The Pelvis and Sacrum David Kanze, DO ABONMM, ABOFP/OMT Kylie Kanze, DO ABOP

Transcription

1 The Pelvis and Sacrum David Kanze, DO ABONMM, ABOFP/OMT Kylie Kanze, DO ABOP Disclosure We have nothing to disclose David is a proud member of the AOA, AAO, OCA and ACOFP. Kylie is a proud member AOA, AAO, OCA, and AAP. objectives Review and discuss the functional anatomy of the pelvis and sacrum Discuss the role of the sacrum and pelvis in gait mechanics Review the diagnostic criteria for the pelvis and sacrum Treatment of the pelvis and sacrum based on the ankle sprain/short leg cascade MET CS LAS/BLT 1

2 Anatomy Think of the area as one unit Split into parts Depicted in the next slides Osteology Pelvis 2 innominate bones Innominate Ilium Ischium Pube Fuse in late adolescence anatomy The top of the sacrum is the sacral base (wide and flat like the top of home plate) The bottom is known as the apex The sacral promontory is the anterior portion of S1 2

3 Anatomy (anterior view) Made of 5 sacral vertabrae Fusion occurs at around age 25 Anatomy (posterior view) Anatomy (lateral view) 3

4 Anatomy (SI in nutation) Anatomy (superior view) Anatomy (transverse section) 4

5 Anatomy (weight bearing) The weight of the upper body is transmitted through the sacrum and its ligamentous attachments to the pelvis via the iliolumbar, sacrospinous, & sacrotuberous ligaments. The anterior and posterior sacroiliac ligaments are extremely strong and connect the sacrum to the pelvis. Joints Sacroiliac joint (SI joint) and pubic symphysis Pelvic Ligaments Anterior sacroiliac Iliolumbar Anterior longitudinal Superior pubic Arcuate pubic Inguinal 5

6 Pelvic Ligaments Interosseous sacroiliac Superficial dorsal sacroiliac Posterior longitudinal Thoracolumbar fascia Pelvic Ligaments Sacrospinous Sacrotuberous Pelvic Ligaments 6

7 Muscles above the pelvis Longissimus Iliocostales Quadratus lumborum Latissimus dorsi Rectus abdominis Obliquus abdominis externus internus Transversus abdominis Pyramidalis Muscles above the pelvis Longissimus thoracics & Iliocostales action: bends spine backwards & laterally; provides lateral stabilization of lumbar spine Quadratus lumborum action: flexing & SB trunk Latissimus dorsi action: adducts, internally rotates & extends the humerus; stabilizes ilia & lumbosacral aponeurosis (co contracts w/ LAT) Rectus abdominis action: flexes T/L spine & pelvis Muscles above the pelvis Rectus abdominis action: flexes T/L spine & pelvis Obliquus abdominis: Externus action: rotates the T spine in relation to pelvis Internus action: rotates T spine in relation to pelvis Transversus abdominis action: segmental lumbar stabilization, rotates T spine in relation to pelvis Pyramidalis action: supports abdominal viscera 7

8 Muscles above/below the pelvis Psoas Iliacus Muscles above/below the pelvis Iliacus/psoas action: assists rectus abdominis in flexing lumbar segments, assists iliacus in flexing hip joint, flexes & externally rotates femur on pelvis, flexes & lateral bends indiv. lumbar; psoas (major & minor) flex the pelvis on spine Muscles below the pelvis Adductors: gracilis pectineus adductor brevis, longus, & magnus Sartorius Rectus femoris 8

9 Muscles below the pelvis Adductor group Action: adduction/flexion of thigh, except gracilis (internal rotation thigh); all participate in external rotation of leg Sartorius Action: external rotator of thigh, flexion of leg on thigh and thigh on pelvis Rectus femoris Action: assists in flexing thigh & extending the leg (when tight, it tilts pelvis forward on femur) Muscles below the pelvis Obturator internus/externus Action: stabilizes femur in acetabulum, weak external rotators Muscles below the pelvis Tensor fasciae latae Action: abducts femur & transmits tension from fibular head to iliac crest; assists in flexing & medially rotating thigh 9

