Pelvic Mechanics, Sacral Mechanics, Pelvis and Sacrum Review
what is Patrick's test?
FABRE patricks test stresses the hip and sacroiliac joints a positive produces back, buttocks, or groin pain
what are forward torsions?
L/L, R/R L5 neutral mechanics (SB left, rotated right)
what are backward torsions?
L/R, R/L L5 nonneutral mechanics (SB right, rotated right)
what are associated symptoms with a flexed sacrum?
LBP SI pain pain with sitting difficulty bending forward difficulty getting up and down from chair
what are associated symptoms with extended sacrum dysfunctions?
LBP difficulty bending backward "leaned over to pick something up and couldn't get back up"
what is the most sensitive test for identification of inflammatory sacroilitis?
MRI
what are backward torsions?
R/L, L/R L5 non-neutral mechanics (SB right, rotated right)
what are associated symptoms with sacral torsions?
SI pain LBP sciatic pain pelvic pain/bowel complaints
what is one of the most common etiologies of LBP during pregnancy?
SIJ pain
what happens in exhalation?
STA sacral base moves anterior flexion/nutation
what happens with inhalation?
STA sacral base moves posterior extension/counter-nutation
what is the sympathetic nervous supply to the pelvic organs?
T12-L4 sacral sympathetic trunk
what does a positive seated forward bending test indicate?
a SACROiliac dysfunction (eg. sacrum) lower extremity mechanics are limited
what are biomechanical considerations?
a change in structure leads to a change in function kyphoscoliosis
what does a positive standing forward bending test indicate?
an ILIOsacral dysfunction (eg. innomiante/pubes) sensitive to lower extremity restrictors such as tight hamstrings
what are the 5 pathophysiologic models for osteopathic perspective?
biomechanical model respiratory-circulatory model neurologic moel metabolic-energy model behavioral model
what are relative contraindications for counterstrain?
cannot voluntarity relax vertebral artery disease, severe osteoporosis treatment position must be modified inability to effectively communicate severe acute rheumatological flare
what is the pelvic outlet?
confined by the pubic symphysis, right and left rami of the pubic arch, the ischial tuberosities, the sacrotuberous ligaments and the tip of the coccyx
what is the superior transverse axis?
craniosacral flexion/extension and respiration
what muscles are in the urogenital diaphragm?
deep perineal and sphincter urethrae muscle/fascia
what is an inferior innominate (pelvic) shear?
down-slipped ilia ASIS - inferior PSIS - inferior Iliac crest - inferior Meidal malleoli - inferior Pubic tubercle - inferior left inferior shear , flexion test would be positive on left
what are the two oblique sacral axes?
dynamic axeses that in which the sacrum engages during walking weight bearing on L leg will engage the left axis and cause the sacrum to turn towards the left
what does the D in DRIP stand for?
dynamic: sacral motion during walking around oblique axes
what are important muscles in the anterior abdominal wall for SIJD?
external obliques linea alba internal obliques transverse abdominals
what is an innominate outflare?
external rotation around a vertical axis ASIS - more laterally displaced from midline PSIS - more medially displaced from midline
what provides self-bracing or self-locking in the SI joint?
fascia and muscles within this region provide significant self-bracing or self-locking to the SI joint and its ligaments through their cross-like anatomical configuration
wha tis the treatment for left sacrum flexed?
gap leg pressure is anterior and towards head push on ILA during respiration
what form X pattern on dorsal aspect of back?
gluteus maximus latissimus dorsi
what is force closure?
how external compression forces add additional stability
what is form closure?
how specifically shaped, closely fit contracts provide inherent stability independent of external load
why is the piriformis so clinically important?
hypertonicity can cause sciatica - pain referred to posterior thigh
what is the Gillet/Stork test?
if the sacroiliac joint is functional then the posterior superior iliac spine (PSIS) will move down (on the side of flexed leg) allowing ilia to rotate
what is a superior innominate (pelvic) shear?
ilial upslip ASIS - superior PSIS - superior Iliac crest - superior Medial malleoli - superior Pubic tubercle - superior right superior shear, positive flexion test on the right
what is the standing flexion test used for?
ilio-sacral motion legs, pubes, ilia
what are ventral ligaments in SIJD?
iliolumbar anterior sacroiliac
what are the accessory ligaments?
iliolumbar sacrotuberous sacrospinous
what is the goal of OMT?
improving range of motion and tissue texture increase extremity movement to facilitate venous return improve musculoskeletal relationships to assist body in restoring homeostasis
where does counterstrain fit in OMM?
indirect away from barrier similar to soft tissue,, myofascial, muscle energy, and cranial
+ standing test on left ASIS appears level pubic tubercle inferior on left crest appears level short leg left
inferior pubic shear on left
what is the inferior transverse axis?
innominate/ilia rotation will occur around this axis (during walking) ilials around the inferior
what does I in DRIP stand for?
innominate: innominate rotation around ITA
what is therapeutic pulse?
intensity approximates radial pulse
what is an innominate inflare?
internal rotation around a vertical axis ASIS - more medially displaced PSIS - more laterally displaced from midline
what are dorsal muscles that are important for SIJD?
latissimus dorsi thoracolumbar fascia gluteus maximus ITB piriformis iliopsoas
+ seated flexion test right sulcus deep right L5 rotated right ILA posterior/caudad left sacrotuberous ligament tight left backward bending test findings improve
left on left sacral torsion
+ seated flexion test left deep right sulcus L5 rotated right ILA posterior/caudad left sacrotuberous ligament tight left backward bending test findings exaggerate
left on right sacral torsion
+ seated flexion test on left sacral base anterior left L5 rotated left ILA inferior/posterior on left sacrotuberous ligaments lax on left backward bending test findings improve long leg left
left sacrum flexed
left sacrum flexed...
