Anatomy:
The pevlic girdle is a closed OSTEOARTICULAR RING
The function of the pelvic girdle is that of Force Attenuation. In other words, its role is the efficient absorption, transmission and distribution of forces that cross the pelvic girdle.
Innominate: the innominate bone is comprised of the ilium, ischium, and pubis. There are two innominate bones. One on the right and one on the left.
Axis of Rotation:
There are transverse axes at the sacrum (superior, middle, inferior transverse axis) which permit flexion/extension movements.
There are also two diagonal axes. The left oblique axis that starts in the upper left, and the right oblique axis which begins at the upper right portion of the sacrum. The oblique axis allow for rotation of the sacrum
PUBIC MOTION: Pubic motion may be either superior or inferior. There is only about 2mm of motion possible at this joint.
Motion: 10-13 degrees of motion is considered normal.
ILIOSACRAL MOTION: this is ilium movement on the sacrum. Movements of the ilium include anterior/posterior rotation, superior/inferior movement and medial/lateral flaring.
SACROILIAL MOTION: this is sacral movement o the ilium. Movements of the sacrum include flexion/extension and rotation.
Common Symptoms:
Pain over the PSIS, ASIS, and posterior iliac crest.
Pain in the posterior thigh, groin, and buttock
Pain with ambulation (walking)
Pain with ascending and descending stairs.
Pain with walking and stairs, is a result of the stuck sacrum that is trying to move but is unable to. Each step will stress this joint and cause pain.
Pain with transitional movements
Pain in the coccyx. This is known as coccydynia and is due to sacral rotation.
Key findings that point to SI problems are pain in the PSIS and pain or popping with a shotgun test.
Mechanisms of Injury:
Rotation with lifting
Forceful movement in a diagonal pattern. Examples include golf swing, baseball swing, shoveling, etc.
Repetitive unilateral standing. (Upslip)
Carrying a child on one hip. (Upslip)
Fall on ischial tuberosity. (Upslip or posterior rotation depending on direction of force)
Vertical thrust on extended leg as with triple jumping. (Upslip)
Unexpectedly stepping off a step or curb. (Upslip)
Note: Pregnant women are predisposed to sacroiliac joint dysfunction due to ligamentous laxity via hormonal changes for up to two years post partum. (This is from the hormone relaxin.) Women who take oral contraceptives are similarly predisposed.
Provocation Tests:
Pelvic gapping Test: supine, cross arms and place palms on th4e ASIS. Push outward. This will stress the anterior ligaments.
Pelvic Compression: Side lying. Push down on ilium. This stresses posterior ligaments.
Sacral Thrust: Prone. Anterior pressure on sacrum with palm.
Patrick Fabre Test: Supine. Cross leg over extended leg and apply pressure down on crossed leg.
Evaluation:
Motion Assessment: (+) indicates NO motion. Remember that a certain amount of motion is NORMAL.
Ilial Motion: March Test: Palpate PSIS bilaterally. Perform hip flexion of at least 90 degrees. The PSIS should drop. A (+) test results when the PSIS does not move.
Flare Test: Palpate ASIS bilaterally in a wide stance. Hip IR/ER on heel. Evaluate the quantity of IR/ER motion of leg as well as the quantity of ASIS movement of the innominate bones. A (+) test is the side that has less motion moving in inward or outward rotation.
Sacral Motion: Rotation:
Palpate the sacrum bilaterally. Perform lumbar lateral flexion. You should find that the sacrum rotates away from the direction you move. (Right lateral flexion results in the right aspect of the sacrum moving inward and the left portion coming back to you.) Remember the rules of concave and convex side rotation. The sacral/coccyx region of the spine is convex so the vertebral bodies rotate opposite the direction of lateral flexion/rotation.
Leg Length Discrepancy:
Leg length discrepancy causes pelvic obliquity. With each step,k the pelvis must drop a distance equal to the amount of the asymmetry. The average person takes approximately 5,000 steps per day. 5 mm is clinically significant.
Clinical Assessment:
Differentiating between an upslip and a true leg length discrepancy (LLD).....
An upslip usually occurs as a result of some identifiable trauma.
An upslip is almost always debilitating and extremely painful.
True LLD: In Standing: ALL landmarks (ASIS, PSIS, iliac crest and greater trochanter are superior.
UPSLIP: In Standing: All landmarks are superior, EXCEPT the greater trochanter.
