Exam 1 Spring Flashcards
(154 cards)
1
Q
Inferior innominate shear
A
§side with the POSITIVE standing flexion test.
- ASIS on affected side is inferior
- PSIS on affected side is inferior
- Pubic rami on affected side may be inferior
Ischial tuberosity inferior
2
Q
A
3
Q
Seated & Standing Flexion Tests: sacrum & ileum
A
Sacrum-
- seated FT lower extremities = not influencing SIJ
- positive test indicates the side (lateralization) but not the specific dysfunction, of sacroiliac dysfunction.
Ilium-
- during the standing FT the lower extremities = influence SIJ
- positive test indicates an iliosacral SD, or excessively tight contra-lateral hamstrings.
4
Q
Joints significant in gait
A
5
Q
A
-Deep sulcus and post/inf
ILA are opposite so we have
an oblique axis
-The sacrum has rotated
towards the right; L5 rotated to
the left
Dx: R on R sacral torsion
6
Q
Shuffling gait
A
typ in parkinson’s
pattern:
- small, flat-foot shuffle (less ground clearance)
- rigid, temor, pausing mvmts, shuffling with haste,
- diff: start, stop, turn
- trucal flex
1st noticable signs: non-rhyth pattern with random/poor timed arm swings
tx: L-dopa
7
Q
cranial concept of pelvis
A
sacrum connects innominates –> occiput motion
alts affect either side: alters biomech model via dural attachement
8
Q
Superior Innominate shear
A
§shear-named for the side with the POSITIVE standing flexion test.
- ASIS on affected side is superior
- PSIS on affected side is superior
- Pubic rami on affected side may be superior
- Ischial tuberosity superior
9
Q
Ataxic gait
A
reeling, unsteady with wide base: tend to fall towards side of lesion
pattern:
- irreg steps
- lateral veering
- carefully watching ground
most prominent with sudden turns/stop/start
reasons:
- injury to cerebellum, SC, peripheral sensory NS
- inpair of joint position sense: afferent fibers disruption in peripheral N/posterior roots/posteiror columns of SC
10
Q
Spondylolisthesis
A
anterior slippage of vert: usu @ L5 on S1
11
Q
Low Back Pain Expanded Differential Dx (10)
A
PPP A A COMIC
Prostatitis
Paget’s disease
PID
AAA
Abscess
Ca lesions
Ovarian cysts/CA; endometriosis
Multiple myeloma
Infection
Compression fracture
12
Q
pubic shear
subjective complaints?
A
caliper: gapping
subjective:
- UTI symptoms: burning, freq, fullness, weak stream, dysuria, dysparunia (painful sex)
13
Q
Muscular Action during STANCE Phase
A
14
Q
most important part of gait
A
flex of stance knee
if knee locked up = E expend up 50%
- another detm lost = 300% lost
15
Q
Sacral/Innominate Motions during Gait
A
- Weight shift to the left
- Posterior rotation of innominate
- Rotation of whole pelvis to the left
- L/L sacral torsion
16
Q
Innominate/Iliosacral Rock/ Compression Test
A
17
Q
Lower Extremity Joints during Gait: Ankle
A
body wt = just medial of center: eversion –> inversion
18
Q
Forward Sacral Torsions with Gait
A
Left stance leg =
Left on Left torsion
Right stance leg =
Right on Right torsion
19
Q
Traumatic Sacral SD
A
slip/fall on butt
MVC –> F from “braking” foot –> leg –> pelvis
20
Q
Anterior SIJ
A
synovial
different orientation than posterior/lig aspect
21
Q
herniated disc
A
type 2 F SD –> flat lordosis –> shearing stress
rad pain –> butt
- init disinterpred as SI pain/dysfx
neuro exam important for distinguishing SI pain from disc protrusion
22
Q
Forward Sacral Somatic Dysfunctions on Oblique Axis
A
- We have 4 possibilities for forward sacral somatic dysfunctions:
- Left on Left sacral torsion
- Left on left sacral rotation
- Right on Right sacral torsion
- Right on Right sacral rotation
23
Q
what does the external oblique form distally?
