Page 1. Page 84 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

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1 American Academy of Osteopathy Convocation Physician Thursday, March 18, :00 AM 12:00 PM Student Friday March 19, :00 PM 3:00 PM The Pelvis in Motion and Gait Dennis J. Dowling, DO, FAAO OUTLINE I. Anatomy A. Osteology 1. Innominates (Pelvic bones; Os coxa) a. Ilium 1) components a) crest b) ASIS (anterior superior iliac spine) c) PSIS (posterior superior iliac spine) d) acetabulum 2) axis of rotation a) eccentric b) posterior-superior to center of bone c) posterior-superior to acetabulum b. Ischium 1) ramus 2) tuberosity 3) acetabular c. Pubi 1) ramus 2) acetabulum 3) symphysis 2. Sacrum a. Five segments b. Joint 1) modified from combination of facets 2) shape a) boomerang, lentil, kidney b) complicated topography forms tongue and groove joint with congruent iliac component c) idiosyncratic d) frequent aymmetry 3) segments a) superior 1) runs (superior)posterior to (inferior)anterior 2) allows anterior to posterior Page 1 Page 84 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

2 motion b) inferior 1) located on the anterior section 2) runs (anterior) superior to posterior) inferior c. Inferior Lateral Angle 1) combination of transverse processes of S4 and S5 2) landmark for determination of sacral mobility d. Hiatus 1) Sacral cornu 2) combined foramen S4-S5 3. Coccyx a. Typically three to four segments b. mobility 1) limited mobility with sacrum 2) segments frequently fused c. Multiple attachments d. Cornu B. Arthrology 1. Sacroiliac Articulation variations a. Symmetry vs. Asymmetry b. Shape variation 2. Congenital malformations a. Transitional L5 & S1 1) Lumbarization of S1 a) Partial b) Full 2) Sacralization of L5 a) Partial b) Full b. Spina bifida 1) occulta 2) cystica C. Ligaments limit motion and support stabilization of the joint 1. Iliolumbar 2. Sacrotuberous 3. Sacrospinous 4. Inguinal 5. Anococcygeal 6. Posterior sacroiliac a. Short b. Long 7. Interosseous sacroiliac D. Muscles 1. Anterior a. Quadriceps Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 85

3 II. b. Rectus abdominus c. Iliacus (Iliopsoas) 1) dysfunction a. Trendelenberg stance & gait b. Thomas test d. Obliques 2. Posterior a. Quadratus Lumborum b. Erector spinae c. External Rotators 1) piriformis 2) gemelli a) superior b) inferior 3) obturator d. Hamstring e. Gluteal 1) Trendelenberg test for gluteus medius weakness d. Obliques 3. Pelvic floor a. coccygeus 1) pubococcygeus 2) iliococcygeus 3) ischiococcygeus b. puborectalis c. levator ani E. Counterbalancing of muscles F. Gravitosis 1. Effect of posture and girth on sacrum and pelvis 2. Increase in lumbosacral angle with a. pregnancy b. obesity c. habit d. high heels e. post-surgical f. bridging exercises 3. Decrease in lumbosacral angle a. military b. slouching c. pelvic tilt exercise d. Earth shoes Pelvic and Sacral Motions A. Activities 1. Ambulation a. alternating physiological motion of the pelvic components into anterior and posterior rotations Page 3 Page 86 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