True LLD: March Test is negative, unless other dysfunction co-exists.
Upslip: March Test is positive.
True LLD: In sitting: Iliac crests are equal.
Upslip: In sitting: Iliac crest is superior.
True LLD: Supine: long leg remains long
Upslip: Supine: Long leg is short.
Radiological Assessment:
X-ray can confirm true LLD.
Standing pelvis x-ray for femoral head height is used.
Must stand with weight equally distributed over both extremities, and with both knees fully extended.
Sacroiliac Joint Dysfunction:
The side of pain is irrelevant in identifying the side of the dysfunction. Use movement testing.
Asymetrical landmarks are commonly seen.
Hypomobility: limited motion progressing in severity to absent motion.
Hypermobility: Excessive motion which compromises stability.
Ilial Lesions:
Anterior Innominate rotation:
+ March Test
ASIS inferior
PSIS superior
Posterior innominate rotation:
+ March Test
ASIS Superior
PSIS inferior
Upslip:
+ March Test
Iliac crest may be superior
Unilateral ASIS and PSIS superior
Upslip with posterior rotation:
+ March Test
Iliac crest may be superior
1 ASIS markedly superior and both PSIS equal
Upslip with anterior rotation:
+ March Test
Iliac crest may be superior
1 PSIS markedly superior and both ASIS equal
Inflare:
ASIS anterior
+ Flare Test
Outflare:
ASIS Posterior
+ Flare Test
Pubic Lesions:
Superior Shear: Pubic symphysis is superior unilaterally
Inferior Shear: Pubic symphysis is inferior unilaterally
Treatment:
Address muscular imbalances:
Stretch short muscles
Strengthen weak muscles
Restore symmetry:
Sub maximal isometric contractions
Warn the athlete of probable soreness
May hear or feel a pop
Contractions are done for 3 seconds and consist of 3 sets of 3
Always end with pubic shotgun
Ultrasound:
non-thermal effects:
Ice
Precautions: instruct patient concerning appropriate/inappropriate stress of sitting, standing, sports, etc.
Pelvic stabilization program: upper and lower abdominals, gluts, Swiss ball.
Treatment Scheme:
Day 1: Do corrections and then ice.
Day 2: If ok: you are done. You may want to address muscle imbalances
If not better: Do corrections + add stretching exercises, ice
Correction for Rt Posterior Innominate Rotation & Rt Superior Pubic Shear
Test Results:
Rt. + March Test
Rt. ASIS Superior
Rt. PSIS Inferior
Rt. Pubic symphysis superior
Correction for the Posterior Innominate rotation:
Position: Supine
Both hips flexed
Rt. Hip is extended more than Lt.
Resist:
Rt. Hip flexion (force)
Lt. Hip extension (counterforce)
Correction of Superior Pubic Shear:
Position: supine
Rt. Hip extended
Lt. Hip flexed
Resist:
Rt. Hip adduction (force)
Lt. Hip extension (counterforce)
Pubic Shotgun:
Position:
Supine with knees flexed to 90 and feet flat on table
Resist: hip adduction with hand/arm wedged between the two knees.
Contract as hard as possible within limits of discomfort.
Home Positioning:
Supine with Rt. Hip fully extended (hip extension causes anterior innominate rotation)
Lt. Hip flexed to 90 and supported (use chair/sofa)
Muscle Imbalance Considerations:
Stretch Rt. Hamstrings
Strengthen Rt. Hip flexors
Correction for Rt Anterior Innominate Rotation & Rt Inferior Pubic Shear
Test Results:
Rt. + March Test
Rt. ASIS Inferior
Rt. PSIS Superior
Rt. Pubic symphysis Inferior
Correction for the Anterior Innominate rotation:
Position: Supine
Both hips flexed
Rt. Hip is flexed more than Lt.
Resist:
Rt. Hip extension (force)
Lt. Hip flexion (counterforce)
Correction of Superior Pubic Shear:
Position: supine
Rt. Hip flexed
Lt. Hip extended
Resist:
Rt. Hip extension(force)
Lt. Hip adduction (counterforce)
Pubic Shotgun:
Position:
Supine with knees flexed to 90 and feet flat on table
Resist: hip adduction with hand/arm wedged between the two knees.
Contract as hard as possible within limits of discomfort.
