Assessment Of The Pelvis (PDF)

ASSESSMENT OF THE PELVIS CHAPTER 10 -- MAGEE - Sacroiliac joints, pubic symphysis, and sacrococcygeal joint - SIs along with the pubic symphysis transfer weight from the spine to the lower limbs - Provide elasticity to the pelvic ring (fig 10.1) - Absorbs shock - Examine SI after...

ASSESSMENT OF THE PELVIS CHAPTER 10 -- MAGEE - Sacroiliac joints, pubic symphysis, and sacrococcygeal joint - SIs along with the pubic symphysis transfer weight from the spine to the lower limbs - Provide elasticity to the pelvic ring (fig 10.1) - Absorbs shock - Examine SI after you've done the spine and/or hip - Particularly if you haven't found the source yet **ANATOMY** - Relatively mobile in young people, but become progressively stiffer with age - In some people, it leads to ankylosing - Only slight movement occurs here -- amphiarthrosis - Synovial -- convex iliac surface, C shaped; sacral surface is concave - Also syndesmosis Resting position Neutral ------------------ ------------------------------- Capsular pattern Pain when joints are stressed Close pack Nutation Loose pack Counternutation - Ligaments fig 10.2 - Long posterior sacroiliac -- limit anterior pelvic rotation or sacral counternutation - Short posterior sacroiliac -- limits all pelvic and sacral movement - Posterior interosseus - Anterior sacroiliac - Sacrotuberous -- limit nutation and posterior pelvic rotation - Sacrospinous -- same as above - Iliolumbar -- stabilizes L5 on ilium - SI and pubic symphysis have no muscles that act on them directly, but the muscles do provide stability table 10.1 - Muscles that support the pelvis, L spine, and hip are divided into groups - Outer grouping -- couplings that stabilize pelvis - Deep posterior longitudinal system fig 10.4 - Superficial posterior oblique system fig 10.5A - Anterior oblique system fig 10.5B - Lateral system fig 10.6 - Innermost grouping - Multifidus, tranverse abs, diaphragm 10.7 - Pelvis floor 10.8 - Anterior-posterior superficial group 10.9 - Pubic symphysis - Little to no movement, has disc and pubic ligament - Fibrocartilaginous joint - Sacrococcygeal joint - Usually a fused line - symphysis Table 10.2 and 10.3 actions of the hip and spine that may stress the SI joints A close-up of a computer screen Description automatically generated  **OBSERVATION** - The book wants the client to be nude... - You can palpate instead, k? OK to adjust clothing if client consents - View from anterior, lateral, and posterior - Nutation (sacral locking) = the forward movement of the base of the sacrum into the pelvis (fig 10.10) - Also described as backward rotation of the ilium on the sacrum - This should happen bilaterally at both SI joints -- as in going from supine to standing or trunk flexion - Ilia move closer together and tuberosities move father apart - If nutation only occurs unilaterally -- as in hip flexion - If unilateral movement occurs pathologically - The ASIS is higher and the PSIS is lower on that side - So can look like a functional short leg on that same side - Action is limited by anterior sacroiliac, sacrospinous, and sacrotuberous ligaments - Occurs when a person assumes a 'posterior pelvic tilt' position fig 10.11 - Counternutation (sacral unlocking) = backward motion of the base of sacrum out of the pelvis (fig 10.10) - Also described as anterior rotation of the ilium on the sacrum - Iliac bones move farther apart and tuberosities approximate - Pathologically, if counternutation only occurs on one side - ASIS is lower and the PSIS is higher on that side - Leg will appear longer (old text) - Leg will appear medially rotated (new text) - Limited by sacroiliac ligaments - Occurs when a person assumes an 'anterior pelvic tilt' position 10.12 - Neutral pelvis = somewhere between anterior and posterior pelvic tilt (11° and 9°, therefore a range of 20°) - Pelvic tilt = angle between a line drawn from the ASIS to PSIS and a horizontal line fig 10.13 - Average is 11° (+/- 4°) - Ideally, the ASIS is in the same vertical plane as the pubic symphysis - Consider same three questions as always when looking for neutral pelvis and whether the pelvis can be stabilized - Can they achieve neutral pelvis - Can they hold it there statically - Cant they hold it there while moving - These questions will help you determine if the pelvis