Valeria Pelvis Course Day 1
Student’s issues with the pelvis:
1. Effective TTT
2. Pelvic floor assessment
3. Interpretation of findings – lack of basics & incomplete diagnosis.
4. Anatomy – SIJ movement?
Pelvis:
 Components – posture/force.
 Focus on lack of movement.
 Use the skin as a way in – not digging in.
 Interpretation – rule in and rule out certain relations.
 Relate qualities of the TLF
Case study: 61 yoa M. B pelvic inflair.
Structural assessment: will change each session
1. +ve findings
2. Reject –ve findings
3. Open minded
4. Be curious
5. Use “impression” of the structures on the patient’s skin.
Standing pelvic assessment:
1. Kneel on floor. Use MCP of index finger – come from above B and
keep soft onto skin above iliac crest. Feel for different density of
tissue. Listening station – feel, possibly for anterior or posterior, do
not interpret what it means.
2. Go with skin anterior on one side and then posterior. Then recheck
the other side anterior and posterior. Do not interpret – go for side
of +ve finding of ↓ ROM.
3. Change hand position to thumbs now inferior B PSIS. Now ask
patient to forward bend. This allows for findings of groin
involvement +ve to one side – on forward bending you will feel
avoidance in patient on that side – possible involvement of
hips/lower abdominal/groin/pubis > more ideas for assessment.
Feel how skin is pulling through the iliolumbar ligaments and TLF.
Should B PSIS move at same time. One PSIS may come before
the other. The one not opening is the +ve finding. Feel for
restriction in groin/hip when bending forward – the patient will
avoid that side on flexion after 50°. L5/S1fixation usually the
sacrum hooks up on flexion of LSp and can be differentiate with
the SIJ > differentiation of the Lumbars from the sacrum.
4. Stork test: squat down and kneel. Applicators under PSIS and on
S2 on ipsilateral side. Get patient to ipsilateral hip flex and hold
with opposite hand. The PSIS thumb should roll posterior and
inferior. +ve test is that the PSIS (innominate) does not move inf
and post on ipsilateral hip flexion. Test contralateral hip flexion with
palpation of sacrum using contralateral innominate. If the sacroiliac
ligaments are good the sacrum should follow the movement and
should go down (counternutate). If these ligaments have an issue
will feel that there will be a struggle in the sacral ligamentous
tissue. This will differentiate the SIJ on one side and the sacrum
from the innominate. However this does give you a diagnois just
yet.
5. Trendelenberg test: Patient lifts hip flexion. Have hands into the
waist. A true +ve trendelenberg is a true ipsilateral drop on
ipsilateral hip flexion. This shows a true muscular weakness of the
gluteal medius on the EXT hip side (contralateral side). It is not a
true weakness if there is a slight dip – the GMed may not be
functioning so well. There should be a normal dip in contralateral
gluteus medius on ipsilateral hip flexion.
Muscle
Att
Function
Antagonist
Gluteal maximus
Iliac crest, sacral
EXT of hip and
Psoas
border laterally,
trunk and EXT
coccyx ITB, gluteal
ROT of hip.
tuberosity,
saxcrotuberous
ligament
Gluteal Medius
Between
ABD and INT
intermediate and
ROT
inferior gluteal line,
Stabilises the
greater trochanter
pelvis
Adductors
6. Gossip test: Hips EXT ROT and then bend one knee and then the
other.
Test
Results
Expected result
Standing palpation
L or R innominate
Restriction = +ve
Anterior/Posterior
finding
PSIS with Flexion
L or R PSIS restriction PSIS should open
+ve is restriction
Stork test
Test for PSIS with
PSIS should move
ipislateral hip flexion
posterior and inferior
Test ipsilateral S2
Sacrum should move
(sacrum) with
inferiorly (counter-
contralateral hip
nutate)
flexion
Sitting pelvic assessment:
1. For +ve stork test. Patient is seated with feet on floor. Pelvic floor
is off stretch when seated; sacrum, ischium and innominate is
taken out of the equation. With forward flexion and there is a much
better response in the SIJ > there is an issue in the pelvis rather
than the LSp.
Supine pelvic assessement:
1. Check ASIS, put your body projected over the pelvis. Is the same
pattern there?
2. Check pelvic floor from feet. Is the diamond shape more oblique or
flat on one side. What is the shape of the diamond by Lifting
patient’s legs at heels. Hold and feel for connection to pelvis.
Light/heavy isn’t a diagnostic tool. Feel for the pelvic floor at feet
and assess for shape. No diagnosis of gynae, Hip, LSp,
innominate/sacrum – these are findings.
