
1. tip of sacrum that becomes articulation for coccyx
2. Articulation for coccyx
3. This is the apex of the triangle (because its inverted)
4. Sacrococcygeal joint
69
What influences the pelvis in standing position?
pelvis influenced by both structural and functional asymmetry of LE’s
**force comes up from LE
anatomical or functional LLD --->uneven as we have ground force coming up one side vs the other
Ambulate with LLD create pelvic obliquity which create a dysfunction in the pelvis: rotational or elevation component
**important to adjust LLD because pelvic obliquity causes lumbar spine side-bend rotation with scoliosis which works its way up thoracic to cervical spine—creates long term low back and pelvis issues
70
why is it important to adjust LLD?
**important to adjust LLD because pelvic obliquity causes lumbar spine side-bend rotation with scoliosis which works its way up thoracic to cervical spine—creates long term low back and pelvis issues
71
What influences the pelvis/sacrum in SEATED position?
POSITION OF SPINE and TENSION IN TRUNK
Innominate stabilized by weight on ischial tuberosity, influenced by position of spine and tension in trunk
72
• Sacral base
another name for it
promintory of the sacrum
73
• Inferior lateral angle
what attaches to it
what is its structure
o Where gluteus maximus attaches on the ILA
o Comes down on an oblique angle then sacrum changes direction at ILA
74
• Sacral Hiatus
what/where is it?
o Opening at the bottom
o Indentation
o Space right above coccyx
75
Sacral Cornu
(tip of sacrum that becomes articulation for coccyx)
o Articulation for coccyx
o Sacrococcygeal joint
o This is the apex of the triangle (because its inverted)
76
Which scoliosis pull on pelvis in seated?
Changes we see in SI joint and pelvis is influenced by position of spine and tension in trunk (scoliosis that is STRUCTURAL not functional will continue to pull on pelvis)
77
Why is pelvis stabilized in prone?
pelvis supported by pubic symphysis and ASIS, sacrum responds to trunk
Stabilizing pelvis because lying on ASIS and pubic symphysis (unless you have a belly)
Sacrum responds to the trunk because stabilizing the pelvis
78
What influences the pelvis in seated position?
Innominate stabilized by weight on ischial tuberosity, influenced by position of spine and tension in trunk
79
Why do we evaluate in supine twice?
go into supine twice in the evaluation (because of the osteopathic sequence of how we should treat, because things will change)
1. Pubic Symphysis Dysfunction
- iliac crests, pubic symphysis, inguinal ligament, SI provocation
2. IS dysfunction (ilium on sacrum)
- ASIS, LLD, Long sitting test
80
What influences the pelvis/sacrum in PRONE position?
SACRUM RESPONDS TO TRUNK
Pelvis supported by pubic symphysis and ASIS, sacrum responds to trunk
81
What influences the pelvis/sacrum in SUPINE position?
INNOMINATE (iliums) respond to tension below
stabilized by WB on table, innominate respond to tension from below
82
Seated: what causes changes we see in SI joint and pelvis?
Sitting on IT’s so basically stabilizing pelvis
Changes we see in SI joint and pelvis is influenced by position of spine and tension in trunk (scoliosis that is STRUCTURAL not functional will continue to pull on pelvis)
Abnormal muscle spasm, tension, tautness muscles coming from trunk to pelvis will influence sitting positon
83
Which scoliosis will we see in seated?
Changes we see in SI joint and pelvis is influenced by position of spine and tension in trunk (scoliosis that is STRUCTURAL not functional will continue to pull on pelvis)
84
Why is pelvis stabilized in prone?
pelvis supported by pubic symphysis and ASIS, sacrum responds to trunk
Stabilizing pelvis because lying on ASIS and pubic symphysis (unless you have a belly)
Sacrum responds to the trunk because stabilizing the pelvis
85
What influences innominate in supine position?
Supine: stabilized by WB on table, innominate respond to tension from below
change in alignment of pelvis from tension in LE --ie if contracture and get asymmetrical alignment from tension
WB is on innominates on the table, get changes in alignment of pelvis from tension of the LE’s
Ex: hip flexion contracture on one side and lying on table and leg held up in Thomas test position will cause asymmetrical tension on the pelvis
We repeat some of the positions
86
Why do we evaluate in supine twice?
go into supine twice in the evaluation (because of the osteopathic sequence of how we should treat, because things will change)
1. Pubic Symphysis Dysfunction
- iliac crests, pubic symphysis, inguinal ligament, SI provocation
2. IS dysfunction (ilium on sacrum)
- ASIS, LLD, Long sitting test
87
Superior pub:
If we were to have 1 side of superior pub higher than the other (looking at the person):
R one that is higher = R superior pub
88
Anterior Innominate
--right anterior innominate: anterior, left lateral and right lateral views:
anterior rotation
Right anterior Innominate:
Anterior View:
- -Right ASIS inferior to left ASIS
- -Right PSIS superior to left PSIS
Lateral view from Left
--ASIS and PSIS equal
Lateral View from right
--AISIS inferior to PSIS
89
Posterior Innominate
posterior rotation
Right posterior Innominate:
Anterior View:
- -Right ASIS superior to left ASIS
- -Right PSIS inferior to left PSIS
Lateral view from Left
--ASIS and PSIS even
Lateral View from right
- -ASIS superior
- -PSIS inferior
90
Inflare
what axis?
medial rotation around the Y axis
91
Inflare
Anterior, Posterior, Lateral views
medial rotation around the Y axis
--Possibility of rotational dysfunction of the pelvis
Anterior View: ASIS on the side of the rotation closer/medial to the umbilicus than the ASIS of contralateral side
Posterior View: PSIS on side of rotation further/more lateral from center of sacrum compared to contralateral PSIS
Lateral View: wont show anything
92
Outflare
Anterior, Posterior, Lateral views
Lateral rotation around the y axis
Anterior view
– ASIS is laterally displaced from umbilicus compared to other side
Posterior view
– PSIS medial to sacrum compared to contralateral side
93
Are inflare/outflare common?
Don’t see inflare and outflare often – usually correct themselves
Thought to be an imbalance of hip rotators (pulls innominate bone one way or the other)
Usually fix when you address the length of the muscle
You will see them and they disappear
94
Upslip
1. another name
2. WB vs NWB
3. what landmark and position to analyze
4. anterior, lateral, posterior view
5. cause
1. also called a “superior ilial sheer” or “superior innominate sheer”
2. **only see in NWB**
3. --look at IT in prone--
4. Anterior view – ASIS superior
Lateral view – unless there is a rotation coupled with it – it wont look different because it’s level
Posterior view – PSIS is superior
5. Unilateral stress with weight coming up one side that displaces your pelvis
95
Upslip: crest heights
Will it be different in WB or in NWB?