10 Muscles below the pelvis Gluteus maximus Gluteus medius/minimus Hamstrings biceps femoris semitendinosus semimembranosus Muscles below the pelvis Gluteus maximus Action: external rotator of femur, extension of thigh & assists adduction, can participate in extension of trunk Gluteus medius/minimus Action: abducts thigh & rotates thigh medially Hamstrings Action: extends hip joint & flexes knee joint (very prone to tightness) Muscles below the pelvis Quadratus femoris Action: stabilizes femur in acetabulum; externally rotates femur, adducts leg Gemellus superior &inferior Action: stabilizes femur in acetabulum; externally rotates femur; adducts leg 10

11 Pelvis floor: Muscles and ligaments Muscles of the Sacrum Piriformis 2 nd 4 th sacral segments Iliacus superolaterally Pelvic diaphragm (esp coccygeus) Ant to sacrotuberous & sacrospinous ligs Aponeurosis of the erector spinae Posterior surface in the U area abt the spinous and transverse tubercles No muscles move the sacrum directly!!! Detail of the piriformis 11

12 Attachments: S2 4 and inserts into the greater trochanter of the femur Action: External rot of thigh; abductor of the hip when the hip is flexed Innervation: S1 2 Importance: See picture to the right Sacral dysfunction can lead to piriformis syndrome The piriformis Nerves of Interest Autonomics S2 4 Pudendal nerve Sciatic nerve Femoral nerve Obturator nerve Lateral femoral cutaneous Lumbosacral angle (Ferguson s angle) The angle is generally between degrees An increase in this angle can increase lumbosacral strain Can anyone think of an example of this? 12

13 Iliosacral vs. Sacroiliac Motion Movement caused by either changes in vertebral column position or by leg movement Iliosacral Caused by leg movement Movement of the ilia on a stationary sacrum Sacroiliac Changes in vertebral column position Movement of sacrum in relation to stationary ilia 3 principal motions Sacral motion on ilium Ilial motion on sacrum Pubic motion Pelvic Motion Gross motions are initiated by motions of other body segments Walking Ilium on stance leg is elevated, ilium on swing side is tilted down & rotated toward the stance leg Pubic shear/torsion Ilial Motion on Sacrum Anterior posterior rotation ilium on sacrum Inferior transverse axis at the inferior pole of lower sacral articulation Translatory motion of the ilium on the sacrum Superiorinferior & anteroposterior directions 13

14 Pubic motion Caliper motion Gapping of the joint Torsional motion Superoinferior translatory motion Axes of Motion Pubic transverse axis Passes through symphysis pubis Find anterior/posterior rotations at sacroiliac joint in this axis Motion occurs as iliosacral Occurs as part of normal walking cycle Independent rotation of ilia in opposite directions via the pubic symphysis and iliosacral joint Stability of this axis of rotation provided by abdominal & upper thighs Axes of Motion Inferior Transverse Axis Loading sacroiliac joint (walking or standing on one leg) requires stable pivot point around which ilium rotate physiologically 2 separate, independent left or right pivot points Occurring one at a time Not correspond to perfect anatomical location (on each side of lowest pole of the sacroiliac joint) 14

15 Pubic & Inferior Transverse Axes The Axes of Sacral motion The sacrum has seven axes of motion 1 vertical: allows for left/right rotation 1 Anterior posterior: allows for sidebending 3 Transverse: Allows for flexion and extension. 2 oblique axes: Combines rotation and sidebending. Axes of sacral motion on the ilia 1. Vertical axis 2. Right oblique axis 3. Respiratory axis (superior transverse axis) 4. Sacroiliac axis (middle transverse axis) 5. Iliosacral axis (inferior transverse axis) 6. Left oblique axis 7. Anteroposterior axis 15

16 The transverse axes of the sacrum Superior transverse / Respiratory axis. (S2) Flexion and Extension occurs with respiration. The sacrum flexes when lumbar lordosis increases (exhalation) The sacrum extends when lumbar lordosis decreases (inhalation) Middle transverse / Sacroiliac axis. (S3) Flexion and extension occurs with motion of the sacrum on the illium. Inferior transverse / iliosacral axes. (S4) Flexion and extension occurs with motion of the ilium on the sacrum. BOTTOM LINE: All 3 axes allow flexion & extension. The transverse axes Flexion and extension of the sacrum 16

