Pelvis and Sacrum Review 2024 PDF

PELVIS AND SACRUM REVIEW Jennifer Wilson D.O. Clinical Associate Professor Oklahoma State University Center for Health Sciences 01/17/2024 Objectives 01 02 03 04 05 06 Review anatomy and key landmarks of the pelvis and sacrum. Review diagnosis and treatment of the sacrum Explain the motion of L5 in...

PELVIS AND SACRUM REVIEW Jennifer Wilson D.O. Clinical Associate Professor Oklahoma State University Center for Health Sciences 01/17/2024 Objectives 01 02 03 04 05 06 Review anatomy and key landmarks of the pelvis and sacrum. Review diagnosis and treatment of the sacrum Explain the motion of L5 in relation to the sacrum (SB & R) Sacrum Practice Questions Review Diagnosis and Treatment of the pelvis Pelvis Practice Questions Sacrum Review Diagnosis Treatment Test Questions Diagnosis Requires 1 motion test Seated flexion test BBT (sphinx) Lumbar Spring Test AND 2 landmarks Sulci depth Posterior and caudad ILA Posterior transverse process of L5 Sacral Motion Sacral flexion occurs around the MTA in response to lumbar extension Sacral base moves anterior Also called sacral nutation (Sacral flexion occurs around the STA in response to exhalation) Sacral extension occurs around the MTA in response to lumbar flexion Sacral base moves posterior Also called sacral counter-nutation (Sacral extension occurs around the STA in response to inhalation) Motion Tests SeFBT Determines side of SI dysfunction Tells you which base moved Base can flex (move forward) or extend (move posteriorly BBT Tests the ability of the sacrum to flex Tells you if the sacrum lives in flexion or extension Sulci depth becomes more even = negative test = flexed dysfunction Sulci depth becomes less even = positive test = extended dysfunction Lumbar Spring Tests the ability of the sacrum to flex Tells you if the sacrum lives in flexion or extension Lumbars spring = negative test = flexed dysfunction Lumbars do not spring = positive test = extended dysfunction Diagnosis reminders 3 categories: Torsion “Torsions twist” – the sacrum moves around oblique axes Deep sulcus and posterior caudad ILA on opposite sides Common Named __ /__ ST (ie. L/RST) First letter tells you the direction the sacrum is rotated Second letter tells you which oblique axis the rotation is occurring around The axis is always opposite to the side of the seated forward bending test. Unilateral “Unilaterals slide on one side” Deep sulcus and posterior caudad ILA are always on the same side Bilateral Nondefinitive seated flexion test Diagnosis reminders The (+) seated forward bending test (SeFBT) will always occur on the side that is either being held flexed or extended. The part that moved and got stuck. For torsions, it opposite of the axis (second letter). Backward bending test (BBT) will be (-) in flexed dysfunctions and (+) in extended dysfunctions. Lumbar spring test will be good (-) in flexed dysfunctions (will spring) and poor (+) in extended dysfunctions (will not spring) Diagnosis Flow Sheet Possible Diagnoses Normal Sacrum Torsions L/L, L/R, R/R, R/L Unilaterals RSF RSE LSF LSE Bilaterals Bilateral flexion Bilateral extension Piriformis Hypertonicity with Anterior Torsions L/L torsion – right piriformis R/R torsion – left piriformis Sacral Dysfunctions: Questions Side of SeFBT Side of the deep sulcus? Side of the posterior/caudad ILA? Do you have a torsion or a unilateral? Same = unilateral Opp = torsion Flexed or Extended? BBT Spring Elimination of options based on info from SFBT and landmarks Is L5 compensated (rotated opposite the sacrum?) Example SeFBT positive on the Right I know the right sulcus moved somewhere Sulcus deep on R Right sulcus moved forward ILA P&C on the left I know it’s a torsion because the sulcus and ILA are on opposite sides Ddx: L/L Deep sulcus on right means rotated left Right sulcus moving around a left axis Good deal because the axis is always opposite the SFBT BBT and Spring should be negative L5 should be N SlRr Compensated L5 A “compensated” L5 means that it has rotated in the opposite direction to which the sacrum is rotated. Eg. If the sacrum is rotated to the left (in a left on left), L5 is rotated to the right. Compensated L5s are good and natural They do not have to be treated prior to treating the sacrum A “non-compensated” L5 means that it has rotated in the same direction as the sacrum. Eg. If the sacrum is rotated to the left (in a left on left), L5 is also rotated to the left. Non-Compensated L5s are not good. You will be unable to fully correct the sacrum without first correcting L5 in this situation. After you have corrected L5, you will need to go back and reassess the sacrum. Compensated L5 If L5 is compensated, it will follow type 1 mechanics for forward torsions and type 2 for extended torsions Forward torsions (L/L & R/R) L5 will follow neutral mechanics e.g. If sacrum is L/L, L5 should be SB left; Rotated right Backward torsions (L/R & R/L) L5 non-neutral mechanics e.g. If sacrum is L/R L5 should be SB right; Rotated right Haukland Beach, Lofoten, Norway Unilateral Sacrum Sacral Flexion Lie the patient prone While monitoring the