and lumbar spine can be stabilized during different positions or movements so that other muscles can function properly - Active hip abduction test -- page 732 - Side-lying with legs, pelvis, torso, and shoulders in frontal place - Client ABducts hip - Leg wobbles, pelvis tips, rotation occurs, hip flexes, abducting leg medial rotates = lack of control, muscle imbalance, inability to stabilize pelvis - Gait - If SIs aren't free to move, stride length is decreased and a vertical limp may be present - Painful SI may also cause inhibition of glute med, leading to Trendelenburg lurch/gait - Are the ASISs level? - Affected side, ASIS tends to be higher and slightly forward - ASIS and PSIS are higher on one side = ilium upslip, a shortened leg on the other side, or muscle spasm in the lumbar region - ASIS is higher, PSIS is lower on same side = anterior torsion (pathological nutation) of the sacrum on that side; could result in scoliosis or altered functional leg length, or both - Counternutation is the most common rotation - Due to falling on ischial tuberosity, lifting when forward flexed with knees straight, repeated standing on one leg, vertical thrusting onto an extended leg, or sustaining hyperflexion and abduction of hips - Are the pubic bones level at symphysis? - If ASIS is higher, the pubic bone may be as well 10.16 - Indicated backward torsion of ilium on that side - When standing, does the client bear weight evenly? - Are the ASIS equidistant from the center line of the body? - Are the iliac crests level? - Could be altered by leg length - Are PSIS level? Equidistant from the midline? - Gluteal folds and buttock contours normal? - May be loss of glue max tone on painful side - Any spasm in the erector spinae? - Ischial tuberosities level? - Excessive lumbar lordosis? - Feet pointing in/out at the same degree? - Painful side is often medially rotated - Is spasm in piriformis = lateral rotation of leg/foot **EXAMINATION** ACTIVE RANGE OF MOTION - Be sure to ask for the exact location of pain during these motions to make sure the pain is pelvic and not hip/spine - Comparing sides is important, a baseline is needed - The SI joints move in a nodding fashion of anteroposterior rotation - Active movements that stress the sacroiliac joints (and could therefore reproduce pain/symptoms) look for unequal movement, loss or increase in movement, tissue contracture, tenderness, or inflammation - Forward flexion of spine -- ilium rotate anteriorly - Test bilaterally - Place thumbs on PSIS - Client flexes forward fig 10-18/19 (keep knees straight) - PSIS should move upward equally in relation to the sacrum and a bit toward one another (standing flexion test) - Sacrum moves forward (nutation) until 60° of flexion, then moves backward - Test this by palpating PSIS with one thumb and the sacrum with the other thumb - Should also move toward one another - Extension of spine -- ilium rotate posteriorly - Test in the same position as flexion but with extension fig 10-21 - PSIS should move inferiorly - Sacrum should move forward evenly with lumbar extension (sacral flexion test palpate both sides of the sacrum) - Rotation of spine - Innominate, on the side to which rotation is occurring, rotates posteriorly; opposite innominate rotates anteriorly - Ipsilateral nutation, contralateral counternutation - Side flexion of spine - Palpate at S1 on either side of sacrum - Thumb should move forward on the same side as the lateral flexion - hip flexion -- ilium rotate posteriorly - fig 10.24A/B (Gillet test) - client is standing, palpate PSIS and spinous process of S2, client flexes hip - thumb on PSIS should drop, if not it indicates hypomobility on the flexed side - if joint is hypomobile, the thumb will move up - then, palpate ischial tuberosity instead of PSIS fig 10.24C/D - should move laterally with flexion - fixed or hypomobile = moves toward superiorly toward head - hip abduction - hip adduction - hip extension -- ilium rotate anteriorly - hip medial rotation - hip lateral rotation - tested with medial rotation - sit in front of client, palpate ASIS - test one leg at a time - client pivots leg on heel into medial and lateral rotation - ASIS should move medially and laterally along with femur PASSIVE RANGE OF MOTION - Not true passive range of motion, they are provocative tests