A
inguinal lig as it txverses ASIS –> pubic tubercle
24
Q
A
25
Sacral Torsion Rules
* Rule #1: When L5 is sidebent, a sacral oblique axis is engaged on the SAME side as the sidebending.
* Rule #2: When L5 is rotated, the sacrum rotates the opposite way on an oblique axis.
* Rule #3: The seated flexion test is found on the opposite side of the oblique axis.
26
respir-circ model of pelvis
pelvic diaphragm & bone --\> interstitial homeostasis
27
M affecting ilial/pubic motion
**RAGS**
Rectus femoris
Adductors
Gracilis
Sartorius
hypertonia = pubic, ant/med knee pain
28
posterior SI lig
referred pain to hip and groin
connects PSIS --\> S3/S4, erector spinae, thoracic/lumbar fascia
29
6 Determinants of Gait:
4 + 5
combined actions of the foot, ankle and knee of the stance leg
smooth pathway:
* heel strike: ankle form dorsi --\> plantar flex (knee @ fulcrum)
* heel lift: metatarsal P (plantar flex) lifts COG, counteracted by knee flex
30
Forward Sacral Somatic Dysfunctions on Oblique Axis
* Left rotation of the sacral base on a left oblique axis with L5 rotated right = Left on Left forward sacral torsion
* Right rotation of the sacral base on a right oblique axis with L5 rotated left = Right on Right forward sacral torsion
* Naming Rule: we name the direction of sacral rotation 1st followed by the oblique axis. So a left on left sacral torsion means the sacrum has rotated left on a left oblique axis.
31
intraspinal dura attaches ...
posterior longitudinal ligament of S2:
integrates cranial base with sacrum
32
subjective complaints of Inferior Innominate Shear
clincal?
pelvic pain with tiss-tex changes @: ipsilat SI jt & pubis
rare --\> usu corrected with ambulation
clinical: bungee jumping
33
Muscular Action during STANCE Phase
before heel strike: dorsiflex contract concentrically
after hell strike --\> onto foot flat: dorsiflexors contract eccentrically
34
possible ways to distinguish functional vs. structural leg length issue?
functional:
* ant-innominate rotation with ipsi med-malleolus lower
structural:
* ant-innominate rotation with ipsi med-malleolus higher
* ant-innominate rotation without change in leg length
* innominate resolved but now medial malleolus ipsi higher after OMT
35
Normal sacral motion during ambulation only involves
•anterior motion of the sacrum around these oblique axes
does not move posterior during normal walking cycle
36
waddling gait
roll side to side: penguin walk - pelvic rotation/tilt on swing side = increased
causes:
* muscular dystrophy
* weak hips
* exaggerated lordosis
* pot-bellied posture
37
subjective complaints of superior innominate shear
clincal scenario?
pelvic pain with tenderness @:
* ipsi SI jt
* QL
* pubic rami/symphysis
Clinical scenario; patient misjudges last step of stairs or curb, landing hard on the ipsilateral foot, creating a superior shear.
38
-Deep sulcus and post/inf
ILA are opposite so we have
an oblique axis
-The sacrum has rotated
towards the right; L5 rotated to
the left
Dx: R on L sacral torsion
39
Left Unilateral Sacral Flexion OMT
pt on stomach
* abduct/interal rotation lower extremity --\> post sacral base
* respir assistance --\> engage barrier with hand
40
•The seated flexion test will be ________ on the \_\_\_\_\_\_side of the deep sulcus in a ________ sacral dysfunction on an oblique axis, _______ the axis
positive
same
forward
opposite
41
Antalgic Gait
**pain**
42
Left Unilateral Sacral Extension
pt on stomach, tv stance
* abduct/internal-rot LE --\> sacral base anterior
* respir assistance: engage barrier with hand
43
How to Differentiate Forward vs. Backward Sacral Dysfx
* Seated Flexion Test
* L5 mechanics: type I for forward; type 2 for backward
* Spring Test
* POSITIVE with Backward Sacral dysfx; Will not spring, non-compliant to posterior to anterior spring if sacral base is posterior.