17 Sacral Side bending via an AP axis Sacral rotation about a vertical axis Oblique sacral axes Named for the SUPERIOR aspect they exit. The axis that runs from the right inferior aspect of the sacrum (right ILA) to the left superior aspect of the sacrum (left sacral sulcus) is the left oblique axis. The axis that runs from the left inferior aspect of the sacrum (left ILA) to the right superior aspect of the sacrum (right sacral sulcus) is the right oblique axis. 17

18 Oblique sacral axes Dynamic sacral motion With walking Torsional motion occurs during the walking cycle, depending on which phase of gait we are in. When we place weight on our left foot the sacrum rotates to the Right, on the Right oblique axis at midstance. The lumbar spine sidebends Right because of QL contraction. This motion is normal, however, when this motion is limited or fixed in a non neutral position dysfunction occurs. Diagnosing Pelvic Somatic Dysfunction History Static exam Iliac crest heights, popliteal creases, the greater trochanters of the femurs, the medial malleoli, and the medial longitudinal arches of the feet Lateralizing tests Standing flexion test Pelvic rocking Landmark palpation/diagnosis 18

19 Standing Flexion Test Lateralizing Tests Patient bends at the waist, while DO monitors PSIS bilaterally. The side that moves the most (elevates sooner and probably farther) is the side of the SD. FALSE POSITIVES Leg length inequality Tight muscles Pelvic Rocking A gentle but firm rocking motion (bilaterally and alternating )against the ASIS is directed along planes that are approximately para sagittal with the patient supine. Exam inconsistencies are usually from the vector of force. Muscles don t create false positives. Landmarks to palpate ASIS Pubic crest PSIS Medial malleoli Dysfunctions of the Pelvis Anteroposterior ilial rotation Anterior rotated innominate Posterior rotated innominate Superoinferior ilial shear Superior innominate shear (Up slipped innominate) Inferior innominate shear (Down slipped innominate) Inflare/outflare innominate Inflareof innominate Outflareof innominate Superior inferior pubic dysfunctions Superior pubic shear Inferior pubic shear Abducted adducted pubic dysfunctions Fixed compression of pubic symphysis Fixed gapping of pubic symphysis 19

20 Physiological and pathological dysfunctions in the pelvis Physiologic Abnormal movements of LE altering joint mobility of one ilium Anterior and posterior rotations Pathologic Trauma or muscle imbalance Subluxations Superior/inferior innominate shear Inflare/outflare of innominate Superior/inferior pubic shears or compression/gapping pubic symphysis Landmarks for diagnosis of the sacrum The sacral sulci may be found moving medial and slightly superior to the PSIS bilaterally. Physician places the palm of his/her hand on the sacrum. The most posterior aspect of the sacrum is the level of the Inferior Lateral Angles. The thumbs are then placed on each ILA. ILAs alone can provide enough info to distinguish sacral torsion from sacral shear (flexion/extension dysfunction) Seated flexion test Seated flexion test determines the motion of the sacrum upon the ilium. This test is performed in the seated position to take away pelvis and lower extremity muscle influences. The side which is positive is usually the side of dysfunction (and opposite the axis) in sacral torsions. False positives exist due to muscle influences. In sacral sheers, (flexions/extensions) one side may be restricted in seated flexion test, it will usually correlate to the side of the dysfunction. 20

21 Lumbar spring test Most tests in medicine are POSITIVE if disease or dysfunction is present. The Spring test determines if the base of the sacrum is able to move FORWARD or if it is stuck BACKWARDS. Pressure applied from posterior to anterior on the lumbosacral junction should initiate FORWARD sacral base motion. Lumbar spring test A board like resistance or lack of spring to the LS junction determines that the sacrum is stuck BACKWARDS. This is a positive Spring Test. Able to move sacral base forward with pressure = normal response/negative spring. Unable to move sacral base forward with pressure = abnormal motion response/positive spring. Backwards bending test (sphinx test) With the patient lying prone, the DO monitors the ILA s (or the sacral sulcus or both!) while the patient comes up on their elbows (like watching TV as a kid or in the Sphinx position). This creates lumbar extension and sacral flexion. 21