left side held flexed about MTA
how to treat piriformis in counterstrain?
leg flexion to 120 degrees
what is the superior transverse axis?
located approximately at the level of S2 flexion/extension associated with respiration and cranial sacral motion inhalation > sacral base moves posterior > sacral extension
LIPLSIP
lower extremities innominates pubes lumbars sacrum ilia psoas/iliopsoas
what is LIPLSIP?
lower extremity innominate shears pubic shears L5 sacrum innominate (ilia) rotations psoas
what is the inferior transverse axis?
lower extremity and innominate motion
inferior transverse axis...
lower extremity including ilial motion
what is the pelvic inlet?
made up of the sacral promonotory, the iliopectineal line and the superior border of the pubic symphysis
what are absolute contraindications for counterstrain?
manifestation of abnormal neurological and or vascular symptoms brought on by the treatment position exacerbation of potentially life-threatening symptomatology by treatment position
what is the sciatic nerve?
muscular branch of sacral plexus (L4-S3) close associated with piriformis muscle passes through greater sciatic notch
what is a tender point?
no characteristic pain pattern located in muscles, tendons, ligaments, and fascia no radiating pattern when pressed
what muscles are in the pelvic diaphragm?
obturator internus, piriformis, coccygeus, levator ani
what is the proprioceptive theory?
one muscle strained while antagonist is hyper-shortened proprioceptors in short muscle act as if muscle is being stretched, reflex continues, leads to somatic dysfunction
what is a trigger point?
patients presents with characteristic pain pattern located in muscle tissue elicits a radiating pain pattern when pressed
what is the parasympathetic nervous system supply to the pelvic organs?
pelvic splanchnic (S2-S4) sacral plexus supply left colon and pelvic viscera
what is the only muscle with direct attachment to sacrum?
piriformis
what is the middle transverse axis?
postural motion occurs here as the pt bends forward, the sacral base moves anterior. at terminal postural flexion, the sacrotuberous ligament becomes tight and the base moves posteriorly
what does P in DRIP stand for?
postural: sacral motion with bending forward and backward around MTA
who came up with counterstrain?
proposed by Lawrence H. Jones "spontaneous release by positioning"
what are the theories for counterstrain mechanisms?
proprioceptive theory sustained abnormal metabolism theory impaired ligamentomuscular reflex theory
superior transverse axis...
respiration cranial sacral flexion/extension
what does R in DRIP stand for?
respiratory: sacral motion during breathing around STA
what do the accessory ligaments do?
restrain anterior movement flexion of the sacrum
right ASIS inferior right PSIS superior crest and pubes appear grossly symmetric right leg longer
right anterior ilial rotation ilial rotates around inferior transverse axis
right ASIS superior right PSIS inferior crest and pubes appear grossly symmetric right leg shorter
right posterior ilial rotation
+ seated forward bending test right sacral base anterior left ILA inferior/posterior left sacrotuberous ligament lax on left backward bending test findings exaggerate short leg right
right sacrum extended
right sacrum extended...
right side held in extension about MTA
what is a posterior innominate rotation?
rotation on a transverse axis, hamstring tightness may contribute ASIS - superior PSIS - inferior Crests - still generally level Pubic tubercle - level Resistance to anterior rotation Medial malleoli - superior
what is an anterior innominate rotation?
rotation on transverse axis, rectus femoris tightness may contribute ASIS - inferior PSIS - superior Iliac crests - generally level Pubic tubercle - level Resistance to posterior rotation Medial malleoli - inferior
what is the lumbar spring test?
sacral extension prevents lumbar spring or flexibility
what is the seated flexion test used for?
sacro-iliac motion sacrum
what are dorsal ligaments in SJID?
sacrospinous sacrotuberous posterior sacroiliac
what is the motion test for sacroiliac dysfunctions?
seated flexion tests
how to treat cervicals in counterstrain?
sidebend away/rotate away (SARA)
what is the middle transverse axis?
spinal (postural) flexion/extension
middle transverse axis...
spinal flexion/extension
what is the posterior sacroiliac ligament?
stretched with extension of sacrum and decreased lordosis
what is the anterior sacroiliac ligament?
stretched with flexion of sacrum and increased lordosis
+ standing flexion test right short right leg superior crest on right superior ASIS on right superior PSIS on right superior right tubercle on right
superior innominate shear on the right
what is the first letter in sacral torsions...
tells you the direction the sacrum is rotated
what is a Maverick?
tender point that does not respond to typical positioning (~5%) usually requires opposite position from standard
what is the backwards bending test?
test the ability of the sacrum to flex with backward bending (extension) of the lumbar spine if will not flex, it is positive
what is Gaenslen's test?
the hip joint is maximally flexed on one side adn the opposite hip joint is extended stresses both sacroiliac joints simultaneously
pubic symphyseal shears...
the side of dysfunction is determined by positive SFT or AP compression
what is SIJD?
the stability or instability of this region is dependent upon these muscular and ligamentous relationships
t-T, a-A
toward or away uppercase letters mean more of that motion lower case means less
left and right oblique axis...
walking and combine spinal motions
what is left and right oblique axis?
walking and combined spinal motion
what is the second letter in sacral torsions...
which oblique axis the rotation is occurring around