44
Trendelenburg Test
Superior gluteal nerve palsy
* Fracture neck of femur
* Dislocation of hip
* Perthe’s disease: avascular necrosis of head of femur, late stages of TB hip.
45
Posterior Innominate Rotations
named for the side with the POSITIVE standing flexion test
- PSIS on affected side is inferior
- ASIS on affected side is superior
- Pubic tubercle superior on affected side
- Ischial tuberosity inferior on affected side
- Motion about an inferior transverse axis
46
if the sacrum and L5 are rotated in the same direction ....
sacral rotation dysfx
tx:
* MET for sacral torsion
* L5
47
Pubic motion
Caliper: flex/extend
Torsional: swing-tilt
Supero-inferior: one legged wt-bearing
fib-cartilaginous jt
M forces = rotational about tx axis
48
ischiorectal fossa
•potential space between the inferior pelvic diaphragm and the urogenital diaphragm.
49
what do we know?
-Deep sulcus and post/inf
ILA are opposite so we have
an oblique axis
-The sacrum has rotated
towards the left; L5 rotated to
the left
Dx: L on L sacral rotation
50
Backward Sacral Rotations and Torsions
•Seated flexion test +
* •contralateral to deep sulcus and oblique axis
•THE SPRING TEST IS POSITIVE !!!
* oblique axis through the deep sulcus & post/inf ILA
•Sacral sulcus is shallow on dysfunctional side
* •By convention we consider and label the deep sulcus
* Posterior and/or inferior ILA
* L5 follows NON-neutral mechanics
51
Coccygodynia
pain in coccyx usu due to trauma
* also: infection, disloc, fx
pain = worse: sit/pooping strain/sex
* can be associated with pelvic diaphragm dysfx
52
Left on Left Sacral Torsion
neutral sacral mechanics (type 1)
* sit up, sidebend L --\> L obliq axis
monitor:
* right index finger = anterior
* left thumb = post-/inferiorly.
53
•Sacralization of L5
L5 fused with sacrum
54
subjective complaints of anterior innominate
ipsilat hamstrin tightess (stretch)
sciatica (piriformis)
55
Unilateral Sacral Extension
56
Alternate Psoas Evaluation
pt prone
grab thigh above knee & extend hip: compare bilat
can get **"end feel"** of motion --\> asses for type 2 SD @ L1/L2
57
Transverse Axes of the Sacrum
Superior Transverse Axis
“Respiratory or cranial” axis; associated with the attachment of the dura at S2
* inhale = base post, exhal = base ant
Middle Transverse Axis
“Postural” axis for flexion/extension spinal motions
* lumb-ext = base ant, lumb-flex = base post
Inferior Transverse Axis
Anterior/posterior rotation of the innominates on the sacrum around S3 segment.
58
pelvic girdle pelvic splanchnics
arise off ventral rami S2-S4
PNS to L colon & inferior mesenteric plexus
* mixes with visceral afferent and SNS
PNS visc-som refelx --\> subQ swelling in sacral region
if doesn't improve with tx --\> look for imbalance or visceral origin
59
Spondylolysis
stress fx pars interarticularis: collar on scotty dog
common in adole atheles, esp gym with hyperext
60
Forward Sacral Rotations
around an Oblique Axis with Gait
* Left rotation of the sacral base around the left oblique axis occurs during the swing phase of the right leg.
* Right rotation of the sacral base around a right axis occurs during the swing phase of the left leg.
* If a normal, forward sacral rotation gets “stuck” in that position, it becomes a somatic dysfunction.
Most somatic dysfunctions in the sacrum involve forward torsions about an oblique axis.