Iliac crest will be high on the side of the superior displacement
In NWB because it is a dysfunction of the pelvis, it will appear to be uneven
Not in weight bearing because when you’re in WBing position, if your leg lengths are the same, and the leg is planted on the ground, the pelvis will level out and your spine will take up the slack (back accommodates for it)
96
How to use IT to see if upslip?
Ischial Tuberosity:
When you look at this, and examine the patient in prone, their ischial tuberosity will also be superiorly displaced because entire hemipelvis will be superiorly displaced
97
What causes an upslip?
Unilateral stress with weight coming up one side that displaces your pelvis
Not a normal situation for pelvis: these only happen secondary to trauma , “traumatically induced”
-->Classic example – step into a pothole, ground force goes up your pelvis causing a superior displacement
-->Not paying attention and theres one extra step – land really hard
98
Downslip
1. another name
2. what landmark and position to analyze
3. anterior, lateral, posterior view
4. cause
1. Inferior ilial sheer or inferior innominate sheer
2. Look at relationship of ITs
3.
Anterior view – ASIS inferior
Iliac crests – iliac crest inferior
Posterior view – PSIS inferior
Lateral view – unless there is a rotation coupled with it – it wont look different because it’s level
4.Trauma-rare: mode of action is unusual and because when you stand on your feet, if one side is pushed down and walk run or pound on that leg – it self correct
99
Is downslip common?
Traumatically induced injury: rarely ever see these because mode of action is unusual and because when you stand on your feet, if one side is pushed down and walk run or pound on that leg – it self correct
If it is really jammed – then it has to be corrected but it is hard to do
Etiology: Example: Somebody thrown from horse and got caught in stirrup – pulls one leg down/Falling form tree – gets stuck in vine or tree and hung from one leg
See more with female patient because of laxity – depending on cycle or pregnant
Self corrects if you just have them hop in standing because of WBing forces
100
Sacrum Axes
1. Superior transverse axis
2. middle transverse axis: Most common – horizontal axis: Around S3: Associated with traditional movement of the sacrum
3. Inferior transverse axis
4. Right oblique axis: diagonal axis: Right promontory and travels obliquely across sacrum and comes out on L ILA
5. left oblique axis: diagonal axis: Left promontory (sacral base) and travels to right ILA
101
Where is the middle transverse axis?
Most common – horizontal axis: Around S3: Associated with traditional movement of the sacrum
102
Which sacrum axis related to respiration?
Superior transverse axis
--axis at which we find motion related to sacrum that is connected to respiration
Inhalation: sacrum is going to come backwards (flatten the lordosis)
Exhalation: sacrum is going to come forward [when to apply P/A]
103
Nutation
1) what is it?
2) where does promontory move?
3) where does apex/cornu move?
4) what happens to pelvic brim?
5) what happens to pelvic outlet?
6. posterior view of sacrum and cornu
1) Anterior rotation around middle transverse axis, S2,3,
2) where promontory moves anteriorly and inferiorly --Movement anteriorly around Middle transverse axis: promontory/sacral base moves anteriorly,
3) apex (cornu) moves posteriorly
4) Pelvic brim is decreased and
5) pelvis outlet is increased
6. Looking from the back: sacrum drops forward and down (anterior inferior),
Cornu moves posterior superior
104
Counternutation
1) what is it?
2) where does promontory move?
3) where does apex/cornu move?
4) what happens to pelvic brim?
5) what happens to pelvic outlet?
posterior nutation: (what we call extension) posterior rotation around the middle transverse axis
Promontory moves superiorly and posteriorly
Cornu moves inferior anterior.
Pelvic brim is increased and
pelvic outlet is decreased
105
Are nutation and counternutation normal movements?
Nutation and Counternutation are normal movements – happen when you breathe
Bring both legs up together to chest– counternutation
Extension – nutation
Normal physiological movements
106
Right on Right
rotate on an oblique: right rotation around a right oblique axis
Anterior rotation/torsion
*related to anterior surface of what would be the vertebral body: Forward rotation moving toward the anterior surface of vertebra
Considered to be a normal physiological movement (Happens in the process of the unilateral stance side)
**problem is when get stuck in the position whether it is a normal or abnormal movement.
R on R: deep L base and a posterior R ILA
107
What type of pelvic movement in gait?
1. heel strike, foot flat, toe off = pelvis rotates: as you do that, sacrum rotates on the oblique axis with every step (doesn’t do nutation counternutation which is symmetrical): this allows for asymmetrical movement
2. Each HS get anterior torsion of sacrum
108
what part of gait anterior torsion?
Happens in the process of the unilateral stance side
109
Left on Left:
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
110
Right on Left
Right rotation around left oblique axis is a posterior torsion,
and it is a non physiological movement (posterior torsion)
111
Sacral Extension
check this
unilateral superior sacral shear
Sacrum slides up and back
SACRAL BASE moves POSTERIOR and SUPERIOR
and the ILA moves SUPERIOR:
112
Sacral Flexion
check this
Inferior Unilateral Sacral Sheer
Sacrum sheers in an inferior direction, it slides along the facet joint
SACRAL BASE goes ANTERIOR and INFERIOR
ILA: moves INFERIOR
113
Opening and closing osteoarticular ring:
Nutation: superior closes, inferior opens
Counternutation: superior opens, inferior closes
114
Childbirth: nutation or counternutation?
Nutation
115
Gait Cycle
--Iliosacral Movement
each innominate rotates anteriorly and posteriorly during the walking cycle
**Start from mid stance in neutral, as swing leg the innominate bone moves posterior on side that we’re swinging, then rotate as get to midstance, and then anterior rotation until push off
116
Gait Cycle
--Sacral Movement
The axis of rotation originates on the side of the weight bearing leg, rotation towards the WB 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.
117
Gait at midstance: sacrum/ilium
At midstance point, the axis of rotation and innominate bone goes from posterior to anterior rotation, innominate neutralizes in midstance because about to reverse, axis of rotation of sacrum is on side of WB leg (midstance leg) and sacrum will rotate anteriorly.
Right on right on midstance right leg.
118
Innominate in Gait
- Initial Swing
- Midstance
- HS
Initial swing – innominate rotates posterior
Midstance – neutral
push off– innominate rotates anterior
119
When sacrum rotates, does sidebending occur?
*** When sacrum rotates it also does contralateral side bending***
when the sacrum rotates to the right, simultaneously it does left side bending
120
How does sacral/lumbar rotation/sidebending relate?
***When sacrum rotates, the lumbar spine rotates to the opposite side/ when sacrum sidebends, lumbar spine sidebends to the opposite side***
It allows us to be upright
Sacrum rotates to side of concavity in the lumbar spine
121
gait:
Iliosacral Movement
Sacral Movement
Iliosacral Movement
--Each innominate rotates anteriorly and posteriorly during the walking cycle
Sacral Movement
--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
122
Baer’s Point
2 ideas
Anterior location that is above the SI joint
Dutton: 1/3 of the way down on the diagonal that goes between ASIS and the pubic symphysis (1/3 of the way down on the line, it is close to the front of the SI joint)**
=Gives more a superior part of the joint
Minel: 2 inches from umbilicus (more medially) between umbilicus to ASIS
=Gives you more inferior part of joint
123
Iliopsoas Muscle
palpate
Proximal attachment to TP’s and vertebral bodies of T12-L1-L5
Palpate medial and deep to ASIS and at insertion on lesser trochanter
124
PSIS
palpate
Locate iliac crests, come down on a 30-45 degree angle
Roll thumbs underneath
125
Sacral base palpate
from PSIS drop in and now on sacral base
126
What is sacral sulcus?