3. Check each leg one at a time and by bending knees, then
extending knees and lifting up leg more you go further up the leg
into the pelvis, LSp and thorax.
Prone sacral assessment:
1. Sacral assessment prone: Go onto inferior angle of sacrum.
Hold onto B PSIS down to inferior angle B and make a shape
with both hands (fingers at S4/S5 and thumbs at S2/PSIS).
 Sacrum recoil TTT: High on left and low on the right > pisiforms
onto superior right (recoil downwards) and inferior angle (recoil
upwards). For opposite presentation do the reverse.
 Gluteus max tech: thumb into sacral origin with reinforced
elbow. Add Long Lever into compression and not stretch, with
passive EXT ROT of hip and active leg into the midline with
thumb on sacral border. Recheck the sacrotuberous ligament
2. Diagnosis of sacral levels and sides prone: Check sacrum with
crab hands one reinforcing the other and compression from S2
down feeling for restricted side and level. For counter-nutation
of sacrum > iliolumbar and Lsp is under tension . For nutated
sacrum > sacrotuberous and sacrospinous ligament under
tension.
 TTT for counter-nutated sacrum: pressure on S2 of opposite
side to plinth with elbow over the gluteals at lateral sacrum with
hand holding leg below the calf. The other hand under the knee
you created passive innominate anterior rotation using knee flex
and thigh ext by leaning back > you nutate sacrum.
 TTT for nutated sacrum: Have pressure of elbow below S2 (ie
S4) on the sacral/ilium line. Press on the sacrum into counternutation and then get patient to Txx the leg down the plinth and
you encourage the movement of lengthening Txx the sacrum.
 TTT for Sacrotuberous ligament and midline gluteals: sidelying
with knee flexed. One hand onto midline gluteal attachment,
knee into belly/hip of operator and have support under the thigh
and link hand onto forearm. Create flexion active and/or passive
to put gluteal fascia under tension and wait for some release.
 TTT to iliacus for L/S restriction: with a sacrum more posterior
to L5. Release the iliacus, which tilts the pelvis posteriorly
rotation as a major hip flexor, leading to sacral release and take
pressure off the L/S.
 Thomas test for hipflexor/quad tension: supine and get patient
to hip flex actively holding knee in their hand. +ve test for hip
flexor tension is opposite hip into flexion and +ve quad tension
is opposite knee flexed.
 Technique awareness: Key to TTT is biomechanics of operator
finding specific vector of own posture and using the patient’s
body to minimise overuse of operators posture and making a
technique energy efficient.
 Rotated pelvis: analysis of muscle bulk in multifidus and into
TLF and relation to the hypotone in the transversus abdominus.
Look for tone and bulk. Check rib elevation in breathing. Look at
posterior ribs, relation to serratus posterior inferior, connect
tissue palpation, obs and findings. Link TES into gluteals and
TLF via TTT – hand on TES and TLF, resist into gluteals with
elbow and get them to actively INT ROT hip prone.
 Groin issue: use skin into tension in thigh. Get patient to EXT
ROT and you hold in resistance. Direct stretch of fascia into a
bind. Wait for change and release. Can use this resistance to
create gapping at the hip joint.
 With lower LSp pain check the Pelvis:
 Check for skin drag at iliac crest
 Check PSIS versus LSp standing & seated – to differentiate
lumbosacral or innominate issue
 Stork test – is it innominate or sacrum?
 Trendelenburg test – is gluteal medius involved.
 Abdominal facscia and TLF test with flat hands and breath on
ribs
 Seated flexion of spine
 Supine and prone check
 Seated - if the SIJ opens smooth on seated means that the LSP
is not involved and the sacrum is therefore in lesion.
 Pelvic floor direct
 Hands under ischial tuberosities > stretch lateral/ anterior and
posterior.
 Pelvic floor indirect
 From heels bi hold the LEx and fascial listen into the pelvic floor
 Do hip exam passive > see if this affects the pelvic floor and
how it relates to presentation.
 ASSESS pubic symphysis > shotgun technique
 Prone assessment of sacrum > nutation/counter nutation/SB/
ROT
 Psoas SL TECH: to get iliacus int rot at hip
 Modify with leg up and patient leg balancing so u don't have to
carry all the weight
 Psoas supine one leg off the couch and other let straight or
bent. Hook operator foot into knee flexion and hip ext and Twist
skin int rot with rocking.
 Leg tug: release groin first int rot of skin with active ext Rot. She
uses compression into the fascia.
 Tug: put other foot on thigh to stop patient moving. Int Rot opp
leg in flex and add > 1st in to POE > focus and then tug.
You can build tension in planes > tug at tibia.