4 1. the swing leg femoral head engages the acetabulum and pulls the ipsilateral pelvic component into posterior rotation 2. the stance leg and push-off leg engages the acetabulum and pulls the ipsilateral pelvic component into anterior rotation 3. the pubic bones goes through a combination of torsion and superior-inferior shear and follow the direction of the ipsilateral ASIS 4. leg length affects static and motion characteristics of the pelvic bones a. short leg may result in non-compensation of pelvic rotation (whole pelvis drops to short leg side) b. short leg may result in compensation (pelvis on the same side rotates forward to keep sacral base level) c. short leg may result in over-compensation (pelvis rotates further than necessary and leg may appear longer) d. long leg may result in non-compensation of pelvic rotation (whole pelvis raises on the long leg side) e. long leg may result in compensation (pelvis on the same side rotates backward to keep sacral base level) f. long leg may result in over-compensation (pelvis rotates further than necessary and leg may appear shorter) b. stance leg establishes torsional-rotational sacral axis 1. the sacral base on the side opposite to the axis rotates forward and towards the axis side creating a forward rotation as part of the physiological motion 2. the joint slides forward and downwards c. differences 1. Running a. typical heel-lateral foot-forefoot-roll-stretch of medial longitudinal ligament-heel lift-toe off-leg swing b. lower extremity adaptations on stance side leg 1. inversion-plantarflexion of foot 2. talus translates anteriorly 3. talocrural joint separates (fibular stylus and distal tibia separate) 4. fibular stylus translates anteriorly 5. tension on interosseos membrane 6. tension on peroneal muscles 7. fibular head translates posteriorly 8. tension on abductors and hip flexors especially iliotibial band c. lower extremity adaptations on swing side leg 1. eversion-dorsiflexion of foot Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 87

5 2. talus translates posteriorly 3. talocrural joint approximates 4. fibular stylus translates posteriorly 5. decrease of tension on interosseos membrane 6. tension on tibialis muscles 7. fibular head translates anteriorly 8. tension on hip extensors (hamstrings) d. barefoot running 1. forefoot-metatarsal makes contact first 2. longitudinal ligament stretched as heel hits the ground 3. heel lifts e. special considerations 1. uneven terrain 2. turtle-backed roads 2. Respiration all of the spinal curves, including the sacrum, flatten during inhalation. The sacrum moves into extension during inhalation and flexion during exhalation 3. Cranial motion - occurs about a horizontal axis and involves the sacral base going into extension when the sphenoid and occipital bases move into cranial flexion and then into flexion when the basi-spenoid and occiput move into extension. Results from anchoring of the dura mater at the foramen magnum through the central spinal canal to an attachment to the S2. 4. Defecation 5. Micturition 6. Parturition a. during the first stage of labor, engagement, the sacrum counternutates (extends); the pelvic brim widens; the ishia approximate b. subsequently, the pelvic brim approximates, the sacrum nutates (flexes), and the ischia and pubic symphysis spread c. somatic dysfunction can occur from asymmetric reposition of the mother s legs following delivery, especially from the lithotomy position B. Sacral Motion on the Ilium 1. Respiration - Superior Transverse Axis 2. Flexion/Extension - Middle Transverse Axis 3. Rotation - Vertical Axis 4. Lateral Flexion - Anterior/Posterior Axis 5. Rotations and Torsions - Oblique Axis a. Forward (SOMATIC DYSFUNCTION Exaggeration of physiological movements; gymnastics) 1) Right on Right 2) Left on Left Page 5 Page 88 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

6 b. Backward (SOMATIC DYSFUNCTION Exaggeration of Non-physiological movements; forward bending with sidebending and rotation to the same side; picking up a pencil) 1) Right on left 2) Left on Right 7. Unilateral Sacral Shears 8. Bilateral Sacral Flexion (SOMATIC DYSFUNCTION backwards fall onto sacrococcygeal region; sitting in a sluped position; often associated with coccygodynia) 9. Bilateral Sacral Extension (SOMATIC DYSFUNCTION - fall, backwards or forwards, that creates lumbosacral hyperextension; obesity; pregnancy) C. Ilial Motions on the Sacrum 1. Anterior/Posterior Rotation - Inferior Transverse Axis (SOMATIC DYSFUNCTION exaggeration of the physiological motions kicking) 2. Vertical Shear (Ilial Translatory Motions) Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 89