61
Pubic Somatic Dysfunction
isolated = rare: usually assoc with innominate SD
respond well to ME: adductor M
consider anterior L5 tender pt (anterior rami) -- counterstrain
DDx of pelvic congestion
* pelvic floor muscles vs. adductors vs visceral
* OB pt secondary to Relaxin.
Dysuria
62
Patellofemoral pain syndrome
altered tib-fem rotation and increase in valgus (knee add) --\> pain
* rearfoot eversion
* weak hip abductors/external rotators
63
Important Causes of SI Dysfunction (10)
**PLS PVC PTSD**
Psoas/piriformis
Lumbar/sacral SD/instab
Short leg
Pubic & pelvic floor dysfunction
Viscero-somatic reflexes
Cranial SD
postural imbalance (with or without pelvic side shift)
traumatic sacral SD
spinal stenosis/spondylysis or spondylolistheis
Disc protrusions
64
“Failed Low Back Syndrome”
"last resort" for LBP
65
1. A 12-year-old girl presents to the office complaining of left low back pain. She is left leg dominant and passes frequently with her left leg when playing soccer. The standing flexion test is positive on the left. However, you observe an inferior right ASIS and pubic rami and a right superior PSIS. What is her diagnosis?
A.Right outflare
B.Right anterior innominate
C.Right posterior innominate
D.Left posterior innominate
E.Left pubic compression
left post innominate
66
Scissors gait
legs add, cross alt in front of other
spastic lower limbs and hip jt add M
compensation motions of trunk and upper extremeties
causes:
* bilat UMN lesions
* cerebral palsy
* adv cerv spondylosis
* MS
67
Hemiplegic gait
due to: cva, SC injury
presentation:
* affected leg = stiff with less flex of hip/knee
* leg circumducted, body leans away
* shoe drag
* arm = fixed: elbow flexed, hand pronated, fist formed with thumb tucked in
68
Sphinx Test
positive = worsening of positional asymm = backwards dysfx
negative = forward dyfx
* deep sulci become even
69
Bilateral Sacral Extension
* Seated flexion test equivocal
* False negative test.
* Spring test POSITIVE, (if equivocal use sphinx test).
* Bilateral shallow sulci
* B/L inf ILA equal and not posterior
* L5 not needed
* There is a decreased lumbar lordosis.
* Base of sacrum has moved backward, posterior or extended, equally and bilaterally about a middle transverse axis.
70
Rotational motions during STANCE Phase
ipsi innominate = posterior @ heel strike --\> anterior @ toe-off
71
Nutation
"nodding"
sacral base anterior --\> sacral flexsion (biomech model)
stopped by sacrotuberous lig
72
Transverse Sacral Axes
1. Superior Axis
* Respiratory
* Cranial-sacral
2. Middle Axis
* Postural or Sacroiliac
3. Inferior Axis
* Iliosacral (Innominate rotation on sacrum)
73
Diagnosing the Pelvis for Somatic Dysfunctions
never assume LBP/pelvic pain purely musc-skel
* visc or emotional origin
* sex hx
OPQRST
74
Lower Extremity Joints during Gait:
Hip
initial contact: hip flex, thigh @ 20-25 degrees
rotation:
* planted: medial rotation
* free: lateral rotation --\> keeps foot parallel to line of mvmt
75
subjective complaints of posterior innominate
inguinal/groin pain (rectus femoris)
medial knee pain (sartorius)
76
biochem model of pelvis
most commonly used
pelvis links truck with limbs for ambulation
sacrum supports v-column
dysfx = superior --\> inferior
77
An evaluation of the sacrum should include an assessment of key associated areas of potential somatic dysfunction, including...
