Final Review

Question 1

What are the 3 joint complexes that make up the pelvis?

Answer 1

1)sacroiliac (diathrosis, true synovial joint with joint cavity, synovial fluid and joint capsule). 2) Pubic Symphsis- fibrocartilagonous joint, amphiathrosis.

Question 2

What is the SI joint shape morphology?

Answer 2

L-shape: upper half articulates at level of S1 and lower half articulates at the level of S2-3

Question 3

Sacral Segment is lined with what type of cartilage?

Answer 3

Hyaline Cartilage

Question 4

What surface is thicker?

Answer 4

Sacral Surface is thicker than the iliac surface

Question 5

Describe the general shape of the sacrum

Answer 5

central groove that gives in a concave shape, it is wedge shaped superior to inferior and S shaped anterior to posterior

Question 6

Describe the iliac surface

Answer 6

PSIS to PIIS, it is made of fibrocartilage (yellow colour) with a central convex ridge and has rough bony surfaces posteriorly and superiorly for ligamentous attachements.

Question 7

Describe the pelvis at birth

Answer 7

joints are underdeveloped, smooth, flat and can glide in any direction. stability is provided by ligaments and it begins to develop during walking

Question 8

Describe the pelvis during teen years

Answer 8

roughened surfaces, development of grooves/ridges. more pronounced in males than females. track bound movement developes (tram and rail)

Question 9

Describe the pelvis in 3rd and 4th decades of life

Answer 9

articular change in the surface anatomy are well established, joint surfaces become more irregular, enlargement of iliac tuberosity/depression, beginning of joint surface erosions and possible DJD on the iliac surface which is more common in males.

Question 10

Describe the pelvis in the 5th/6th decade of life

Answer 10

Joint surfaces become more irregular, each individual joint is unique in its topography to varying degrees (more pronounced in males), possible DJD develops on the sacral surface and continuing on iliac surface (more in males) possible development of joint adhesions, osteophytes and fusion (esp in males)

Question 11

Describe the pelvis in the 7th decade and beyond

Answer 11

interarticular adhesions, high prevalence of bony anklylosis, Gender dependant (more in males) and age dependance in males (more in males over 80 years old. Fusion occurs mainly in the superior part of the joint

Question 12

What are the Intrinsic SI ligaments?

Answer 12

Intrinsic SI ligaments bind sacrum to ilium.

Question 13

Define the Anterior and posterior SI ligaments

Answer 13

1) Posterior SI ligaments include the interosseous (major stablizer) and dorsal ligaments (smaller, non-critical, limits nutation, runs from PSIS to iliac tuberosity)
2) Anterior SI ligaments: thin, thickening of the anterior joint capsule and it is weaker than the dorsal SI ligaments
3) Joint capsule is well developed anteriorly not posteriorly

Question 14

What are the two Extrinsic ligaments

Answer 14

Sacrotuberous: Sacrum to Isch. Tube and limits posterior movement of sacral apex
Sacrospinous: Sacrum to Coccyx to Isch Spine, limits posterior moment of the sacral apex

Question 15

What is the Symphysis Pubis

Answer 15

Amphiarthrosis joint with an interpubic fibrocartilaginous disc

Question 16

Do muscles directly cross the SI joint

Answer 16

NO

Question 17

What muscles load the SI joint?

Answer 17

Erector Spinae, QL, PSOAS, ILLIACUS, Piriformis, Gluteals.

Question 18

What are some key static features of the pelvis?

Answer 18

1) Keystone effect: sacrum forms the keystone of the arch, inferior displacement is resister by this shape ligaments prevent AP displacement
2) Self locking mechanism: promotes stability and form closure due to wedging and form closure is aided by the thoracolumbar fascia and ligaments

Question 19

Why is the SI a good shock absorber

Answer 19

it transmits forces between lower and axial skeleton. it glides/pivots during locomotion and decreases stress to the lumbar spine and opposing SI joint.

Question 20

Describe SI kinematics

Answer 20

Unclear, amount of movement is debated and generally thought to be very small. Movability decreases with age, range is greater in females. Predominent ROM is around X-axis

Question 21

What is thought to be the axis of rotation for the SI joint

Answer 21

posterior to the iliac tuberosity with some coupled motions with joint seperation

Question 22

What is the most influencial model of locomotion

Answer 22

Illi’s: reciprocal motion between ilium and sacrum. flexion of hip and ilium is accompanied by ipsilateral anterior inferior movement of the sacral base and likewise extension of the hip and ilium is accompanied by ipsilateral posterior superior movement of the sacral base.
Motion is gyroscopic (oblique and horizontal figure 8)
Correlation to Gillet’s test!