Sacral sulcus is relationship between sacral base and PSIS
127
Palpate ILA
1. Hiatus: finger goes in and find SP and dip in to get the hiatus
2. If move lateral from hiatus to get ILA-can have finger posterior or inferior to ILA
128
palpate piriformis
Go from ILA to trochanter to find piriformis, take finger in and trace piriformis and note is feel spasm
129
Palpate sciatic nerve
Look at relationship PSIS and IT find the space to dip into for the sciatic nerve—can find path by the indentation you can get into—area of foramen as it starts to course down
130
Palpate sacrotuberous ligament
Find IT, drop in medially, and feel the sacrotuberous ligament
131
Piriformis muscle
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
132
Sacral sulcus
palpate
what it tells us
Space between sacral base and PSIS:
tells us about relationship between innominate and sacrum
133
What happens to sacral sulcus if innominate rotated poseriorly?
If innominate is rotated posteriorly: PSIS and sacrum relationship increases and get a deeper sulcus
134
What happens to sacral sulcus if innominate rotated anteriorly?
If innominate is rotated anteriorly, PSIS and sacrum relationship diminishes and get smaller sacral sulcus
135
Palpate sacral hiateus
travel down sacrum and in area of S5 there is an indentation before the coccyx
S5 – feel an indentation
136
palpate ILA
| why palpate posterior and underneath?
Move laterally, 1-1/2 inch from sacral hiatus, you’re on ILA
rotation detect on posterior aspect of ILA
sidebending we put finger underneath ILA (feel for shear)
137
quadratus lumborum
posterior iliac crest and iliolumbar ligament
--> 12th rib and TP of L1-L5
***Sensitivity at inferior aspect of last rib indicates spasm or muscle contraction
138
Iliolumbar ligaments:
Indirectly palpate through the erecti spinae along the superior, medial aspect of the iliac crests
Sensitivity implies involvement
139
Standing posture
scoliosis/kyphosis
in WB: can see functional scoliosis
upslip/downslip cannot create LLD in WB , so the accommodation that occurs for change in elevation of the pelvis will be a functional scoliosis because it pulls on the lumbar spine
140
Sitting Posture and Ability to Sit
Asymmetrical sitting posture: patients with SI issues have a hard time sitting and don’t like sitting involved side, see them with their legs crossed
141
Sit to stand
a posterior rotation to an anterior rotation as I go from sit to stand:
as my pelvis has to rotate to get up in movement from sit to stand, then one side is stuck and painful for patient to transition and therefore the transition of sit to stand will be a complaint of the patient in addition to sitting
142
Gait
abnormalities in gait pattern?
(2)
when in gait get pain?
1. decreased stride length on side of affected SI
2. antalgic gait
PAIN:
pain on unilateral stance
(HS-->midstance)
pain if stuck b/c R on R and
L on L in gait
143
Why watch facial expression for SI discomfort?
SI derangement is very uncomfortable
Different kind of pain than discogenic patient, the pain is very deep and painful with daily activities ie sit, sit to stand, walk
144
Pseudo Sciatica
piriformis attach on inferior lateral sacrum,
sciatic nerve pass under/near piriformis
rotation that can occur in sacral and innominate dysfunction
SI dysfunction can create tension on area sciatic nerve passes through or under piriformis
=distal part of sciatic nerve under piriformis
**McKenzie WONT help
145
LBP
where will the LBP be if it is SI?
intimate relationship between the lumbar spine and the SI creates LBP
the LBP will be centered further down (lumbar point to low back, SI point to SI deep inside or buttock pain)
146
Pesudotrochanteric bursitis
distal piriformis attach at greater trochanter --need to tx SI
147
Inguinal ligament/ Groin pain:
SI
change in relationship of where the inguinal ligament attaches based on rotation of innominate bone
148
Buttock pain
SI:
2 causes
1. Related to piriformis, sciatic nerve
| 2. Glut spasm secondary to change in the alignment
149
Pain with prolonged sitting, standing, walking or transitions of positions
SI
these are classic SI complaints
150
Pelvis floor pain
SI
1. Attachments underneath onto pubic ramus, inferior aspect, sacrum
(ie Pubococcygeus)
2. Can get pelvic floor dysfunction as well
151
Classic history for SI dyssfunction
| 8
1. Direct trauma to the area:
2. Low back injury secondary to lifting with flexion and rotation
3. Unexpected heelstrike
4. Asymmetrical sitting/standing posture:
5. Asymmetrical sleeping posture
6. Pregnancy
7. Childbirth
8. Menstrual cycle
(Menstruation and ovulation there is more laxity in pelvis)
152
Pelvic girdle questionnaire
4 point scale
20 items
very typical
- how you dress yourself
- can you stand for less than 10 minutes
- bend
- sitting/parameters for sitting
- things that are directly related to SI rather than using a generic back questionnaire
- can use it as an outcome measure if you know they have pelvic issue
developed in Norway – more in tuned to this issue
good scale, high ICC
153
SI
Typical Pain Patterns (3)
1. Pain centered over the SI joint
- -Use the one finger and tell me where it is, patients put their finger into the SI – not diffuse, can really pinpoint it for you
- One finger test in literature =“Fortin finger test”
2. Pseudo SI pattern
3. Diffuse pain from buttock radiating to posterior LE
- -Rarely see pain go below knee joint, usually just buttock and if it does radiate it goes down posterior aspect of thigh
154
Structural Examination
| 4
1. Static pelvic examination (ART)
- --Asymmetry
- --ROM abnormality
- --Tissue texture alteration
2. Use the dominant eye
3. Have the patient appropriately disrobed
4. Leg length discrepancy
functional vs anatomical
155
Static Pelvic Examination
ART
- --Asymmetry
- --ROM abnormality
- --Tissue texture alteration
156
MOBILITY TESTS AND EXAMINATION
| Standing: what we do?
6
* in stand: pelvis influenced by both structural and functional asymmetry of LE’s
1. Asymmetry structural exam (crest heights, ASIS, PSIS)
2. Forward Flexion Test
3. Backwards Bending Test
4. Marching Test
5. Weight Bearing Provocation
6. Lumbar Movement
157
STANDING
Asymmetry
Structural exam (crest height, ASIS, PSIS, anterior, posterior, lateral views)
158
STANDING
Forward Flexion Test
1. The test
2. Normal
3. Positive
INNOMINATE ON SACRUM
Innominate rotation round the sacrum and it is an IS problem:
1. Eyes level to PSISs, fingers under the PSISs.
DO NOT stabilize pelvis because we want it to move following the lumbar spine.