cranial base
upper cerv-spine
anterior/posterior ab wall
respir diaphragm
78
OMT for Coccygodynia
rectal exam --\> localize pain
jt mobil with intra-rectal tech
muyofasical pelvic diagphragm
CS --\> SI tenderpts: caudad/medial to PSIS on posterior surf of sacrum
79
Mitchell Model
ME to sacral SD
80
sacroiliac jt
innominate articulates posteriorly with sacrum @ SI jt
kidney shaped
convex ventrally (anteriorly)
diarthrodial: synovial fl --\> great variability
81
Standing Flexion Test
iliosacral
* eye lvl with PSIS
* thumb that moves farthest is restriction side
postiive --\> SIDE of SD: lateralization
82
High Steppage Gait
1st pattern
* toe touches first: paralysis pretib/fib M --\> **slapping noise** with foot after
* leg raised high: abnorm knee/hip flex
2nd pattern:
* heel touches first: loss of position --\> **stomp**
* bilat: ataxia, side-to-side reeling
* romberg's sign - dysfx afferent of peripheral N/posterior roots
83
Psoas muscle
lumb-spine --\> lesser troch
major hip flexor
sparms = flat lumbar lordosis (type II SD @ L1/L2), sacral rot @ oblique axis, pelvic shift
hyperton: sitting-like motions (excessive flexing)
84
•Dx = R on R sacral torsion technique
ME:
* L5 rot R, sacral base post, hip flex
* pt contract L QL aga resistance --\> reciprocal inhib R QL --\> R QL relax
* moniter: L/S jxn --\> F mobilizing L5/S1 articulation
85
sacrotub lig attachment for:
* long head bicep femoris
* piriformis
* glut-max
86
Subjective complaints of innominate flare
pelvic & SI pain
increased M lax on outflared side
inflare --\> internal rotation, anterior iliac
outflare --\> external rotation, posterior iliac
87
Musculoskeletal Gait Patterns
## Footnote
Gluteus medius lurch
Psoas gait
glut max/extensor lurch
Gluteus medius lurch - waddle side to side
Psoas gait - leans over
glut max/extensor lurch - leans backwards
88
Standing
* Width of the base (heel to heel) = 2-4”
* Feet - slight lateral rotation
* Only a few muscles usually active
–Erector Spinae
–Triceps surae
–Iliopsoas
* Forward sway
* Lateral sway
89
6 Determinants of Gait –
6
**Minimizing lateral displacement of the Center of Gravity (COG)**
stable gait = shift of COG to wt-bearing leg
add of hip & tib-fem angle = reduces lateral displace for balance
90
Swing phase in the pelvis…
glut-med contraction --\> pulls opp side pelvis fwd @ same time of free limb swing
91
innominate dx: medial malleolus
leg length
careful: congeintal short leg/fasical torsions of lower-extrem --\> cause leg lengths to appear normal
92
Seated Flexion Test:
Lateralizing Special Test
* Positive test indicates a sacro-ilial somatic dysfunction.
* It distinguishes the side of dysfunction with the dysfunctional side moving furthest.
* In the seated position the ilia are initially “locked” in place by the ischial tuberosities.
* As the patient bends forward the restricted sacral side brings the ipsilateral PSIS and ilium “further” then the contralateral side.
93
pelvis lig: true and accessory
true:
* Anterior sacroilliac ligaments
* Interosseous sacroiliac ligaments
* Posterior sacroiliac ligaments
accessory:
* Sacrotuberous
* Sacrospinous
* Iliolumbar
94
Piriformis Muscle
arterior sacrum --\> greater trochanter
fx:
* ext-rot of hip
* int-rot if hip flex to 90
hyperton = ext-rot LE, SI dysfx, LBP, butt pain
95
If one sacral sulci deeper
can mean sacrum is rotated to opposite side on oblique axis.
ILA Palpation: check for ILA that is
more posterior and/or inferior = OBLIQUE AXIS DYSFUNCTION!
96
Oblique Axes of the Sacrum
named for superior pole of sacrum they pass thru
gait
* left stance leg/right swing: L oblique axis --\> sacral base moves anterior on R, ILA moves post/inf on L
97
Check L5 Transverse Processes for Rotation
* This differentiates sacral rotation from sacral torsions.
