assessment of the pelvis
Prepared and presented by Nichole Hamilton, Physiotherapist
for Clinical Edge
Assessment of the Pelvis
Anatomy Review
Bony Landmarks
Function of the pelvis and SIJ
Tests of Dysfunction
Directions and ideas for treatment
www.clinicaledge.com.au
Anatomy Review
!
Ligaments of the SIJ
• Anterior SI ligament
• Interosseous and Posterior
L shaped joint with shorter
vertical arm and longer
horizontal arm
ligaments
• Sacrotuberous ligament
• Sacrospinous ligament
• Iliolumbar ligament
• Long dorsal ligament
! Innominate: Ischium, pubis and
ilium
! Sacrum: sacral base and apex
Palpation
Innominate:
! ASIS
! PSIS
! Ischial Tuberosity
Sacrum:
! Sacral base
! Sacral apex and hiatus
! Sacral Sulcus
! Inferior lateral angle
Copyright Clinical Edge 2011
Physiological movements of
the SIJ
• Innominate anterior rotation
• Innominate posterior rotation
www.clinicaledge.com.au
1
SIJ and pelvis: function
Physiological movements of the SIJ
! SIJ:
! Functions to transmit forces
between the lumbar spine and
lower limb
Sacrum
• Nutation and
Counternutation
• Torsion- combined rotation
and contralateral side flexion
SIJ Stability
• Vertical orientation makes
the SIJ’s susceptible to to
shear forces in the vertical
plane (Snijders et al 1993)
• Therefore requires
adequate lateral
compression to stabilise
and transfer load
efficiently (Lee 1999)
SIJ Stability
!
The closed packed position
for optimal stability is a
combination of:
• Sacral Nutation
• Innominate Posterior
Rotation
! (Sturesson et al 1989, 2000, Hungerford et al 2004)
Factors improving SIJ compression
Examination and Testing for SIJ
dysfunction
• Form Closure (Sturesson et al 1989,
2000, Hungerford et al 2004)
• Force Closure
• Ability to achieve closed
packed position
Copyright Clinical Edge 2011
To test for SIJ and pelvic dysfunction we need to analyse
its ability to achieve normal function:
• Functional tests of SIJ load transfer ability
• Tests of force closure
• Tests of form closure
www.clinicaledge.com.au
2
Functional Tests of Load
Transfer
Functional Tests of Load
Transfer
Forward Flexion Test:
• Palpate PSIS bilaterally and
flex forward at hips
• Positive when one PSIS
raises superiorly (anterior
innominate rotation and
unlock SIJ)
• Can retest one SIJ at a time
Stork Test: Stance Phase
• Palpate PSIS and S2 spinous
process
• Ask patient to stand on one
leg and flex contra-lateral hip
• Positive for SIJ dysfunction if
innominate anteriorly rotates
(or unlocks) relative to sacrum
(Stuerrson et al 2000, Hungerford et al 2004)
SIJ Dysfunction
Tests of Force Closure
!
Active Straight Leg Raise
• Tests ability to maintain LP
stability during load transfer
• Patient Supine
• Actively raise one leg off plinth,
then repeat on opposite side
• Differences in subjective effort
noted and compensation strategies
observed
!Positive functional and load transfer tests indicate
a failure to efficiently transfer load between the
trunk and lower limb through the pelvis
Why?
(Mens et al 1999, 2001, 2004)
Tests of Force Closure
Tests of Form Closure
! If intra-articular glide is restricted in
the SIJ, the ability to efficiently
achieve form closure and load
transfer can be compromised
• Squish test (Buyruk et al 1995)
• Articular Glide test (Lee 1999)
ASLR Test with Compression
• Retest ASLR with compression
around the pelvis
• Does this improve or change
patients ability to ASLR?
• Can also test PHE
(Lee 1999)
Copyright Clinical Edge 2011
www.clinicaledge.com.au
3
Directions for Treatment 1
Passive Joint Glide Test (Squish)
!"#$#%$&'()&#%*(+()&+#,'&-.
! !"#$%%&'$!"#$()*+,$! -./0#1$0*.1$)+.23-#+$/2$4#0"/3$5)6.)$
2##13$-7+)6#+$#8.9/2.)/*2:
! (;<$=+)/>70.+$?0/1#$)#3)3$#@7.0
! =(AB$)#3)$;CDBEFG($H/)6$>*94+#33/*2
• Glide the ilium on the
sacrum along the joint
line (posteriorly and
slightly superiorly)
• Compare left and right
feeling for R1 and R2
symmetry in resistance
$ /0121#2!342#!45!67/1#/0!2#87/!14/#41152#9:;1#
6:98;122!:4#!4#/01#81<=!2#/:#>?46/!:4@##
# /0!2#674#6:91#>;:9#;107A#1B1;6!212#/7;31//!43#
>?46/!:47<#145?;7461#!4#/;742=1;2?2C#
9?</!>!5!2#745D:;#3<?/17<2@
Directions for treatment 2
directions for treatment 3
!"#$#%$&'()&#%*(+()&+#,'&-.