Patient stands with knees extended. Ask patient to roll down as though you are going to touch your toes
2. Normal: both PSIS rise forward simultaneously and equally
3. Positive finding: one side *(PSIS) moves first and further*: ultimately more superiorly/cranially displaced that side is positive = IS PROBLEM
159
STANDING
Backward Bending Test
1. The test
2. Normal
3. Positive
SACRUM ON INNOMINATE: SI Issues
1. PT hands on sacral base (drop in from PSIS); pt hands on butt and backwards bend
- Increase lordosis, so sarcum should dip into kyphosis
3. Normal: both of PT’s thumbs dip forward simultaneously and symmetrically
4. Positive: *sacral base remain posterior* and not drop anterior on one side (=dysfunction side)
160
STANDING
Stork (marching) test
1. The test
2. Normal
3. Positive
INNOMINATE ON SACRUM
innominate rotation round the sacrum and it is an IS problem
1. NWB side: PT has one thumb under PSIS and other thumb on ipsilateral sacral base
Instruct patient to march in place: 90-90 hip-knee flexion
2. Innominate bone rotate posterior in relation to the sacrum: feel PSIS drop down and back as the pt comes up into hip and knee flexion
3. Positive: *PELVIS SHEAR UP*,
PT feel stiffness in pelvis: PSIS grabbed cranially and not drop down, whole unit come up b/c innominate cannot rotate normally around the sacrum
161
STANDING
Weight Bearing Provocation
1. The test
2. Normal
3. Positive
SI DYSFUNCTION
1. 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
***no lumbar side bending/rotation bc want to rule out lumbar
3. Positive finding: reproduction of pain
162
STANDING
Lumbar Movement
1. The test
2. Normal
3. Positive
Already done this as a part of lumbar exam
Flexion, extension, sidebending, rotation
Incorporate findings into differential diagnosis to figure out patient problem
163
STANDING
which tests for IS?
1. Forward Bend
2. Marching
[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.]
ALSO THE SECOND SUPINE
164
STANDING
which test for SI?
1. Backwards bending test
2. SEATED Foraward flexion test
[When we’re looking at backward bending in standing we are looking at sacrum moving on the innominate bone, sacrum either moving forward or its inability to move forward and its an SI problem. \]
165
MOBILITY TESTS AND EXAMINATION
| Seated:
what we do?
2
1. Asymmetry in static position
| 2. Sitting Forward Flexion Test
166
SEATED
Sitting Forward Flexion Test
1. The test
2. Normal
3. Positive
SI Issue
1. PT at eye level w/ dominant eye, fingers underneath PSIS, pt seated end of table with feet supported: "Drop your head, curl down, drop your arms between your legs"
Normal: PSIS rise superior direction simultaneously
– same finding as the standing forward bending test
***pt WB ITs, movement from lumbar spine: reverse lordosis and take up slack: innominate bones move
Positive: one PSIS will move first and further = SI ISSUE
167
SEATED
What influences pelvis/SI in seated position?
POSITION OF SPINE and TENSION IN TRUNK
Innominate stabilized by weight on ischial tuberosity, influenced by position of spine and tension in trunk
168
Difference in results of forward bending test:
Standing vs Sitting
Sitting position: positive finding is indicative of issues in the SI Joint
Standing position: positive findings in standing are indicative of IS joint
169
SEATED
Why is seated FB test indicative of SI issue?
pt WB ITs, movement from lumbar spine: reverse lordosis and take up slack: innominate bones move
170
SEATED
R/O Fx
seated/prone
1. how to test for fx
2. positive
3. what to do if positive
1. Palpate all areas of the sacrum and SI joint, use moderately deep pressure: just enough to contact the bone
2. Ask them to point to painful spot with one finger: classic sign for fracture
POSITIVE: localized, point tenderness
Bone bruise also tender but don’t jump off table with it, xray is worth it to make sure ok
Send patient for an x-ray
171
MOBILITY TESTS AND EXAMINATION
| SUPINE #1: what we do?
6
PUBIC SYMPHYSIS DYSFUNCTION
1. Iliac Crests
2. Pubic Symphysis
3. Inguinal Ligament
4. SI Provocation
172
SUPINE #1
Iliac Crests
1. The test
2. Normal
3. Positive
why is supine different from WB?
1. supine NWB position: compare crest heights
3. UPSLIP: change in crest heights in NWB position (get suspicious issue is pelvis and not LLD)
Muscle Spasm: Occasionally you will find muscle contraction /muscle spasm that pull innominate bone upward (ie QL spasm)
Findings different from WB --> when stand on ground, both legs will be even on the ground and pelvis will look level, but curve in lumbar spine to accommodate for the fact that the pelvis will be pushed up
PUBIC SYMPHYSIS DYSFUNCTION
173
SUPINE #1
Pubic Symphysis
1. The test
2. Normal
3. Positive
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
PUBIC SYMPHYSIS DYSFUNCTION
174
SUPINE #1
Inguinal Ligament
1. The test
2. Normal
3. Positive
In groin line, looking for tenderness/tension between sides
PUBIC SYMPHYSIS DYSFUNCTION
175
SUPINE #1
SI Provocation
1. The test
2. Normal
3. Positive
look to see if discomfort at the SI joint : Anterior/Posterior SI joint Stress Test
Can be done 2 different ways:
COMPRESSION: separate ASIS anteriorly to create compression at the SI: cross my arms to push ASIS laterally to compress SI
DISTRACTION: 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
PUBIC SYMPHYSIS DYSFUNCTION
176
Why find upslip in supine and not in WB?
Findings different from WB --> when stand on ground, both legs will be even on the ground and pelvis will look level, but curve in lumbar spine to accommodate for the fact that the pelvis will be pushed up
177
COMPRESSION: component of SI provocation
1. pt position
2. Test
3. what we are looking for
1. 1st supine
2. separate ASIS anteriorly to create compression at the SI: cross my arms to push ASIS laterally to compress SI
3. see if discomfort SI joint (pubic symphysis dysfunction)
PUBIC SYMPHYSIS DYSFUNCTION
178
Distraction: component of SI provocation
1. pt position
2. Test
3. what we are looking for
1. 1st supine
2. 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
3. see if discomfort SI joint (pubic symphysis dysfunction)
PUBIC SYMPHYSIS DYSFUNCTION
179
MOBILITY TESTS AND EXAMINATION
| Prone: what we do?
