Pelvic Anatomy Evidence-Based Evaluation & Treatment n Innominates of the Sacroiliac Joint n ischium n ilium n pubis James R. Scifers, DScPT, LAT, ATC Moravian College n Sacrum Athletic Training Program Articulations Biomechanics of the Pelvis n Function of the SI Joint n transmit vertical forces n Sacroiliac Joints n transmit ground n Pubic Symphysis reaction forces n Lumbo-Sacral Joint Sacral Motions Arthrokinematics of the SI Joint n During trunk flexion… n Sacral Base (S1) n Initially, sacral flexion occurs (base of sacrum n Sacral Apex (S5) moves anterior) n Flexion (nutation) n Later, sacral extension occurs with continued trunk flexion (base of sacrum moves posterior) n occurs during exhalation n Extension (counternutation) n occurs during inhalation 1 Dysfunction Classification Ilio-Sacral (IS) Dysfunctions n Sacroiliac Joint (SIJ) n Named for motion at n Any injury to SIJ PSIS n Ilio-Sacral (IS) n anterior rotation n ilium (innominate) n posterior rotation moving on sacrum n up-slip n Sacro-Iliac (SI) n down-slip (rare) n sacrum moving on ilium n in-flare n Pubic Shear n out-flare n Pubic symphysis / Pubic shear lesion Sacro-Iliac (SI) Dysfunctions Pubic Shear Lesions n Sacral Rotations n Named for “direction facing on axis” n Named for any movement at pubic n Forward Rotations symphysis n right on right n Indicates injury to pubic n left on left symphysis n Backward Rotations n right on left n left on right SI Evaluation Evidence-Based Practice (EBP) n Reliability (k) is reproducibility of test results, can be n History* intra-tester (within one clinician) or inter-tester (between n Observation** multiple clinicians) n Palpation** n Sensitivity (sens) is the ability of test to RULE OUT a condition. The higher the sensitivity, the greater n AROM / PROM chance that a NEGATIVE test means the condition is n MMT absent n Special Tests* n High sensitivity + negative test = rule condition out (SnNout) n Neurologic Exam n Specificity (spec) is the ability of test to RULE IN a condition. The higher the specificity, the greater chance that a POSITIVE test means the condition is present n High specificity + positive test = rule condition in (SpPin) 2 Evidence-Based Practice (EBP) Strength of Recommendation Taxonomy (SORT) n Positive Likelihood Ratio (+LR) indicates the likelihood that a POSITIVE test means the condition is SOR T C at egory Level of Evidence present SORT Consistent, good-quality, patient-oriented evidence n Negative Likelihood Ratio (-LR) indicates the A likelihood that a NEGATIVE test means the condition is absent SORT Inconsist ent or limit ed-quality, patient-oriented evidence B SORT Consensus, disease-oriented evidence, C usual practice, expert opinion, or case series History Pain Referral Patterns2-3 n SI pain typically unilateral, may refer n Pain typically localized to involved SI joint Pain Location Fr equency Sensitivity Specificity + LR - LR 1 n Sens = .76, Spec = .47, +LR = 1.4, -LR = 0.51 Lum bar S pine 72% N/A N/A N/A N/A n Pain may increase with trunk rotation, sidegliding, Buttock1 94% 0.80 0.14 0.9 1.42 trunk/hip extension or sidelying Gr oin1 14% 0.19 0.63 0.51 1.29 n MOI may include falling or twisting Thigh 48% N/A N/A N/A N/A n MOI more often insidious (48 hour rule to assess for cause) n Aggravating Activities usually includes sitting Lower Leg 28% N/A N/A N/A N/A n Sens = .03, Spec = .90, +LR = 0.3, -LR = 1.071 Foot 12% N/A N/A N/A N/A Clinical Application #1: Failure to report pain at the PSIS is a good predictor for patient NOT suffering from SIJ pathology SORT B SORT Clinical Application: Failure to report buttock pain is a Clinical Application #2: Pain increased with sitting is a good good predictor for patient NOT suffering from SIJ pathology indicator that patient may be suffering from SIJ pathology B Observation4-6 Palpation4-6 n Observe for spasm n Standing: n erector spinae n ASIS n Observe muscle tone n PSIS (k = .13 - .37) n (k = .23 - .41) n gluteals Iliac Crests n Greater Trochanters n Observe symmetry: n Prone: n PSIS n Sacrum n Iliac Crests n Inf Lat Angle of Sacrum (k = .69) n ASIS n Sacral Sulcus (k = .24) n Greater Trochanter n Sacrotuberous Ligament n Pubic Tubercle n Piriformis (or sidelying) n Supine: n Pubic Tubercle 3 Palpation Location of Pain1 Piriformis Palpation Locations Sensitivity Specificity + LR - LR Sacral Sulcus & PSIS 0.49 0.60 1.2 0.85 Sacral Sulcus & Groin 0.11 0.73 0.40 1.22 PSIS & Groin 0.16 0.85 1.10 0.99 SORT Clinical Application: Patients reporting pain in the region of the B PSIS and the groin are likely to be suffering from SIJ pathology Sacrotuberous Ligament Palpation ASIS Palpation PSIS Palpation Iliac Crest Palpation 4 Alignment & Symmetry Active / Passive Range of Motion n Iliac Crest Heights n Greater Trochanter n AROM