* If sacrum is rotated opposite to L5 then you have a torsion.
* If sacrum is rotated in the same direction as L5 then you have a rotation.
98
sacral development
5 segments:
lateral --\> body: 2 years
sacral seg sep by IV disc until 25-30
99
Multifidus muscle trigger points
can refer pain to
lower abdomen
and groin.
100
Backwards Sacral Dysfunction
* In this situation, the sacral base has moved posteriorly up the short arm of the SIJ o the side of the oblique axis.
* The anterior part of the sacrum is facing left, although it’s from the left part of the sacral base moving posteriorly.
* This is associated with a Type 2 L5 somatic dysfunction, and is commonly caused by a flexion and sidebending type of injury to the L/S junction that drives the sacral base posteriorly.
101
Rotational motions during Swing phase
pelvis = 4 degrees to stance side **with** spine = swing side: go opposite directions
102
QUADRICEPS and gait
before heel strike: concentrically
after heel strike --\> foot flat: eccentrically
foot flat --\> mid-stance: concentric: contraction of knee extensors to absorb shor and keep knee from buckling until it reaches full extension
103
Counternutation
sacral base moves posteriorly
Motion is checked by posterior SI ligaments
104
Naming Backwards Sacral Dysfunction on an Oblique Axis
* Right on Left Sacral Torsion
* Left on Right Sacral Torsion
* Right on Left Sacral Rotation
* Left on Right Sacral Rotation
* “L”s and “R”s go together for forward sacral dysfx
* “L”s and “R”s are opposite for backward sacral dysfx
105
Q – angle
angle b/w femur and tibia
increased in women: wider hips
106
•Dx = L on R sacral torsion
ME:
* L5 rot L, lower leg extended = sacral base anterior
* pt contract L QL --\> R QL recip-inhib
107
Sacral Mechanics Rule: torsion
torsion:
* oblique axis = same side as L5 SB
108
seated flexion test
- Patient is seated with feet on floor.
- D.O. monitors PSISs as patient
bends forward
- Positive test if one PSIS moves further
- Positive test = side of SIJ dysfunction
- OR-
= if oblique axis dysfunction,
will be positive on side opposite oblique axis
109
Thomas Test- psoas spasm
increased distance b/w knee and table = positive
110
Patient with LBP
never assume purely musc-skel
111
Swing Phase – Mid-swing
mostly momentum
knee extension added
112
axes of sacrum
1. Superior transverse axis
2. Middle transverse axis
3. Inferior transverse axis
4. Left oblique axis
5. Right oblique axis
113
Forward Sacral Somatic Dysfunctions on Oblique Axis
* Left rotation of the sacral base on a left oblique axis with L5 rotated left = Left on Left forward sacral rotation
* Right rotation of the sacral base on a right oblique axis with L5 rotated right = Right on Right forward sacral rotation
* Biomechanical Rule: If the sacrum and L5 rotate in the same direction we name the somatic dysfunction as a sacral rotation.
•
114
2. A 23-year-old male presents to the office complaining of low back and right posterior thigh pain. The pain started after he drove home from College in Ohio. You diagnose a right anterior innominate. What are your findings and which muscle may be contributing to his pain?
A.Right positive Seated Flexion Test, left PSIS high, right ASIS high and right pubic rami high and piriformis.
B.Right positive Seated Flexion Test, right PSIS high, right ASIS high and right pubic rami high and quadratus lumborum.
C.Left positive Standing Flexion Test, right PSIS high, right ASIS high and right pubic rami high and quadratus lumborum.
D.Right positive Standing Flexion Test, right PSIS high, right ASIS low and right pubic rami low and hamstring.
E.Right positive Standing Flexion Test, left PSIS high, right ASIS high and right pubic rami high and hamstring.
A.Right positive Standing Flexion Test, right PSIS high, right ASIS low and right pubic rami low and hamstring.