7 III. IV. a. Superior (SOMATIC DYSFUNCTION asymmetrical impact on one extended leg stepping of the stairs without realizing there is an additional step downwards; skydiving; panic braking during a front-end collision) b. Inferior (SOMATIC DYSFUNCTION asymmetrical traction on one extended leg foot caught in stirrup or rope; bungee jumping) 3. Horizontal Shears (SOMATIC DYSFUNCTION anterior/posterior shear forces during trauma; MVAs; falls) a. Anterior b. Posterior 4. Flares a. Inflare (SOMATIC DYSFUNCTION trauma; MVA (inertia activation of lap portion of the seat belt-harness complex) b. Outflare (SOMATIC DYSFUNCTION post-partum; cephalo-pelvic disproportion sizes) D. Pubic Motions 1. Caliper 2. Torsional 3. Vertical Shear (PubicTranslatory Motions) (SOATIC DYSFUNCTION typically, pubic symphysis follows ASIS) a. Inferior b. Superior 4. Translatory a. Anterior b. Posterior 5. Transverse a. Adducted b. Abducted Pelvis During Pregnancy A. Nutation and Counternutation B. Post Partum - Proper means of removing patient from stirrups Motion tests A. Standing Flexion test forward motion of the spine engages the sacrum into Flexion and the restricted iliosacral side will engage sooner and cause the pelvis on that side to rotate further B. Seated Flexion Test the patient fixates the pelvic bones into position by sitting on his ischial tuberosities. The sacrum floats between the ilia and the restricted sacroiliac side engages sooner and pulls the pelvic bone into anterior rotation C. Stork test D. Sphinx test E. Supine Iliosacral test F. Ilial rocking G. Sacral rocking V. Pelvic Somatic Dysfunctions Page 7 Page 90 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

8 A. Primary Pubic Dysfunctions 1. Shears - Physiological a. Superior b. Inferior 2. Lateral a. Adducted b. Abducted B. Sacrum on Ilium Dysfunctions 1. Unilateral a. Right unilateral sacral shear (flexion) b. Left unilateral sacral shear (flexion) 2. Bilateral a. Flexion b. Extension 3. Forward - Physiological a. Rotations 1) Right on Right 2) Left on Left b. Torsions - involve compensatory motion of L5 1) Right on Right torsion 2) Left on Left torsion 4. Backward a. Rotations 1) Right on Left 2) Left on Right b. Torsions - involve compensatory motion of L5 1) Right on Left torsion 2) Left on Right torsion C. Ilium on Sacrum Dysfunctions 1. Anteroposterior Rotation - Physiological a. Anteriorly rotated ilium (pelvic bone; innominate) b. Posteriorly rotated ilium (pelvic bone; innominate) 2. Superoinferior Ilial Shear a. Superior ilial shear (pelvic bone; innominate) b. Inferior ilial shear (pelvic bone; innominate) D. Coccygeal dysfunctions 1. Coccygodynia 2. Reduced mobility VI. Examination procedures for Sacrum A. Seated flexion test - Patient sits on a table or stool with feet flat on the floor. Examiner s hands rest on the iliac crests with thumbs on the PSIS bilaterally. Contact should be similar to the standing flexion test. Patient is asked to bend forward at the waist with their hands between their knees. Examiner watches for which thumb if any moves farther. If you are unsure have the patient repeat the bending. Write down the side of the positive seated flexion test Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 91

9 This will tell you to look for a problem in the sacrum. B. Spring Test - Rest your (the examiner s) hand over the lumbo - sacral junction and press down. Is there spring in this junction? If YES (there is spring) - this is a negative spring test; If NO (there is No spring) - this is a positive spring test C. Assess L5 - Locate the iliac crests. Drop your thumbs onto the TP's of L5 (spinous processes are at the same level).evaluate L5 rotation component by pressing anteriorly (through the patient) on the TP's - which side is more posterior (closer to the ceiling) or more resistant to anterior motion testing: that will be the side of rotation D. PSIS levels - Once again, place the length of your examining fingers around the iliac crests bilaterally, your thumbs should be facing medially and rest on the PSIS. Roll your thumbs to the caudad edge (below) of the PSIS bilaterally, with the pads of your thumbs pressing cephalad (upwards against the bone). Is the PSIS on the side of the positive standing flexion test higher, lower or even with the opposite side? Record this finding with your ilial findings standing flexion test, ASIS level, pubic level. E. Deep sulcus - Place your thumbs over the PSIS bilaterally with the tips of the thumbs facing medially. Turn your thumbs down medially off the PSIS and into the area between the two PSIS. Your thumbs should be pointing down toward the sulcus at the top of the sacrum. Note which thumb feels like it goes deeper into this area. If in doubt close your eyes and sense which sulcus is deeper, if any. Record this finding with your seated flexion test & spring test results as the location of the deep sulcus. VI. Interpretation for Sacral Diagnoses If : deep sulcus and posterior inferior ILA are on the same side Then: Diagnosis is a unilateral sacral flexion or unilateral sacral shear If : There is a Negative Spring Test and the deep sulcus and posterior ILA are on opposite sides Then : There are only two diagnostic choices : Left (rotation) on a left axis or Right (rotation) on a right axis Page 9 Page 92 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