Home Positioning:
Supine with Rt. Hip flexed to 90 and supported (hip flexion causes posterior innominate rotation)
Lt. Hip fully extended
Muscle Imbalance Considerations:
Stretch Rt. Hip flexors
Strengthen Rt. Hip extensors
Upslips:
almost always occur with either an anterior or posterior innominate rotation. Correct the upslip first before addressing the pubic shear. Position patient for upslip correction by remembering the saying "never put the 2 P's together" (ie. Prone and posterior)
Left Upslip with an Anterior Innominate Rotation:
Test Results:
+ Lt. March Test
Lt. Iliac crest most likely superior
Lt. PSIS is markedly (about 1") superior
Both ASIS are equal
Correction Technique:
Position: Prone:
Grasp proximal to the Lt. Ankle with the him in slight external rotation, abduction, and extension
Start with a gentle sustained long axis distraction for 5 seconds for 2-3 repetitions.
Take up the slack and provide a quick low amplitude pull so that the athlete barely slides down the table.
Correction of Inferior Pubic Shear:
Position: supine
Lt. Hip extended
Rt. Hip flexed
Resist:
Lt. Hip adduction (force)
Rt. Hip extension (counterforce)
Perform a Pubic Shotgun
Lt. Upslip with a Posterior Innominate Rotation:
Test Results:
+ Lt. March Test
Lt. Iliac Crest most likely superior
Lt. ASIS markedly superior
Both PSIS equal
Correction Technique:
Position Supine
Grasp proximal to the Lt. Ankle with the hip in slight external rotation, abduction, and flexion.
Start with a gentle sustained long axis distraction for 5 seconds for 2-3 repetitions.
Take up the slack and provide a quick low amplitude pull so that the athlete barely slides down the table.
Note: With an upslip with a posterior innominate rotation, you must also correct the superior pubic shear on that side.
Correction of Superior Pubic Shear:
Position: supine
Rt. Hip extended
Lt. Hip flexed
Resist:
Rt. Hip adduction (force)
Lt. Hip extension (counterforce)
Perform a Pubic Shotgun
A self mobilization can be done by hip hiking the opposite leg as a home program exercise.
Stretching the quadratus lumborum is done by leaning away while maintaining an erect posture (no trunk flexion or extension).
Correction for a Right Inflare:
Test Results:
+ Rt. Flare test
a positive test exhibits limited ROM of the foot and/or painful ROM in one direction (in this case, it will be an inability to rotate outward as far as the unaffected leg). The motion limitation may not be readily observable.
Rt. ASIS anterior
The ATC should be able to see the difference in height for it to be considered clinically significant.
Rt. Inflare Correction Technique:
Position: Supine with Rt. Hip flexed to 45 degrees and the foot flat on the table.
Resist: Rt. Hip abduction.
Note: do not perform a shotgun with this condition as the adductors will pull the flare back in.
Correction for a Right Outflare:
Test Results:
+ Rt. Flare test
a positive test exhibits limited ROM of the foot and/or painful ROM in one direction (in this case, it will be an inability to rotate inward as far as the unaffected leg). The motion limitation may not be readily observable.
Rt. ASIS posterior
The ATC should be able to see the difference in height for it to be considered clinically significant.
Rt. Outflare Correction Technique:
Position: Supine with the Rt. Hip and knee flexed to 90 degrees and the leg supported by the athletic trainers arm.
Resist: Hip adduction and apply a lateral distraction to the Rt. PSIS simultaneously.
Notes of caution:
For outflares - no ER of hip during correction as a home program
reminder. Use elastic belt (3" preferable) to help with maintaining
inflare tendency. No sleeping with leg in ER. ie as when you sleep
prone and flex,er leg.
for inflare problems, sleep with pillows between legs to keep thigh out
of inflare tendency. keep thigh in at least a neutral adduction posture.
Sofa Exercise for Outflare home program: While lying on your back with your right calf resting on the sofa, position your leg so that your knee is bent to a right angle. Push your right knee into the arm of the sofa. Hold for 2 seconds. Repeat 6 times.
Precautions for patients with sacroiliac joint problems
It is important to protect your sacroiliac joints while we are working to restore their normal function. The sacroiliac joints are the junction between your lower back and your pelvis. The position of your legs can affect the position of your SI joints. The following precautions will help to protect your SI joints.
You will probably develp increased soreness and discomfort following the evaluation and treatment. This is to be expected. You can decrease the inflammation and soreness by applying ice to the area for 15 minutes. Do not use heat because the heat will increase the inflammation.