22 BBT If the findings improve the sacrum likes flexion and the direction of ease of the SD is forward. If the findings do not improve, the sacrum is in extension, or the base of the sacrum is stuck backwards. Motion testing With the patient prone, the DO applies a posterior to anterior pressure over all four corners of the sacrum (bilateral ILA s and sulci) Note which corner moves anterior the easiest. Motion testing, along with landmarks, can give you a sacral diagnosis. Naming a sacral torsion We diagnose the sacrum based on the position of ease with the anterior superior aspect of S1 as our reference point. Rotation is stated first with the axis stated 2 nd. For example, a right rotation on a right axis R on R 22

23 The sacrum and L5 L5 rules/sacral torsion rules (will help you name SD of the sacrum) Based on gait: 1. The sacral oblique axis will be to the same side as L5 side bending So if L5 is FRSL then the sacral axis will be left 2. The sacrum rotates opposite of L5 So if L5 is FRSL then the sacrum will rotate right 3. The seated flexion test is positive on the opposite side of the oblique axis 1. So +SeFT on the right, we will have a left oblique axis 23

24 Short leg cascade Can occur if anatomic or functional short leg Can occur if there is ankle sprain Short leg cascade Utilizing the right foot with an inversion ankle sprain R fibular head posterior R anterior innominate R on R sacral torsion There are other common findings but think about these for today The Fibular Connection Proximal fibular head Attachments Iliotibial band Biceps femoris Myofascial connection Initiate and sustain iliosacral dysfunction 24

25 Treatment Finally Diagnose Watch them walk Static exam with landmarks Include pelvic rock Can do seated/standing flexion tests Short leg cascade If one leg appears short Check fibular heads and treat accordingly Not going over this today 25

26 Pelvic Torsion Technique 26

27 Cross hand Sacral Release Decompression Sacral Release LUMBAR AND LOWER THORACIC SPINE 27

28 Inguinal ligament TP is superior surface of pubic bone Pt: supine Technique: flex both legs 90 degrees and place on doc s thigh. Move leg on tender side under the opposite leg. Adduct the femur. Internally rotate the femur by moving the ipsilateral leg towards yourself until the TP resolves Hold for 90 seconds Recheck Psoas TP is anterior and deep in iliac fossa Pt: supine Technique: stand on tender side. Flex patient s legs and place them on your thigh. Flex, sidebend and internally rotate the legs toward the TP until it resolves Hold for 90 sec Recheck Piriformis (very important point) TP is in the belly of the piriformis 8 9 cm medial and slightly superior to greater trochanter (but can be anywhere along the track of the muscle) Pt: prone Technique: doctor is seated on side of TP. Suspend pt s leg off table and rest the leg on your thigh. Flex the hip to about 135 degrees, abduct slightly via the knee and internally or externally rotate the knee until the TP resolves Hold for 90 sec Recheck 28

29 Sacral tenderpoints Found along the median crest of the sacrum They would be located on the spinous and transverse processes of the sacrum if it were not fused The sacrum fuses around age 25 so if the patient is younger than that the TPs will be on the respective transverse and spinous processes Pt: prone Technique: doctor is standing and will apply gentle pressure to the opposite part of the sacrum of where the TP is located For example if it is a PS1 right point, the doctor will push on the left ILA Hold for 90 sec Recheck Sacral Scissor MET Patient: lateral recumbent Doctor: standing facing patient, between their legs, monitoring the LS jxn and SI joints holding the top leg Technique: Position patient table leg into hip and knee extension while feeling that in the SI joint Position the held leg into hip flexion and knee extension while feeling for the feather edge of the restrictive barrier at the si joints and jxn Have the patient squeeze you for 3 5 sec Reposition the legs at the next barrier Repeat 3 5 times Reassess Homework for patients 29