10 A. FORWARD SACRAL ROTATION OR TORSION If : The deep sulcus is on the right and the posterior, inferior ILA is on the left, with a negative spring test Then: the diagnosis is Left rotation on a left axis (L on L). If : The deep sulcus is on the left and the posterior, inferior ILA is on the right, with a negative spring test Then : the diagnosis is Right (rotation) on a right (axis) (R on R) Note: shaded areas are deep If : L5 is rotated in the direction opposite to that of the sacral rotation Then: the diagnosis becomes a left or right forward sacral torsion If : L5 is rotated in the same direction as the direction of the sacrum Then: the diagnosis becomes a left or right forward sacral rotation IF : there is a POSITIVE Spring test and the deep sulcus and posterior, inferior ILA are on opposite sides THEN: there are only two possible diagnostic choices Right (rotation) on a Left (axis) = R on L or Left (rotation) on a right (axis) = L on R Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 93

11 B. BACKWARD SACRAL ROTATION OR TORSION If : The deep sulcus is on the LEFT and the posterior, inferior ILA is on the RIGHT and there is a positive spring test Then : the diagnosis is Right (rotation) on a Left (axis) If : The deep sulcus is on the right and the posterior, inferior ILA is on the left and there is a positive spring test Then : the diagnosis is Left (rotation) on a right (axis) Note: shaded areas are deep The axis goes through the deep sulcus in backward sacral torsions or rotations If: L5 is rotated in the direction opposite to the direction of the sacrum Then: the diagnosis is a right or left backward sacral torsion If: L5 is rotated in the same direction as the direction of the sacrum Then: the diagnosis is a right or left backward sacral rotation Remember: The rotation of L5 must be opposite that of the direction of sacral rotation for the diagnosis to be a torsion. C. UNILATERAL SACRAL SHEAR (FLEXION) If : The deep sulcus is on the RIGHT and the posterior, inferior ILA is on the RIGHT and there is a negative spring test Page 11 Page 94 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

12 Then : the diagnosis is Right Unilateral Sacral Shear (Flexion) If : The deep sulcus is on the left and the posterior, inferior ILA is on the left and there is a negative spring test Then : the diagnosis is Left Unilateral Sacral Shear (Flexion) D. BILATERAL SACRAL FLEXION or EXTENSION Difficult to diagnose by palpatory findings or seated flexion tests since both sides are restricted. Determining mechanism of injury and examining by movement restriction during respiration VII, Diagnosis of Pelvis A. Review of Landmarks 1. Posterior Superior Iliac Spine (PSIS) 2. Anterior Superior Iliac Spine (ASIS) 3. Anterior Inferior Iliac Spine (MIS) 4. Pubic Tubercles B. Tests 1. Standing flexion test - Patient stands with bare or stocking feet about 6 to 8 inches apart, facing away from examiner. Examiner places their hands on the patient s iliac crests, with thumbs resting on the PSIS bilaterally. (look for dimples) Make a meaningful contact but the area must be allowed to move.patient is asked to bend forward slowly. Examiner watches the thumbs on the PSIS to see which if any moves further during the forward bending, if in doubt repeat the forward bendingassess the ASIS 2. Have the patient lie on the table in the supine position. ( on their back ) Locate the ASIS bilaterally with your ( the examiner s ) thumbs. Roll the thumbs off the ASIS inferiorly and press up against the bones.note whether the ASIS is higher or lower on the side of the positive standing flexion test. 3. Assess the Pubic Bones - Patient is still supine.using the heel of your examining hand, starting at the navel, proceed inferiorly toward the pubes. After locating the bone, use your index fingers to evaluate whether the pubic bone is higher (more cephalad) or lower (more caudad) on the side of the positive standing flexion test. Record this finding. Place the heels of your hands over the ASIS and Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 95