designed to stress the joints' ligaments and the joints themselves - Not very reliable - See next page RESISTED ISOMETRIC MOVEMENTS - Use contraction of adjacent muscles (table on page 744) - Perform supine, attempt to recreate symptoms PASSIVE ROM/PROVOCATION TESTS - Stress ligaments of the SI and the joint itself - Looking for symmetry rather than hypermobility versus hypomobility because the effectiveness is highly questioned need more than one to be positive (2/4 from the list below) - Approximation test (compression provocation test) - Gapping test (distraction provocation test) - Sacral thrust test - Thigh thrust test - Gaenslen's test (see "Special Tests") - Pain on palpation of the sacral sulcus medial to posterior superior iliac spine - Looking for these tests to reproduce the client's symptoms (not just pain or discomfort) +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE | CLIENT | RMT | POSITIVE | +=============+=============+=============+=============+=============+ | Approximati | SI joint | Side lying | Hands over | Feeling of | | on | | | upper part | pressure in | | Test | \- lesion | | of iliac | the SI | | (transverse | | | crest | joint(s) | | posterior | \- sprain | | | | | stress) | of | | Press | | | | posterior | | toward the | | | p\. 739 | sacroiliac | | floor | | | | ligaments | | | | | yellow | | | | | | | | | | | | 10.27 | | | | | +-------------+-------------+-------------+-------------+-------------+ | Gapping | Sprain of | Supine | \- apply | \- | | (transverse | anterior | | crossed-arm | unilateral | | anterior | sacroiliac | | pressure to | gluteal or | | stress of | ligaments | | the ASISs | posterior | | distraction | | | (push down | leg pain | | provocation | | | and out) | | | ) | | | | | | Test | | | | | | | | | | | | p\. 739 | | | | | | | | | | | | green | | | | | | | | | | | | 10.29A and | | | | | | B | | | | | +-------------+-------------+-------------+-------------+-------------+ | Prone | Posterior | Prone | Flex knee | Compare | | Gapping | sacroiliac | | to 90° or | amount and | | (Hibb's) | ligaments | (but hips | greater | ease of | | Test | | must have | | movement on | | | | full ROM | Medially | each side | | p\. 742 | | and be | rotate hip | | | | | pathology | as far as | | | yellow | | free) | possible | | | | | | | | | 10.29C | | | Palpate SI | | | | | | on same | | | | | | side | | +-------------+-------------+-------------+-------------+-------------+ | Sacral Apex | SI joint | Prone | Place base | Pain over | | Pressure | problem | | of hand at | the joint | | (prone | | | apex of | | | springing | | | sacrum | | | or sacral | | | | | | thrust) | | | Apply | | | Test | | | pressure in | | | | | | a cranial | | | p\. 742 | | | or anterior | | | | | | direction | | | yellow | | | | | | | | | | | | 10.34 | | | | | +-------------+-------------+-------------+-------------+-------------+ | Sacroiliac | Sacrotubero | Supine | Flex their | Pain at SI | | Rocking | us | | knee and | | | | ligament | (knee and | hip fully, | | | (knee to | | hip need to | then adduct | | | shoulder) | SI joint | be free of | hip | | | Test | | pathology | | | | | | and have | Rock leg | | | aka | | full ROM) | toward | | | sacrotubero | | | opposite | | | us | | | shoulder | | | ligament | | | | | | stress test | | | (can add | | | | | | med rot of | | | p\. 742 | | | hip) | | | | | | | | | green | | | Palpate L | | | | | | or SI joint | | | 10.35 | | | at same | | | | | | time | | | | | | (optional) | | | | | | for | | | | | | tenderness | | +-------------+-------------+-------------+-------------+-------------+ | Squish Test | Posterior | Supine | Place hands | Pain | | | sacroiliac | | on outside | | | p\. 743 | ligaments | | of | | | | | | ASIS/ilium | | | red | | | | | | | | | Push down | | | 10.36 | | | and in at a | | | | | | 45° angle | | +-------------+-------------+-------------+-------------+-------------+ | Thigh | SI joint | Supine | Passively | Pain in SI | | Thrust Test | | | flex hip on | joint on | | (Oostagard, | | | test side | thrusting | | 4P, | | | to 90° | | | sacrotubero | | | | | | us | | | Use one | | | stress, or | | | hand to | | | posterior | | | palpate SI | | | pelvic pain | | | joint | | | provocation | | | | | | test) | | | Thrust down | | | | | | through the | | | p\. 