115
quadatus femoris hypertonicity refers to...
hip
116
Inversion ankle sprain
Predisposing factors:
1. Longer total foot contact time (more time in stance phase)
2. More laterally directed pressure (causing inversion)
Findings after LAS (ligament ankle sprain):
1. later inversion (prolonged pronation - eversion)
2. Metatarsophalangeal joint extension ROM greater
117
Sacro-ilitis (Ankylosing Spondylitis)
inflam SIJ: bilat
negative for rheumatoid factor
genetic: HLA-B27
males: disease moves up spine, female = begin anywhere without pattern
bamboo spine (fusion) as disease progresses - the outer fibers of annulous fibrosis ossify and the vertebra become more square
118
Right on Left Sacral Torsion
backwards sacral torsion
* patient flex trunk fwd (type II @ L5) , sidebend left --\> L obliq axis
monitor
* right ILA = post-/inferiorly.
119
With unilateral flexion or extension the seated flexion test is _______ on the side which is “stuck” in flexion or extension
positive
SD: side of positive seated flexion
120
•Lumbarization of S1
S1 detached from sacral base
121
eccentric versus concentric
concentric = shortening of M
eccentric = lengthening of M
122
Lumbosacral Instability
spondylo-lysis/listhesis, congenital abnorm, spinral stenosis
* hypomobile side: pain only with opp hypermob --\> congestion
* ex: L SIJ hypo = R SIJ pain but not R SD
* mob painful SIJ --\> not relieve pain
closure of SIJ: M inbalace of LE and thoracolumbar
* iliolumbar lig = tender
* sacral base unlvl
* innominate dysfx: pelvic side shift
* lower lumbar som dysfx
123
Sacrum-
•keystone of the pelvic arch transmitting body weight down into the legs via the acetabulum.
124
The primary muscles of the pelvis
intrinsic muscles of the pelvic diaphragm.
## Footnote
levator ani (iliococcygeus, pubococcygeus, puborectalis)
coccygeus muscles
125
Short Leg Syndrome or Postural Imbalance
compensation: convex @ side of low sacral base
SI discomfort, exacerbated by walk/run with TTC & tenderness
pattern:
* short: fwd torsion (anterior), deep sacral sulcus, anterior innominate rot
* upper sacrum slides down upper SIJ --\> attempt to lengthen
* long: pelvic shift
126
What do we know?
What do we know?
-Deep sulcus and post/inf
ILA are opposite so we have
an oblique axis
-The sacrum has rotated
towards the left; L5 to the right
-Torsion
Dx: L on L sacral torsion
127
Reflex Causes of SI Dysfunction
PNS pregang in lateral horn S2-S4
128
L5 and Sacral Diagnosis
Physiological Sacral Diagnosis: L on L or R on R
* L5 follows neutral mechanics type 1 ex. L5NSLRR.
* THE LEFT SIDEBENDING AT L5 WILL INDUCE THE AXIS OF MOTION FOR THE SACRUM HENCE A LEFT AXIS.
* (L ROTATION ON L AXIS)
NON-PYSIOLOGICAL SACRAL DIAGNOSIS: L ON R OR R ON L
* L5 follows non-neutral mechanics type 2 ex. L5FSLRL
* side bending will induce the left axis of motion for the sacrum.
* (Right rotation on a Left axis.)
129
Pubic Symphysis-Gapping
child birth
fx/trauma
degree can be seen on radiograph
tx:
* SI jt
* core M
* SI belt
130
Lower Extremity Joints during Gait:
Knee
terminal swing: quad straighten leg for heel strike
initial ontact: knee flexed 5 deg (vastuses, rec-fem not involved), IT band for stab
131
torsion
sacrum rotating opposite of L5
type 1 mechanics
132
Bilateral Sacral Flexion
* Seated flexion test equivocal
* A false negative test
* Spring test negative
* Bilateral deep sulci
* Post/inf ILA equal (posterior)
* L5 not needed
* There is an increased lumbar lordosis
* Base of sacrum has moved anterior, equally and bilaterally about a middle transverse axis.