13 gently rock each side while assessing for freedom of motion. Record which side feels more restricted. E. Assess leg length - While patient is still in the supine position. Have the patient place their feet flat on the table and lift their buttocks off the table and then allow the buttocks to rest on the table, in the new position. (This will allow the sacrum, pelvis & soft tissue to be squared off.) The examiner stands at the foot of the table and places his/her hands around the anterior surface of the patient s ankles with the thumbs under the medial malleolus bilaterally. Assess the level of the malleoli. Which is malleolus is higher or lower? F. PSIS levels - place the length of your examining fingers around the iliac crests bilaterally, your thumbs should be facing medially and rest on the PSIS. Roll your thumbs to the caudad edge (below) of the PSIS bilaterally, with the pads of your thumbs pressing cephalad (upwards against the bone). Is the PSIS on the side of the positive standing flexion test higher, lower or even with the opposite side? Record this finding with your ilial findings standing flexion test, ASIS level, pubic level. G. Findings description Standing Flexion test - Positive R or L ASIS - higher or lower on side of standing flexion test Pubes - higher or lower on side of standing flexion test PSIS - higher or lower on side of standing flexion test ASIS Rocking - side of greater restriction R or L Leg Length - R or L longer or shorter Iliac Crest height - R or L Higher Lower Even H. Interpretations If: The ASIS is lower, & the pubic bone is lower or equal, and the PSIS is higher on the side of the positive standing flexion test: the diagnosis is an anteriorly rotated ilium If: The ASIS is higher, & the pubic bone is higher or equal, and the PSIS is lower on the side of the positive standing flexion test: the diagnosis is a posteriorly rotated ilium If: The ASIS is higher, the pubic bone is higher & the PSIS is higher on the side of the positive standing flexion test: the diagnosis is a superior shear If: The ASIS is lower, the pubic bone is lower & the PSIS is lower on the side of the positive standing flexion test: the diagnosis is an inferior shear Page 13 Page 96 Pelvis and Sacrum: Where It All Comes Together 2010 AAO Convocation

14 Calais-Germain, B. Anatomy of Movement, Eastland Press, Seattle, 1993 Dowling, D.J. Evaluation of the pelvis, in DiGiovanna, E. Schiowitz, S., & Dowling, D. J. Eds., An Osteopathic Approach to Diagnosis and Treatment, 3 rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2004, Heinking, K.P. & Kappler, R.E.; Pelvis and Sacrum in Ward, R.C. (Ed.), Foundations for Osteopathic Medicine (2 nd Ed), Lippincott, Williams & Wilkins, Philadelphia, 2003, Kapandji, I. A.; The Physiology of the Joints: Volume Three - the Spinal Column, Pelvic Girdle and Head, Churchill Livingston, NY Kapandji, I. A.; The Physiology of the Joints: Volume Two- the Lower Limb, Churchill Livingston, NY 1983 Moore, K. L.; Clinically Oriented Anatomy; Williams and Wilkins, Baltimore, 1980 Mitchell, F.L.; The Muscle Energy Manual: Volume 3, MET Press, East Lansing, Michigan, 1999 Nordin, M. & Frankel, V.H.; Basic Biomechanics of the Musculoskeletal System, 3 rd Edition, Lippincott Williams & Wilkins, Philadelphia, 2001 Page AAO Convocation Pelvis and Sacrum: Where It All Comes Together Page 97