10
SACRAL DYSFUNCTION
1. Sacral Position
2. ILA
3. LLD
4. Observe gluteal tone
5. Palpate ITs
6. Tension on sacrotuberous ligament
7. Palpate PSIS heights
8. Evaluate lumbar curve
9. Spring Lumbar Curve
10. Spring Sacrum
180
PRONE
Sacral Position
1. The test
2. Normal
3. Positive
SACRAL DYSFUNCTION
Evaluate sacral base: fingers on PSIS and move to sacral base
compare depth on both sides
181
PRONE
ILA
where to palpate it?
SACRAL DYSFUNCTION
move laterally from sacral hiatus
Fingers posterior to ILA: see of anterior/posterior rotation
Fingers under ILA: inferior/superior
182
PRONE
LLD
why diff than supine?
SACRAL DYSFUNCTION
Prone: Pelvis supported by pubic symphysis and ASIS, sacrum responds to trunk
**prone LLD is a function of how the sacrum is located between the two innominate bones **
supine LLD as a function of innominate bone and as a function of anatomical leg length
they don’t have to be the same.
183
PRONE
Observe gluteal tone
what are we looking for? why?
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
184
PRONE
Palpate ITs
what are we looking for? why?
SACRAL DYSFUNCTION
note a height difference from one side to the other
=true upslip and half of the pelvis has actually slid up: would find IT higher on the side of the upslip
185
PRONE
Sacrotuberous ligament tension
What are we looking for?
SACRAL DYSFUNCTION
Slide medially off IT and feel the ligament next to your hand
Upslip: IT elevated and sacrutuberous ligament mushy b/c IT-->sacrum
= on slack
186
PRONE
PSIS Heights
SACRAL DYSFUNCTION
Don’t know if higher or lower is the significant finding so just note it at this point
187
PRONE
Evaluate Lumbar Curve
1. what view
2. normal
3. abnormal
SACRAL DYSFUNCTION
1. Lateral View
2. ==>Should see a lordosis
3. ==>Some people may have a flattening due to spasm or bony alignment changes
188
PRONE
Spring Lumbar Curve
1. The test
2. Normal
3. Positive
SACRAL DYSFUNCTION
1. Hand on, spring from L5-L1 vertebrae by vertebrae
2. If increase or normal lordosis should feel nice springing
3. If flattened lordosis feel decrease springing and it feels stiff
189
PRONE
Spring Sacrum
1. The test
2. Normal
3. Positive
SACRAL DYSFUNCTION
1. now the hand is sitting over the sacrum
2. normal give / moves symmetrically on both sides
3. Note: PAIN, not normal movement
190
If there is a unilateral sheer on right and the sacrum goes into flexion on right, ILA will move inferiorly
If there is a unilateral sheer on right and the sacrum goes into flexion on right, ILA will move inferiorly
191
Influence on pelvis/sacrum in prone?
SACRUM RESPONDS TO TRUNK
Pelvis supported by pubic symphysis and ASIS, sacrum responds to trunk
192
Supine #2
purpose
IS DYSFUNCTION
193
Supine #1
purpose
PUBIC SYMPHYSIS DYSFUNCTION
194
MOBILITY TESTS AND EXAMINATION
Supine #2
(3)
1. ASIS
2. LLD
3. Long Sitting Test
IS DYSFUNCTION
195
SUPINE #1
ASIS
1. The test
2. Normal
3. Positive
compare, use dominant eye
IS DYSFUNCTION
196
SUPINE #1
LLD
true anatomical vs functional
how can we find combination of anatomical and functional leg length discrepancy on the same side?
IS DYSFUNCTION
POSTERIOR INNOMINATE: functional LLD: leg shorter
=It is a functional change to accommodate for a true anatomical change:
vs 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
197
SUPINE #1
Long Sitting Test
1. The test
2. Normal
3. Positive
IS DYSFUNCTION
***this is only for functional LLD***
1. supine position, pt told to level pelvis: bend knees in hooklying lift pelvis and drop back down to table, allow to straighten out legs.
Compare LE lengths at medial malleoli
pt longsit from supine
2. NORMAL: leg length equal in supine and remains equal in long sitting position
3. 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 (ie b/c posterior innominate)
{**False negatives/positives: Weak abdominals, uneven hamstring length**}
198
Why the supine #2 Long Sitting Test Works?
If 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 )
199
FABERE (Patrick) Test:
Rationale:
Test:
SI vs. Hip
RATIONALE: differentiate between hip joint and sacroiliac joint pain
TEST: 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
HIP = If figure of four hurts we suspect the hip
SI = if one hand on the pelvis with the other compressing on the knee makes the pain more intense we suspect the SI joint
200
Prone Knee Bending (Nachlas)
Rationale:
Test:
RATIONALE: L3 NR
TEST: pt prone, flex knee so heel approach buttock
Pain anterior thigh = tight rectus femoris
POSITIVE:
1. reproduction of symptoms radiating anterior thigh/medial knee and/or backpain = correlated with L3 diagnosis
2. If patient has very hypomobile SI on ipsilateral side or tight anterior structures, as you pull the knee to the flexed position the iliac rim will start to move because it doesn’t tolerate this and get ASIS rotating forward as it gets pulled
201
Gaenslen’s Test
Test
Indications (4)
Test: Put patient toward the edge of table / 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
indications
1. SI dysfunction
2. Pubic symphysis instability (creating a hemipelvic rotation)
3. Hip pathology (capsular pattern hip hyperextension is limited)
4. L4 nerve root irritation
(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)
202
Thigh Thrust (POSH test – posterior sheer test):
1. Test
2. Positive
3. what it confirms
1. Test:
- ->pt supine, painful hip flexed 90 degrees
- ->PT stand opposite side of table, one hand under sacrum (bridging effect),
- ->Force: toward table in line of femur through the SI joint on that side
2. POSITIVE: reproduction of symptoms [creating posterior shear of the innominate bone through the femur]
3. confirms: side
203
Squish Test
Test: 2 options
Positive:
Test:
patient supine,
Hands on ASIS and push posterior and medial force: apply downward and medial force (adduction and posterior)
Force: towards sacrum and back
*can 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
POSITIVE: reproduction of pain
=determines side of dysfunction
204
Special Tests
| 5
1. FABERE
2. Prone Knee Bending
3. Gaenslen's Test
4. Thigh Thrust
5. Squish Test
205
Flexibility Tests:
| 5
1. Hamstring SLR
2. Hip Flexor Thomas Test
3. Rectus Femoris: Ely's Test
4. TFL: Ober's Test
5. Piriformis Length
206
Flexibility Tests:
Hamstring SLR
With the patient’s knee extended, take the patient’s foot by the heel and ele- vate the entire leg 35–70 degrees from the examining table. As the leg is raised beyond approximately 70 degrees, the sciatic nerve is being completely stretched and causes stress on the lumbar spine. The patient will complain of increased lower-extremity pain or pares- thesias on the side that is being examined. This is a positive response on the straight-leg-raising test.
If the patient complains of pain down the opposite leg, this is called a positive crossed response on the straight- leg-raising test and is very significant for a herniated disc.
The patient may also complain of pain in the posterior part of the thigh, which is due to tightness of the hamstrings.