affected sacral sulcus, abduct the leg approximately 15 degrees and add slight internal rotation. This will help unlock the SI joint. You may fine tune the amount of abduction if needed. Place the heel of your hand on the ipsilateral ILA and apply an anterior and cephalad force. Encourage this motion during inhalation and resist with exhalation through 5 deep breaths. Recheck Sacral Extension Lie the patient prone While monitoring the affected sacral sulcus, abduct the leg approximately 15 degrees and add slight internal rotation. This will help unlock the SI joint. You may fine tune the amount of abduction if needed. Place the heel of your hand on the ipsilateral base of the sacrum and apply an anterior and caudad force. Encourage this motion during exhalation and resist with inhalation through 5 deep breaths. Recheck Sacral Treatment Forward Torsions Lie on side of axis Rotate shoulders so they are parallel with the table, localizing rotation to L5. They should be “hugging the table” with their arms off the edge. Flex their knees and hips up to 90 degrees. They are now in the Sims position (lateral recumbent). Ask the patient to push the shoulder (the side opposite the axis) towards the ceiling for 3 rounds of muscle energy. This will help de-rotate L5. This step can be also done without muscle energy and only with use of deep breaths, with the patient reaching toward the ground with their shoulder on each exhale. Rest the patient’s knees and distal thighs on your distal thigh. Monitor the lumbosacral region While monitoring the lumbosacral junction, ask the patient to push both their ankles towards the ceiling 3-5 times with muscle energy. Take up the slack each time by slightly pushing the ankles towards the floor. Recheck Gets better, same letter, feet together, face the leather For forward torsions: The Backwards bend test gets better; it is a flexed torsion and the letters are the same. Therefore, in treatment, the feet are together and the chest faces the leather. As the treatment for backwards (extended) torsions are similar, this may help you differentiate them. Sacral Treatment Backward Torsions Lie the patient on the side of the axis with both knees slightly bent. Extend the lower leg while you monitor the lumbosacral area. The top leg should be slightly flexed in front of the lower leg. Grasp the patient’s arm (on the side touching the table) and rotate shoulders so they are parallel with the table, localizing rotation to L5. Their chest should be facing the ceiling. Monitor the lumbosacral region Ask the patient to push their shoulder (the side opposite the axis) towards the ceiling for 3 rounds of muscle energy. This will help de-rotate L5. This step may also be done without muscle energy and only with use of deep breaths, with the patient rolling their shoulder posteriorly toward the table with their shoulder on each exhale. While monitoring the lumbosacral junction, move the top foot off the table and apply inferior pressure at the knee towards the floor. Ask the patient to push both their knee towards the ceiling 3-5 times with muscle energy. Take up the slack each time by slightly pushing the knee towards the floor. Recheck WORLDS MOST AMAZING BEACHES Navagio Beach, Zakynthos Island, Greece La Playa Escondida, Mexico Horseshoe Bay, Bermuda Pelvis Review Diagnosis Treatment Practice Questions Pelvis Diagnosis and Treatment Included in Diagnosis 2 landmarks Possible Diagnoses 1. Innominate shears – superior or inferior ASIS 2. Innominate rotations – anterior or posterior PSIS 3. Innominate flares – inflare or outflare Pubic tubercle Iliac crest height Medial malleoli height 1 lateralizing test Standing FBT AP Compression 4. Pubic shears – inferior or superior Superior Innominate Shear Non-physiologic dysfunction Findings: ASIS - superior PSIS - superior Iliac Crest - superior Medial malleoli - superior Pubic tubercle - superior Right Superior Shear (+ SFBT right) Inferior Innominate Shear Non-physiologic dysfunction Findings: ASIS - Inferior PSIS - Inferior Iliac Crest - Inferior Medial malleoli- inferior Pubic tubercle - inferior Left Inferior Superior Shear (+ SFBT left) Anterior Innominate Rotation Physiologic dysfunction Associated with rectus femoris tightness Findings: ASIS- inferior PSIS- superior Iliac crests- generally level Pubic tubercle - level Resistance to posterior rotation Medial malleoli- inferior Right Anterior Rotation (+ SFBT right) Posterior Innominate Rotation Physiologic dysfunction Associated with hamstring tightness Findings: Left Posterior Rotation (+SBT left) ASIS- superior PSIS- inferior Crests - still generally level Pubic tubercle - level Resistance to anterior rotation Medial malleoli- superior Innominate Flares Inflare ASIS- more medially displaced to midline PSIS- more laterally displaced from midline Outflare ASIS- more laterally displaced from midline PSIS- more medially displaced to midline Pubic Shear Superior shear Findings: Dysfunctional pubic tubercle superior Medial malleoli- inferior (assuming no short leg exists) ASIS and PSIS- even Inferior shear Findings: Dysfunctional pubic tubercle