! G8.940#3$*-$9.27.0$)6#+.4I$-*+$#.>6$/21/"/17.03$K+#3)+/>)#1$
! !"#$%%&'$!"#$()*+,$!
-./0#1$0*.1$)+.23-#+$/2$4#0"/3$5)6.)$2##13$-7+)6#+$
#8.9/2.)/*2:
! =+)/>70.+$?0/1#$)#3)3$=33I9#)+/>
! =(AB$)#3)$)6.)$1*#3$JE&$/94+*"#$H/)6$>*94+#33/*2
)/337#L$>.2$/2>071#$9.33.M#'$2##10/2M'$3)+#)>6#3'$)+/MM#+$4*/2)$
+#0#.3#'$CG&$N$)6/3$H/00$1#4#21$*2$I*7+$3,/00$.21$)+./2/2M
! G8#+>/3#$)*$/94+*"#$3).O/0/)I$>.2$/2>071#$4/0.)#3'$4*3)7+.0$
.H.+#2#33'$-72>)/*2.0$>*+#$#217+.2>#$#8#+>/3#3'$-72>)/*2.0$
M07)#.0$3)+#2M)6#2/2MP
$ /0!2#97E#!45!67/1#/01#87/!14/#!2#7<;175E#F/::#6:98;12215G#745#
41152#974?7<#/01;78E#5!;16/15#7/#;12/;!6/15#2!H#:;#/!30/#
9?26<12@
#
# /0!2#;1I?!;12#!45!=!5?7<#722122914/C#A?/#674#!46<?51#
8!;!>:;9!2C#/><C#I<#:;#0792/;!432
# 6JKKJ)LM#%$&'()&+#,'LL#)((N#$#OJKP')$&'J)#J"#K$)Q$L#
&-(*$%M#"J*#*(+&*'O&(N#&'++Q(DRJ')&#$)N#+&$P'L'+$&'J)#
(S(*O'+(+#"J*#J%&'K$L#*(OJT(*M#J"#"Q)O&'J)
References
•
•
•
•
•
•
Buyruk H M, Stam H J, Snijders C J, Vleeming A, Lameris J S, Holland W P J 1997 Measurement of sacroiliac joint stiffness
with color doppler imaging and the importance of asymmetric stiffness in sacroiliac pathology. In: Vleeming A, Mooney V, Dorman
T, Snijders C, Stoeckart R (eds) Movement, Stability and Low Back Pain. Churchill Livingston, Edinburgh, p 297
Damen L, Buyruk H, Guler-Uysal F, Stam H 2001 Pelvic pain during pregnancy is associated with assymetrical laxity if the sacroiliac joints. Obs Gynae Scand 80: 1019-1024
DonTigny R 1985 Function and Pathomechanics of the Sacroiliac Joint A Review. Physical Therapy 65(1): 35Hungerford B, Gilleard W, Hodges P 2003 Evidence of altered lumbo-pelvic muscle recruitment in the presence of sacroiliac joint
pain. Spine 28(14) 1593-1600
Hungerford B, Gilleard W, Lee D 2004. Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain
using skin markers. Clinical Biomechanics.
Hungerford B, Gilleard W, Hodges P, Lee D 2004 Paper presented at the 5th World Congress on Low Back and Pelvic Pain.
Altered Lumbo-Pelvic muscle recruitment occurs in the presence of sacroiliac joint pain.
References
•
•
•
•
•
•
•
Copyright Clinical Edge 2011
Lee D 1999 The Pelvic Girdle; An approach to the examination and treatment of the lumbo-pelvic-hip region. Churchill Livingston,
Edinburgh, pp145-151.
Mens J, Vleeming A, Snijders C, Stam H, Ginai A 1999 The active straight leg raise test and mobility of the pelvic joints. European
Spine 8:468
Mens J, Vleeming A, Snijders C, Koes B, Stam H 2001 Reliability and Validity of the active straight leg raise test in posterior pelvic
pain since pregnancy. Spine 27(2):196
O’Sullivan P, Beales D, Beetham J, Cripps J, Graf F, Lin I, Tucker B, Avery A 2002 Altered motor control strategies in subjects
with sacroiliac joint pain during the active straight leg raise test. Spine 1:21(1): E1-8
Snijders C, Vleeming A, Stoeckart R 1993 Transfer of lumbosacral load to the iliac bones and legs. 1: Biomechanics of self bracing
of the sacroiliac joints and its significance for treatment and exercise. Clinical Biomechanics 8: 285-294
Sturesson B, Uden A, Vleeming A 2000 A radiosteriometric analysis of movements of the sacroiliac joints during the standing hip
flexion test. Spine 25(3): 364
Vleeming A, Mooney V, Dorman T, Snijders C (eds) 1995b Second Interdisciplinary world congress on low back pain: The
intergrated function of the lumbar spine and sacroiliac joint, San Diego.
www.clinicaledge.com.au
4