Question 23

Sacral base nutation (AI movement) creates what

Answer 23

LS extension and SI Flexion

Question 24

Sacral counter nutation (PS movement) creates what

Answer 24

LS extension and SI Extension

Question 25

SI movement is based on what the ____ does

Answer 25

Ilium

Question 26

Pubic symphysis kinematics

Answer 26

gliding/shearing compression and seperation, rotation in the saggital plane with flexion/extension of the SI joint and it may play a role in the SI dysfunctions

Question 27

What is the pideau's test

Answer 27

PSIS and sacral apex should seperate when flexion happens. Can be done seated/standing

Question 28

What is gillet's test

Answer 28

evaluate the upper /lower portion of the joint, knee bent, raise up flexion, contacts move together, extention contacts move apart.

Question 29

Define allydonia

Answer 29

pain produced by normal painless stimuli

Question 30

Leg length evaluations can describe inequalities that are

Answer 30

anatomical or functional.

Question 31

If you bend the knees to 90 degrees it does what

Answer 31

1) isolate the tibia/fibula length 2) if discrepency persists-->tib/fib inequality 3) if inequality is gone then its functional LLI or femoral inequality

Question 32

Side posture: Lumbar segmental motion palpation can be done for flextion/extention, lateral flexion and rotation. What are they

Answer 32

flexion/extension: heel of hand/SP contact rotation: hypothenar-mamillary resisted, spinous pull resisted, spinous push pull counter-resisted LF: icshial push and double leg lift (long lever)

Question 33

Side posture: SI joint motion palpation can be done by _________

Answer 33

one or two handed contacts for flexion and extension

Question 34

Sitting: lumbar motion palpation can be done by

Answer 34

PA scan checking for pain/stiffness, Sectional/Segmental motion palpation and end play.

Question 35

Sitting: SI motion palpation:

Answer 35

PA glide-->if motion is induced it is most likely extension Sacral Shear/Illiac Shear Sacral Push==> lean back and the sacrum should counternutate Leg flare: PSIS movement M to L Piedau's test: SI joint extends and the sacrum counternutates.