133
6 Determinants of Gait: 1-3
**GOAL: reduce vertical displacement**
1. Pelvic Rotation: post --\> ant = enlong leg
2. Downward pelvic tilt
3. Knee flexion of the STANCE leg (error in DSD)
first- pelvic rotation – elevates the extremities of the arc
second and third – pelvic tilt and knee flexion – depress its summit.
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pelvis functionally consists of
–the left innominate
–the right innominate
–the sacrum
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Swing Phase - Acceleration
knee flexes simul due to momentum --\> dorsiflex ankle --\> shortens free limb
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center of gravity
smooth undulating - low amplitude
**anterior to 2nd sacral vert** - 1.8 in vert displacement, 1.75 in horizaontal displacement
highest @ 25% and 75% gait cycle, midpt = lowest (dbl-wt-bearing)
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Leg length & Innominate Rotation
post-innominate = short leg
ant-innominate = long leg
structural short leg --\> body compensates ipsi via anterior innominate rotation to lengthen
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Unilateral Sacral Flexion
seated flexion test is positive on the same side which is “stuck” in flexion
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Patients with pelvic diaphragm restrictions or dysfunctions may present with...
LBP
UTI
dysmenorrhea
dyspareunia (painful sex)
constipation
hemorrhoids
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Backwards Sacral Torsion: M affected
QL and piriformis on same
side become hypertonic
and dysfunctional
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what do we know?
-Deep sulcus and post/inf
ILA are opposite so we have
an oblique axis
-The sacrum has rotated
towards the left; L5 to the right
-Torsion
Dx: L on R sacral torsion
L5 FRrSr because backwards dysfx
follows type 2 mechanics
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subtalar jt
proper fx = critical to **efficient gait**
2/3 eversion (pronation) --\> 1/3 inversion (inversion)
motion @ jt = 5-7 degrees: cavus = 3-4, flat = 16
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who does pubic dysfx be a source of pelvic floor tension?
restriction of UG diaphragm --\> UG fx --\> congestion of prostate/uterus
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tight hamstring leads to...
sacral base unleveling and posterior innominate
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Introduction to Gait
* Average step length = 15”
* Cadence of 90-120 steps per minute
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Psoas Syndrome
**type 2 SD F L1/L2**
* ipsi lumbar SB, contralat rot
sacral SD = same side as SB
pelvic shift, piriformis, sciatic irritation = opp of spasm
chronic: fwd sacral torsion --\> engage oliq axis with lumbar SB
acute: L1/L2 F, L5 E (type 2) --\> bwd sacral torsion
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Muscular Action during SWING Phase
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Floor contact as foot progresses: gait
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Anterior Innominate Rotation
named for side with POSITIVE standing flex test
- ASIS on affected side is Inferior
- PSIS on affected side is Superior
- Pubic tubercle inferior on affected side
- Ischial tuberosity superior
- Motion about an inferior transverse axis
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Innominate Flares
flare = ASIS more medial on one side vs other
measure from xyphoid/umbilicus --\> each ASIS
named for side of postiive standing flex test
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why are strong pelvic ligaments are needed?
balance pelvis during wt-brear
without:
* base = tip forward --\> stress --\> lumb/sac imbalance --\> low bavk pain/ jt degen
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•Organic causes of psoas hypertonicity
**FAD CUPS**
* Femoral bursitis
* Arthritis of the hip
* Diverticulosis\*
Cancer of the descending or sigmoid colon
Ureteral calculi\*
Prostatitis\*
Salpingitis\*
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Spring Test
spring lumbo-sac jxn with hell of hand
ease = NEGATIVE
resistance = POSITIVE - bwkwards sacral dyfx
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Swing Phase Deceleration
quad contract --\> extension for desired length & pos of foot for hell strike
extensors of hip/flex of knee --\> contract eccentrically @ end of swing phase --\> decel fwd mvmt