743 | | | knee on the | | | | | | test side | | | green | | | | | | | | | | | | 10-38 | | | | | +-------------+-------------+-------------+-------------+-------------+ SPECIAL TESTS - Trying to reproduce symptoms - Test muscle length if tightness is suspected +-------------+-------------+-------------+-------------+-------------+ | TEST | STRUCTURE | CLIENT | RMT | POSITIVE | +=============+=============+=============+=============+=============+ | Straight | SI joints | Supine | Flex hip | Pain after | | Leg Raising | | | with knees | 70° \*\* | | (Lasegue's) | (also tests | There are | extended | | | Test | neuro | active | | (may be | | | tissue, see | alternative | Can do this | after this | | p\. 744 | Lumbar) | s | bilaterally | if person | | | | (10.41) | | is | | green | | | | hypermobile | | | | \- test | | ) | | 10.40 | | muscles | | | | | | acting on | | Pain before | | | | SIs | | 70° | +-------------+-------------+-------------+-------------+-------------+ | Flamingo | SI | Stand on | observe | Pain at | | Test or | | one leg | | pubic | | Maneuver | Pubic | | | symphysis | | | symphysis | | | or SI -- | | p\. 746 | | | | usually in | | | | | | stance leg, | | green | | | | can ask | | | | | | them to hop | | 10.42 | | | | to stress | | | | | | more | +-------------+-------------+-------------+-------------+-------------+ | Gaenslen's | Ipsilateral | Side lying | Stabilize | Pain -- | | Test | SI joint | | pelvis | could | | | lesion | Upper leg | | indicate | | p\. 746 | | (test leg) | Extend hip | any of the | | | Hip | hyper-exten | of their | structures | | green | pathology | ded | upper leg | listed, | | | | | | location | | 10.43A | L4 nerve | Hold lower | Pull both | determines | | | root lesion | leg to | legs to | which one | | | (px/sensati | chest | chest then | | | | on | | lower test | Pain in SI | | | loss along | Can do | leg into | | | | anterior | supine but | ext | | | | thigh and | leg has to | | | | | medial leg, | hang off | | | | | decreased | table | | | | | patellar | (10.43B) | | | | | reflex) | | | | +-------------+-------------+-------------+-------------+-------------+ | Gillet's | SI | Standing | Palpate | Thumb on | | (Sacral | hypomobilit | | sacrum and | PSIS moves | | Flexion, | y/blocked | Flex hip | PSIS on | up or | | Stork, | SI | | same side | minimally | | Ipsilateral | | | (parallel | | | Posterior | (only | | thumbs) | | | Rotation) | difference | | | | | Test | between | | Test | | | | this and | | bilaterally | | | p\. 747 | testing | | | | | | active hip | | | | | yellow | flexion is | | | | | | the point | | | | | 10.44 | of | | | | | | palpation) | | | | +-------------+-------------+-------------+-------------+-------------+ | Patrick | | | | | | Test | | | | | | | | | | | | See hip | | | | | +-------------+-------------+-------------+-------------+-------------+ | Yeoman's | Anterior | Prone | Flex knee | Pain | | Test | sacroiliac | | to 90° and | localized | | | L pathology | | extend hip | to SI joint | | p\. 748 | | | | | | | Lumbar | | | Pain in | | green | involvement | | | lumbar | | | (test with | | | region | | 10.51 | knee flexed | | | | | | and | | | Anterior | | | extended) | | | thigh | | | | | | paresthesia | | | Femoral N | | | , | | | stretch | | | pain (may | | | | | | also | | | | | | affects | | | | | | anteromedia | | | | | | l | | | | | | knee, | | | | | | medial leg | | | | | | and foot) | +-------------+-------------+-------------+-------------+-------------+ | Leg Length | | | | | | Test | | | | | | | | | | | | Same as | | | | | | knee/hip | | | | | +-------------+-------------+-------------+-------------+-------------+ | Trendelenbu | | | | | | rg | | | | | | Test or | | | | | | Sign | | | | | | | | | | | | Same as hip | | | | | +-------------+-------------+-------------+-------------+-------------+ \*\*DonTigny73 has reported that the straight leg raise can be affected by sacroiliac problems. If, when doing SLR, the pain in the sacroiliac joint is unaltered or decreases, the examiner may suspect an anterior torsion. If the pain in the sacroiliac joint increases, a posterior torsion is possible. If pain increases on the opposite side, an anterior torsion on the opposite side should be suspected. REFLEXES AND CUTANEOUS DISTRIBUTION - Fig 10-54 dermatomes & Peripheral nerve injuries about the pelvis p. 676