tested in standing n higher or lower Levels or sitting n PSIS Relationships n higher or lower n PROM tested in supine or n superior-inferi or n Sacral Sulcus Depths prone n medial-lateral n deeper or shallower n Stress at SI Joint: n ASIS Relationships n superior& inferior n Spine flexion 40-60° n Spine extension 20-35° n superior-inferi or n Inferior Lateral Angle of n Spine rotation 3-18° n medial-lateral Sacrum n Spine side glide 15-20° n deeper or shallower n Hip flexion 100-120° Very low inter-tester reliability values (k = .13 - .37) with n Hip extension 0-15° exception of inferior lateral angle of sacrum (k = .69)4-6 SORT Clinical Application: Pain increased with AROM or PROM Hip Extension to end-range can help differentiate SIJ C pathology from Lumbar Spine pathology Manual Muscle Testing Neurologic Assessment n As needed (not usually necessary for diagnosis) n Trunk flexion n Abdominals n Should be normal in n Hip flexion presence of SI dysfunction n Hip abduction n Dermatomes (L1-S2) n Gluteus Medius n Myotomes (L1-S2) n Gluteus Minimus n Hip adduction n Reflexes n Hip extension n Patellar Tendon (L3-L4) n Achilles Tendon (S1-S2) n Knee flexion n Trunk extension n Br idging SORT Clinical Application: Pain increased with bridging is often C indicative of SIJ pathology Special Tests Special Test Literature Pain Provocation Tests Positional Tests n Provocation Tests have little predictive value in 1 n Straight Leg Raise Test n Trunk Flexion Test isolation or combination n Gaenslen Test n March Test n Inter-tester Reliability of Positional Special Tests is low 6,8 n Thigh Thrust Test n Supine to Sit Test n Positional Special Tests performed in combination n FABER / Patrick’s Test n True LLD Test greatly increase value of findings 7-10, 22-23 n Gapping Test n Apparent LLD Test n Compression Test n Trendelenburg’s Sign n Sacral Spring Test n Thomas Test n SI Rock Test n Flamingo Test SORT Clinical Application: SIJ special tests should always be A used diagnostically in combination & not in isolation 5 Special Test Literature Special Test Literature n Laslett, et al (2005)23 n Van der Wuff, et al (2006) 22 n 2 of 4 Positive Special Tests n 3 of 5 Positive Special Tests n Thigh Thrust, Distraction, Compression & Sacral n Thigh Thrust, Distraction, Compression, Patrick’s & Spring Gaenslen’s Sens. Spec. + LR - LR Sens. Spec. + LR - LR .88 .78 4.00 0.16 .85 .79 4.02 0.19 n Take Home Message: n Take Home Message: n In combination, tests are good for ruling in and n In combination, tests are good for ruling in and ruling out SIJ dysfunction ruling out SIJ dysfunction Special Test Literature Special Test Literature n Laslett, et al (2003)7 n Cibulka & Koldehoff (1999)9 n 3 of 5 Positive Special Tests n 4 of 4 Positive Special Tests, 219 subjects n Thigh Thrust, Distraction, Compression, Gaenslen’s n Standing Flexion, Sitting PSIS Palpation, Supine to & Sacral Spring Sit & Prone Knee Flexion Test Sens. Spec. + LR - LR Sens. Spec. + LR - LR .91 .87 4.16 0.11 .82 .88 6.83 0.20 n Take Home Message: n Take Home Message: n In combination, tests are excellent for ruling in and n In combination, tests are good to excellent for ruling out SIJ dysfunction ruling in and ruling out SIJ dysfunction Straight Leg Raise Test Gaenslen Test n Clinician passively flexes n Patient is supine with both hip with knee extended legs extended n Pain at 0-30 degrees---hip n Uninvolved knee is pathology or nerve root brought to chest while n Pain at 30-50 degrees--- involved hip remains in sciatic nerve involvement extension n Limited ROM of less than n Overpressure is applied to 70 degrees---hamstring tightness involved side n Pain at 70-90 degrees--- n Positive test is pain sacroiliac joint involvement indicating SIJ involvement Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR 0.78-0.97 0.10-0.57 1.00-1.98 0.05-0.35 0.21-0.71 0.26-0.77 0.75-2.21 0.65-1.12 All data for detecting lumbar disc herniation, not SIJ pathology11 K = .54 - .761, 6, 8, 20-21 6 Thigh Thrust Test FABER or Patrick Test n Patient is supine n Patient supine with hip positioned in flexion, abduction and external n Involved hip is flexion and rotation adducted n Clinician applies over-pressure at n Posterior shearing force is knee toward table while applied through femur in stabilizing opposite ASIS varying degrees of hip n Positive test is pain indicating SIJ adduction / abduction pathology n Positive test is buttock pain n If patient exhibits a decrease in indicating SIJ involvement pain, an out-flare should be suspected Sensitivity Specificity + LR - LR Sensitivity Specificity + LR - LR 0.36-0.88 0.50-1.00 0.70-2.80 0.20-1.28 0.10-0.77 0.16-1.00 0.41-0.82 0.23-1.94 K = .64 - .881, 6, 8, 18, 21 K = .60 - .621, 6, 21 Gapping or Distraction Test Compression Test