30 Balance exercise Three parts Three levels to each part Be very careful with any patient who maybe a fall risk, anti coag Great for back pain, gait retraining MUST BE DONE COMPLETELY BAREFOOT Diabetics must check feet before and after Balance Exercise Part 1 Level 1 3 Stand with bare feet on carpet Contract foot to increase arch height Toes should not grip/be curled Stand on one foot with the c/l foot raised Try not to hold on to anything Ok to be near something if you should start to fall Try to get to goal of 15 sec per foot Move on to second level (handout) arms crossed over chest Move on to 3 rd level (handout) arms crossed over chest, eyes closed Picture depicts Levels 1 3 of part 1 Balance Exercises Part 2 Level 1 3 Forward tandem walking Place one heel in front of the c/l foot s toes Be sure to place the heel down prior to the toe. Repeat for 10 steps Eyes must look forward Repeat until you can do it without wobbling Move on to second level (handout) arms crossed over chest Move on to 3 rd level (handout) arms crossed over chest, eyes closed 30

31 Balance Exercise Part 3 Level 1 3 Backward tandem walking Place one toe behind of the c/l foot s heel Be sure to place the toe down prior to the heel. Repeat for 10 steps Eyes must look forward Repeat until you can do it without wobbling Move on to second level (handout) arms crossed over chest Move on to 3 rd level (handout) arms crossed over chest, eyes closed Pelvic clock Lie supine Imagine a clock on your belly 6 on the pubes 12 on the xiphoid Monitor ASIS so the move evenly Start by tilting pelvis by pushing umbilicus to 12 for 5 sec Pushes lumber spine forward Move umbilicus to 6 for 5 sec Pushes lumbar spine backward Then go to 3 for 5 sec then 9 for 5 sec Lumbar rotation Level 2 is to try all the numbers on the clock Hamstring Stretch Lie supine on firm surface with hips & knees bent Tilt pelvis to 12 o clock Lift leg(s) so you can grasp the backs of your thighs with your hands Hands should be near knee(s) Keep back and neck straight Slowly extend leg(s) by contracting gluts and pushing your heels to the ceiling Hold for 15 sec Repeat 6 times Length of time is less important than the posture Once this is easy pull toes down to you and alternate with heels to ceiling Work up to holding it for 30 seconds 31

32 The Psoas For the R side Kneel on R knee with L knee bent to 90 degrees (thigh parallel) Turn R foot inward Place hand on R buttock and contract Flatten belly and pelvic tilt to 12 Using L leg, pull body forward but keep your back straight while maintaining buttock contraction You will feel this in front of R thigh and hip Hold for 10 sec with 6 rep Work up to 30 sec (I usu just have them do 30 sec off the bat) Repeat on L Piriformis Level 1 Part 1 Lie supine on a firm surface with legs extended Tilt pelvis to 12 o clock Place R foot on floor along outside of L knee Above 90 Degrees Grasp the R knee with L hand and pull it gently toward the L hip If tightness occurs, push knee into hand for 5 sec Relax and try to bring knee closer Repeat 3 times Below 90 Degrees Piriformis Level 1 Part 2 After part 1 Lift the R leg toward you with both hands on the knee Straighten neck and back so the muscles are not in use Slowly pull right leg towards left shoulder If tightness occurs, push knee into hand for 5 sec Relax and try to bring knee closer Repeat 3 times You can use a belt or towel for leverage if needed Do on L side 32

33 Piriformis Level 2 (pigeon pose) Begin by resting hands/arms and knees on a firm padded surface For R piriformis Place R Foot in front of L knee Slowly stretch L leg until it is fully extended while bending the torso forward onto the R leg Bend forward until you feel a decent stretch of the piriformis or your chest touches the R leg Hold for as long as tolerable Up to 30 sec Repeat once Do on L side I tend to have patients do this one if they are able References Special thanks to David Furrow, D.O. for the use of his Pelvis lecture content. DiGiovanna, Eileen L., et al. An Osteopathic Approach to Diagnosis and Treatment, 3 rd ed., 2005, Pages chapter 57, 60 and 61 (pictures from 2 nd edition as well) Mitchell, Fred L., Jr., P. Kai Galen Mitchell, The Muscle Energy Manual, Evaluation and Treatment of the Pelvis and Sacrum, Vol. 3, 1999, pages Muscle Energy Manual, Graham, pages Netter Lower extremities/pelvis. Atlas of Osteopathic Technique, 1 st ed. Nicholas and Nicholas; pages Foundations of Osteopathic Medicine; 3 rd ed. Chapter 41 Phil Greenman, DO, FAAO Exercise RX Ligamentous Articular Strain 2 nd edition: Speece, Crow, Simmonds 33