You can determine whether the pain is caused by tight hamstrings or is of a neurogenic origin by raising
the leg up to the point where the patient complains of leg pain, and then lowering the leg slightly. This should reduce the pain in the leg. Now passively dorsiflex the patient’s foot to increase the stretch on the sciatic nerve. If this maneuver causes pain, the pain is neurogenic in origin. If this move- ment is painless, the patient’s discomfort is caused by hamstring tightness
207
Flexibility Tests:
Hip Flexor Thomas Test
3 parts
POSITION: Sit at edge of table and table up to buttocks and upper thigh and lie back down.
Take both knees to their chest.
TEST:
1. Person holds their R knee, bring the left leg down and see if it can make contact with the table.
=>If it doesn’t come down: there is tightness in the illiopsoas
2. 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. abducts hip = tight TFL
208
Flexibility Tests:
Ely's Test
1. Test
2. What its for
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)
209
Flexibility Tests:
TFL: Ober's Test
1. test
2. positive
1. --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.
2. ---Positive: TFL tight if they do not adduct to neutral or if drift into hip flexion when you do it.
210
Flexibility Tests:
Piriformis Length
1. why it is important
2. Options: 2 tests
1.
- -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
211
AIF Test
For Piriformis Length
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
212
Piriformis length test in prone
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
213
Tests for IS joint
pubis and innominate:
Standing FB and Marching Tests are better to determine side of issue,
also some information from WS, squish, thigh thrust but not as specific
214
SI Joint: sacral dysfunction
what test to use
use Sitting FB test
215
Pubic Symphysis Dysfunctions
RIGHT SUPERIOR PUBIC DYSFUNCTION
1. Standing Forward Flexion Test
2. Pubic Tubercle/Symphysis
3. Inguinal Ligament
4. SI Provocation
1. Standing Forward Flexion Test: positive right (standing)
2. Pubic Tubercle/Symphysis: superior right (supine #1)
3. Inguinal Ligament: tender right (supine #1)
4. SI Provocation
216
Pubic Symphysis Dysfunctions
RIGHT INFERIOR PUBIC DYSFUNCTION
1. Standing Forward Flexion Test
2. Pubic Tubercle/ Symphysis
3. Inguinal Ligament
4. SI Provocation
1. Standing Forward Flexion Test: positive right (standing)
2. Pubic Tubercle/ Symphysis: inferior right (supine #1)
3. Inguinal Ligament: tender right (supine #1)
4. SI Provocation
217
Iliosacral Dysfunctions
RIGHT ANTERIOR INNOMINATE
1. Standing Forward Flexion Test
2. ASIS
3. Medial Malleolus
4. PSIS
5. Sacral Sulcus
1. Standing Forward Flexion Test: positive right
2. ASIS: inferior right
3. Medial Malleolus: long right (Supine #2)
4. PSIS: superior right
5. Sacral Sulcus: shallow right
218
Iliosacral Dysfunctions
RIGHT POSTERIOR INNOMINATE
1. Standing Forward Flexion Test
2. ASIS
3. Medial Malleolus
4. PSIS
5. Sacral Sulcus
1. Standing Forward Flexion Test: positive right
2. ASIS: superior right
3. Medial Malleolus: short right
4. PSIS: inferior right
5. Sacral Sulcus: deep right
219
Iliosacral Dysfunctions
RIGHT OUTFLARED INNOMINATE
1. Standing Forward Flexion Test
2. ASIS
3. Medial Malleolus
4. PSIS
5. Sacral Sulcus
1. Standing Forward Flexion Test: right positive
2. ASIS: lateral right
3. Medial Malleolus: not affected
4. PSIS: medial right
5. Sacral Sulcus: same, but more medially displaced (may seem more shallow)
220
Iliosacral Dysfunctions
RIGHT INFLARED INNOMINATE
1. Standing Forward Flexion Test
2. ASIS
3. Medial Malleolus
4. PSIS
5. Sacral Sulcus
1. Standing Forward Flexion Test: positive right
2. ASIS: medial right
3. Medial Malleolus: not affected
4. PSIS: lateral right
5. Sacral Sulcus: wide right
Sulcus will move laterally away from midline –will appear to be deeper because we pulled it away
221
Iliosacral Dysfunctions
RIGHT SUPERIOR SHEAR: Upslip
1. Standing Forward Flexion Test
2. ASIS
3. Medial Malleolus
4. PSIS
5. Ischial Tuberosity
6. Sacrotuberous Ligament
upslip **1st supine**
1. Standing Forward Flexion Test: positive right
2. ASIS: superior right (iliac crest also superior)
3. Medial Malleolus: short right because whole leg is hiked up by pelvis, functional LLD short
4. PSIS: superior right (prone)
5. Ischial Tuberosity: superior right
6. Sacrotuberous Ligament: LAX right (lax on side of superior displacement)
222
Iliosacral Dysfunctions
RIGHT INFERIOR SHEAR: downslip
1. Standing Forward Flexion Test
2. ASIS
3. Medial Malleolus
4. PSIS
5. Ischial Tuberosity
6. Sacrotuberous Ligament
downslip **1st supine**
1. Standing Forward Flexion Test: positive right
2. ASIS: inferior right
3. Medial Malleolus: long right
4. PSIS: inferior right
5. Ischial Tuberosity: inferior right
6. Sacrotuberous Ligament: TIGHT right
223
Sacroiliac Dysfunctions
RIGHT UNILATERAL FLEXED SACRUM / inferior shear
1. Seated Flexion Test
2. Base of Sacrum
3. ILA
4. Lumbar Scoliosis
5. Lumbar Lordosis
6. Medial Malleolus Prone
1. Seated Flexion Test: positive right
2. Base of Sacrum: anterior right
3. ILA: inferior right
4. Lumbar Scoliosis: convex right
5. Lumbar Lordosis: normal to increased
6. Medial Malleolus Prone: LONG right
224
Sacroiliac Dysfunctions
RIGHT INFERIOR SHEAR-unilateral flexed
1. Seated Flexion Test
2. Base of Sacrum
3. ILA
4. Lumbar Scoliosis
5. Lumbar Lordosis
6. Medial Malleolus Prone
1. Seated Flexion Test: positive right
2. Base of Sacrum: ANTERIOR right
3. ILA: INFERIOR right
4. Lumbar Scoliosis: convex right
5. Lumbar Lordosis: normal-increased
6. Medial Malleolus Prone: long right
225
Sacroiliac Dysfunctions
RIGHT UNILATERAL EXTENDED SACRUM /superior shear
1. Seated Flexion Test
2. Base of Sacrum
3. ILA
4. Lumbar Scoliosis
5. Lumbar Lordosis
6. Medial Malleolus Prone
1. Seated Flexion Test: positive right
2. Base of Sacrum: posterior right
3. ILA: superior right
4. Lumbar Scoliosis: convex left
5. Lumbar Lordosis: DECREASED
6. Medial Malleolus Prone: short right
226
Sacroiliac Dysfunctions
RIGHT SUPERIOR SHEAR-unilateral extended
1. Seated Flexion Test
2. Base of Sacrum
3. ILA
4. Lumbar Scoliosis
5. Lumbar Lordosis
6. Medial Malleolus Prone
1. Seated Flexion Test: positive right
2. Base of Sacrum: posterior right
3. ILA: superior right
4. Lumbar Scoliosis: convex left
5. Lumbar Lordosis: decreased