inferior Medial malleoli- superior (assuming no short leg exists) ASIS and PSIS- even Leg length change with pelvic dysfunctions Posterior Rotation Ilium axis of rotation is around the ITA so ASIS moves superior. This means the acetabulum moves superior as well Shorter appearing leg Pubic superior shear. The axis of rotation is through the symphysis so it moves superior. This means the acetabulum moves inferior Longer appearing leg Queens Bath, Kauai, Hawaii Pelvis Treatment Superior Shear Patient lies supine Gently abduct the lower extremity approximately 510 degrees. Internally rotate the leg to lock out acetabular motion. Apply gentle traction followed by a short impulse inferiorly. Do not whip (hyperextend) the knee. Reset the pelvis and recheck your findings. Inferior Shear Ask the patient to gently drop the ischial tuberosity on the dysfunctional side down onto the table top. An alternative method is to ask the patient to stand on the dysfunction leg and jump up and down. Repeat 2-3 times if necessary. Reset the pelvis and recheck your findings. Pelvis Treatment Anterior Rotation Lie the patient supine Flex the hip and knee to the first restrictive barrier on the involved side. Stabilize sacral base with your fingertips. This keeps the sacrum from rotating posterior along with the ilia. Ask patient to try to extend their hip by pushing with the knee into your shoulder or hand for 3-5 seconds creating an isometric contraction. Pause for 1-2 seconds Flex the hip further to the next restrictive barrier and repeat muscle energy 3-5 times. Reset the pelvis and recheck your findings Posterior Rotation Lie the patient supine near the edge of the table on their affected side. Extend hip of the involved side off the table to the barrier. Stabilize the opposite ilium. Ask patient to flex their hip by pushing their knee towards the ceiling creating an isometric contraction for 3-5 seconds. Pause for 1-2 seconds Extend the hip further to the next restrictive barrier and repeat muscle energy 3-5 times Reset the pelvis and recheck your findings (You can also treat in the lateral recumbent or prone position.) Pelvis Treatment Ilial Outflare Stand or sit on the ipsilateral side of the somatic dysfunction. Flex the knee to 90 degrees on the affected side and place the affected foot lateral to the non-affected knee. Move the bent knee medially by adducting the hip while applying lateral traction on the PSIS until you hit your first barrier. Ask the patient to push their knee laterally, creating an isometric contraction for 3-5 seconds, 3-5 times Reset the pelvis and recheck your findings Ilial Inflare Flex the knee and externally rotate the hip of affected side so that foot is resting against opposite leg (forms a figure "4"). Abduct the ipsilateral knee to barrier with one hand. Stabilize opposite hip at the ASIS with the other hand. Ask patient to adduct the hip, performing muscle energy 3-5 times. Reset the pelvis and recheck your findings Pelvis Treatment Superior Pubic Shear Lie the patient supine near the edge of the table on their affected side. Extend hip of the involved side off the table to the barrier. Stabilize the opposite ilium. Ask patient to flex and adduct their hip creating an isometric contraction for 35 seconds. Pause for 1-2 seconds Extend the hip further to the next restrictive barrier and repeat muscle energy 3-5 times Reset the pelvis and recheck your findings Inferior Pubic Shear Lie the patient supine Flex the hip and internally rotate the affected side. Stabilize the ipsilateral ischial tuberosity. (You can choose to add anterior and superior force between isometric contractions if needed) Ask patient to try to extend their hip by pushing with the knee into your shoulder or hand for 3-5 seconds creating an isometric contraction. Pause for 1-2 seconds Flex and internally rotate the hip further to the next restrictive barrier and repeat muscle energy 3-5 times. Reset the pelvis and recheck your findings Sample Board Questions A 65 year old woman presents to the office with sacroiliac pain for 4 weeks after a right knee replacement. On osteopathic exam, you note a positive seated flexion test on the right. The left sulcus is anterior. The left ILA is posterior and caudad. You correctly diagnosis what somatic dysfunction? A 44 year old man presents to the ER with acute sacroiliac joint pain after falling from a ladder at home. An Xray of the lumbar spine and pelvis is within normal limits. On osteopathic exam, you find a deep sacral sulcus on the right. The right ILA is anterior and superior. A backwards bend test is negative. If L5 is compensated, what direction would you expect L5 to be sidebent and rotated? Sacroiliitis is a common complaint and sometimes termed a diagnosis of exclusion. What is the true underlying problem? An innominate that is caught rotated by a tight muscle? A sacrum held in torsion by a piriformis tightness? A short leg creating a chronic problem? An autoimmune process? Misdiagnosis from a lumbar radiculopathy? Referred pain from a visceral pelvic problem? Osteobite… SEE YOU IN LAB! MARGARET RIVER,AUSTRALIA