6. Medial Malleolus Prone: short right
227
Sacroiliac Dysfunctions
ANTERIOR TORSION: R on R
1. Seated Flexion Test
2. base of Sacrum
3. ILA
4. ILA Motion
5. Lumbar Scoliosis
6. Lumbar Lordosis
7. Medial Malleolus Prone
1. Seated Flexion Test: positive left
2. base of Sacrum: anterior left
3. ILA: posterior right
4. ILA Motion: right increased in FB
* All forward torsions look worse in flexion and better in extension
5. Lumbar Scoliosis: convex LEFT [Rotate right and sidebend left so the lumbar spine sidebend right and rotate left]
6. Lumbar Lordosis: increased (b/c anterior torsion)
7. Medial Malleolus Prone: SHORT RIGHT
- Longer leg on side of convexity of the lumbar spine: so the left leg is longer and right leg is shorter
228
Sacroiliac Dysfunctions
POSTERIOR TORSION: R on L
1. Seated Flexion Test
2. base of Sacrum
3. ILA
4. ILA Motion
5. Lumbar Scoliosis
6. Lumbar Lordosis
7. Medial Malleolus Prone
1. Seated Flexion Test: positive right
2. base of Sacrum: posterior right
3. ILA: posterior right
4. ILA Motion: right increased in backwards bending
* posterior torsion, look worse in extension and better in flexion
5. Lumbar Scoliosis: left convexity
- ->sacrum is rotated right there is left sidebending which means that in the lumbar spine there is sidebending right and rotation left
6. Lumbar Lordosis: reduced
- -> looks flatter because the sacral base is back so there is a reversal of lordosis
7. Medial Malleolus Prone: SHORT RIGHT
- ->Leg is longer on side of convexity, shorter on side of concavity
229
Sacroiliac Dysfunctions
BILATERAL FLEXED SACRUM
1. Seated Flexion Test
2. Base of Sacrum
3. ILA:
4. Lumbar Lordosis
5. Medial Malleolus Prone
Nutated
1. Seated Flexion Test: positive bilaterally
2. Base of Sacrum: anterior bilaterally
3. ILA: posterior bilaterally
4. Lumbar Lordosis: increased
5. Medial Malleolus Prone: even
230
Sacroiliac Dysfunctions
BILATERAL EXTENDED SACRUM
1. Seated Flexion Test
2. Base of Sacrum
3. ILA:
4. Lumbar Lordosis
5. Medial Malleolus Prone
Counternutated
1. Seated Flexion Test: positive bilaterally
2. Base of Sacrum: posterior bilaterally
3. ILA: anterior bilaterally
4. Lumbar Lordosis: decreased (sacrum does not want to drop forward, stiff)
5. Medial Malleolus Prone: even [no change in leg length because this is around the middle transverse axis so no rotation component ]
231
**Patient doesn’t change in flexion/extension with shears, patients who have torsions do change in flexion and extension**
**Patient doesn’t change in flexion/extension with shears, patients who have torsions do change in flexion and extension**
232
All forward torsions look better or worse in flexion/extension ?
All forward torsions look worse in flexion and better in extension
233
Posterior torsion looks better/worse flexion/extension?
Better: flexion
Worse: extension
234
Anterior torsion looks better/worse flexion/extension?
Better: Extension
Worse: Flexion
sacral base already in forward bend position so look better in extension where sacral bases need to go into forward bend position and its already there
235
Universal pattern
Upshear
Left upshear
236
Universal pattern
Downshear
Right downshear:
237
Universal pattern
Inferior Pub
Right inferior pubs
238
Universal pattern
Superior Pub
Left superior pubs
239
Universal pattern
Anterior Torsion
L on L
240
Universal pattern
Posterior Torsion
L on R
241
Universal pattern
Sacral Flexion
Left sacral flexion
242
Universal pattern
Anterior Innominate
Right anterior innominate
243
Universal pattern
Posterior Innominate
Left Posterior innominate
244
Confirmation of the Diagnosis
INJECTION
Injection of small volume of anesthetic and steroid into the synovial portion of the joint under fluoroscopic control
Inject SI with the anesthetic in synovial portion of the joint under flousoscopic control, if symptoms dissipate , pain goes away, can conclude the joint is the issue
If find SI is the issue, add in steroid and it become therapeutic
May be diagnostic or therapeutic
245
Clinical Prediction Rule: Diagnosis of Pain originating from SI joint
Predictor Variables: if three/five or more predictors are positive, likelihood ration of 4.3
Predictor Variables: if three/five or more predictors are positive, likelihood ration of 4.3
1. Positive SIJ Compression test
2. Positive SIJ Distraction Test
3. Positive Femoral Shear Test (POSH test, thigh thrust)
4. Positive Sacral Provocation (P/A glide)
5. Positive Right Gaenslen’s Test
6. Positive Left Gaenslen’s Test
GOLD STANDARD REFERENCE
standard fluoroscopy-guided SIJ injection" If it is positive and give anesthetic said to relieve 80% of the pain
246
ORDER OF TREATMENT
| 5
1. Pelvis: upslip/downslip
2. Pubs
3. L5
4. Sacrum
5. Ilium
247
TREATMENT
Pelvis: upslip/downslip
grade 5 thrust
1. liac crest high in NWB position
2. Look at where the IT is, sacrotuebrous ligament, both ASIS and PSIS, abductor weakness along with that
3. Note: crest can appear higher if it has turned, don’t be fooled by patient when rotated crest which is why need to look at IT and sacrotuberous ligament as well as PMH and symptoms
4. Upslips are very uncomfortable and patient cannot bear weight on that side –cannot sit, or stand on it. Will have a significant history fell on pothole down a step etc. something strenuous on that joint, and WB will be a significant thing for them
248
TREATMENT
Pubic Symphysis
Shot Gun Technique
muscle energy technique: this works for superior and inferior pubs
1. Patient in supine with knees flexed: hooklying
2. Resist abduction approximately 3 times (for an inhibition)
3. Resist adduction by placing your arm between the patients knees
- Do not put olecranon into their adductor
- Be careful of your own wrist: extended but not hyperextended
- Don’t need maximal contraction, just enough contraction to get the muscle to pull on its origins without fx radius/ulna—feel a full contraction but not one that will hurt me
249
how shot gun technique works
Create an isometric contraction of the adductors which attach to inferior pubic ramus: create a reversal of the origin and insertion by fixing the distal attachment and tell patient to isometrically contract so that the proximal attachment will pull inferiorly and the side that is higher will drop down lower. Usually accompanied by popping/cracking sound. Patient may be temporarily uncomfortable. Significant change after.
250
TREATMENT
L5 vertebrae
Put the patient in prone and look at alignment of sacrum and of L5 vertebrae. L5 should be in opposite direction to sacrum because it is diametrically opposed and rotates and side-bends opposite of sacrum. In the neutral position they should be the opposite. If they are not the opposite treat L5 first. When L5 is corrected it may change what happens in the sacrum because sometimes sacrum is pulled by L5. If correct L5, sacrum may change. If L5 rotated in the wrong direction de-rotate it at SP or TP.
If no issue with L5, go straight to sacrum
251
TREATMENT: SACRUM
Sacrum Counter-Nutated
Patient Prone
Force: anterior on SACRAL BASE on EXHALATION because want sacral base to come anterior
252
TREATMENT: SACRUM
Sacrum Nutated
Patient Prone
One hand stabilize distal lumbar spine
Force: anterior on apex on INHALATION because want sacral base to come posterior
253
TREATMENT: SACRUM
Anterior Torsion
Prone
One hand sacral base to monitor
other hand on opposite ILA
force: ANTERIOR and SUPERIOR
R on R:
force on right ILA in anterior direction on inhalation
254
TREATMENT: SACRUM
Posterior Torsion
Prone
one hand posterior sacral base FORCE: ANTERIOR
other hand opposite ILA to monitor
Mixed up left and right here
R on L: force on left base to anterior and monitor on ILA on exhale so base goes forward
255
TREATMENT: SACRUM
Sacrum Superior Shear
with exhale so base goes anterior
force on sacral base: ANTERIOR and INFERIOR
monitor ipsilateral ILA
256
TREATMENT: SACRUM
Sacrum Inferior Shear
on inhalation because want sacral base to come posterior
one hand force ILA: ANTERIOR and SUPERIOR
hand on sacral base to monitor
257
TREATMENT: Ilium
Posterior Innominate
Patient Left Sidelying, left lower extremity flexed for BOS
Preplace: upper leg: right lower extremity slightly extended
Force couple: Right hand on iliac crest, left hand on ischial tuberosity
- ------Push forward with my hand on the crest
- ------Push posteriorly with my hand on the Ischial Tuberosity
Simultaneously rotate ilium ventrally
- ------Rotate the innominate bone from posterior to anterior position
- ------Can then increase the extension of the uppermost leg and rotate again.
- ------**can also do in supine like in a modified Thomas Test position: bring the right leg into extension off the table and create same fulcrum of bringing innominate bone anteriorly
combine with muscle energy technique: isometric hip flexion and she releases and I push into more extension
258
Supine Posterior Innominare
Ilium: Posterior Innominate:
Supine: off the edge, take the leg up so she stabilizes, pull up on the iliac crest (my hand is under the iliac crest) and ask her to bring the leg gently to the ceiling (something is flexed) and as she releases I bring my hand forward –so I am pulling underneath her innominate
259
Prone Posterior Innominate:
a. Patient prone
b. Lift from under distal femur towards ceiling (extend the leg)
- ----Since cannot put both hands on the pelvis: lift leg and pull on anterior hip flexors, then push anteriorly on the posterior iliac crest: pushing downwards as I lift up the femur
- ----Other hand moves crest of ilium in ventral-caudal direction
Muscle energy technique: she contracts isometrically to flexion and then I take up the slack and bring her into more extension as I push down on iliac crest to create forward rotation from posterior to anterior
260
Ilium: Anterior Innominate
1. want preplace LE in flexion to pull innominate posteriorly
- -----Patient left sidelying
- -----Left LE is extended as a BOS
- -----Preplace: The right LE is flexed
- -----Force couple: One hand on iliac crest, other hand on ischial tuberosity
- Handhold so can pull posteriorly and get the rotation
- Can increase the flexion to get more rotation
- Sustained hold works nicely with this
------Simultaneously rotate ilium dorsally (posteriorly to correct the innominate)
- -----To use muscle energy technique: to move anterior innominate posteriorly: Use hamstrings which attach to the IT:
- Hamstrings: supine/sidelying: take paitent leg into flexion and ask patient to extend hip into my hand by activating the hamstring and the glut simultaneously, proximal attachment of the hamstring will pull on the IT, it will pull the innominate bone posteriorly, and I can manually use the force couple and rotate the innominate bone posteriorly
261
Anterior Innominate
Supine
a. Supine:
------Hand underneath or put her over, my hand on anterior iliac crest and under her ischial tuberosity –and rotate. She can push into my shoulder to extension and as she releases I increases the amount of rotation
Anterior to posterior rotation using the hip extensor
262
Anterior Innominate
Prone
- -----Patient leg off side of the table
- -----Preplace: The right LE is flexed
- -----Force couple: One hand on iliac crest, other hand on ischial tuberosity
Can have her push back gently, and as she releases I bring her to more flexion and I rotate
I have patient above malleoli between my two knees so I can support it, holding patient in flexion. Pelvis is off the side of the table to allow me to rotate. I can manually rotate.
In this position energy technique:
Force for the hamstring, they push into me, I take up a little more slack into flexion, and rotate the pelvis
263
How to use muscle energy technique
------Illiopsoas and Rectus: patient in Thomas test position and want to bring innominate anteriorly: resist distal femur, ask patient to go slightly to flexion without any movement because it is an isometric contraction, increase the amount of extension and also mobilize the joint : take the innominate and rotate it (can do in sidelying, supine, and prone)
------Patient in extended position, contract the muscle isometrically, take up some slack and increase amount of extension, and simultaneously rotate and mobilize the joint
Use the flexor muscle by virtue of its attachment: pt in extension, isometrically flex, take up slack and move more into extension, and simultaneously rotate and mobilize the joint using the force couple to move it from posterior to anterior
264
Right rotation with left sidebending: So there is mostly posterior to anterior but also have some inferior
More the anterior and posterior for the rotations because it is a rotation
When rotate sacrum right, sidebends left
-it goes forward and drops slightly: left base goes anterior and slightly inferior
-ILA comes posterior and up a little bit
-posterior on the ILA on the side on to which it is rotating
unitlateral shears: superior inferior with the shears
more superior with the posterior on the ILA but it is more superior than it is posterior because it is a shear
Right rotation with left sidebending: So there is mostly posterior to anterior but also have some inferior
More the anterior and posterior for the rotations because it is a rotation
When rotate sacrum right, sidebends left
-it goes forward and drops slightly: left base goes anterior and slightly inferior
-ILA comes posterior and up a little bit
-posterior on the ILA on the side on to which it is rotating
unitlateral shears: superior inferior with the shears
more superior with the posterior on the ILA but it is more superior than it is posterior because it is a shear