Question 36

What are some supine evaluations for the SI joint

Answer 36

``` leg length: same as prone, allis test (knee bent, checking for femoral or tib/fib inequalities or LLI). sit up test: most helpful. if leg length remains the same -->anatomical LLI if lengths change: functional LLI...remember that the short leg becomes long on the PI side!!!!! ```

Question 37

What are the two ways to evaluate the low back

Answer 37

Neurological testing and orthopedic testing

Question 38

What are the components of neurological testing,

Answer 38

1) nerve root compression/irritation a)sensory (pin prick), b) motor (muscle testing) c) reflex (DTR, superficial reflexes) d) radicular pain (pain from nerve root compression or irritation, sharp shooting pain) 2) Sclerotogenous pain: referred pain from deep somatic structures, deep, dull achy, hard to localize, diffuse, differently refferal areas than radicular

Question 39

What is the straight leg raise?

Answer 39

patient raises their leg when supine (on their own). this stretches their sciatic nerve and spinal nerve roots primarily L5,S1,S2.

Question 40

What are the degrees that indicate particular types of pain when doing the SLR

Answer 40

If symptoms shown between 0-35 degrees: extradural sciatic involvement. if between 35-70: radicular pain into extremities, in this range the sciatic nerve root tenses over the intervertebral disc causing futher irritation to a sensitve nerve root. IVD lesion/ nerve root compression 75-90: pain in the lumbars. lumbar pain suspected, dull posterior thigh pain indicates tight hamstrings.

Question 41

What is the Braggards test

Answer 41

patient is supine, raises leg to point of SLP and DR dorsiflexes the foot passively which increases sciatic nerve tension and is used as a confirmatory test for SLR. Radicular pain in the 35-70 degree range indicates IVD lesion, nerve root compression

Question 42

What is the Bowstring test

Answer 42

patient is supine, bend leg and tuck between forearm and body, apply pressure on the popliteal fossa, increasing tension on the sciatic nerve. used as a confirmation test for the SLR. Lumbar or radicular pain and nerve root compression suspected

Question 43

What is the Gaenslen's test

Answer 43

knee flexed, thigh of unaffected side down and hanging off the side. flexing unaffected leg stablizies lumbar spine. pain on affected side indicates SI lesions

Question 44

Sacroiliac stretch test

Answer 44

patient supine, dr crosses arms and puts lateral pressure on the ASIS's, stretching the SI joint, pain indicates SI lesion

Question 45

What is the SI compression test

Answer 45

pt lies on side, dr presses down on ilium and compresses the SI joint more posteriorly. Pain in SI indicates SI lesions

Question 46

Sacral thurst

Answer 46

good test! PA thrust on sacral base on level of S2-3. NOT HVLA. pain suggest pathology or dysfunction

Question 47

Hibbs test

Answer 47

patient is prone and the dr flexes patient knee towards the butt and moves leg outward causing internal rotation of the hip. this causes distraction of the SI

Question 48

Yeoman's

Answer 48

patien is prone, dr flexes knee, lifts it to extend SI joint

Question 49

What are the qualifications for taking xrays of pelvis

Answer 49

dont take them to check for malpositions only use them to check for pathologies. If already done use them to check for positioning but do not over interpret the xrays

Question 50

Spinographic methods: Femoral head line

Answer 50

a horizontal line is compared to that drawn connecting the two femoral heads, if discrepency it suggests leg length issue

Question 51

Spinographic methods: Scanogram

Answer 51

three seperate exposures on the same film of hip, knee and ankle joint. limits distortion and gives the most accurate respresentation of actual leg length

Question 52

Spinographic methods: intercrestal line

Answer 52

a line drawn across the most superior margins of the iliac crests and it should be parallel to the femoral head line.

Question 53

Spinographic methods: sacral base line

Answer 53

a line formed by connecting two dots placed btwn junctions of the sacral ala and the superior sacral articulating facets. also should be paralel to the femoral head line

Question 54

Ilium misalignments- describe what happens during flextion/extension when compared to neutral

Answer 54

flexion: PI ilum, appears larger than normal extension: AS ilium, appears smaller than normal

Question 55

Illium: what happens during internal and external malpositions

Answer 55

internal: psis roles in and ilium appears wider external: psis roles out and ilium appears narrow.

Question 56

How are sacral misalignments measured

Answer 56

The sacrum is evaluated for rotational misalignments by measuring the distance from the second sacral tubercle to the most lateral margin of the sacral ala. The wider side is the apprarent posterior rotation.

Question 57

How is lateral flexion evaluated

Answer 57

evaluated with the aid of the sarcal base line which converges with the femoral head line on the side of the lateral flexion.

Question 58

Is there a gold standard test for assessing SI syndrome?

Answer 58

NO

Question 59

what are the three theories that can explain SI joint dysfunction

Answer 59

``` Joint subluxation (based on misalignment) Joint dysfunction (abnormal mobility) Inflammation of joint (chronic low grade, can be detected with bone scans and stress tests) ```

Question 60

The SIJ is more vulnerable to ____ and ____ over the lumbar

Answer 60

axial compression faliure and axial torsion overloading

Question 61

Axial compression and torsion can be a result of

Answer 61

1) Acute Trauma: Forward bending, twisting, lifting, falling on your butt, unexpected step, return from flexed posture 2) Repetivitve stress injury (MOST COMMON) 3) Static overstrain (bad posture) 4) Post traumatic complications of sprains and strains (myofiborsis, perarticular fibrosis) 5) Osteoarthrosis ( doesn't ness. correlate with symptom or dysfxn) 6) Gender (more DJD in women, pregnancy, childbirth)

Question 62

What is the prevelance of SI dysfunction

Answer 62

estimates say 50-70%, mireau study: 23% LBP, 28% hypomobility of SI joint and most abnormalities found in 12-17 years old group)

Question 63

What are some general characteristics of SI syndrome?

Answer 63

Unilateral deep achy pain over SI region. Episodes of sharp pain and referred sclerotogenous pain to butt, post thigh and groin and occasional to lateral calf and ankle and dorsum of the foot.

Question 64

How does SI pain differ from lumbar pain?

Answer 64

lumbar pain is often bilateral, and is reffered (sclerotogenous) only to knee and above-->facet syndrome lumbar pain with radicular pain into butt, leg and calf is a disc herniation.

Question 65

What are sensory changes associated with SI syndrome

Answer 65

hypersthesia and paresthesia are not consistent with this condition but hypersthesia may be found in the butt/leg

Question 66

What can aggrevate SI syndome? what can alleviate pain?

Answer 66

aggravate: increasing weight in joint, activities that involve extreme SI motion and sustained postures alleviate: mild wlaking, rest, direct pressure (massage), stretching, ice, heat, anti-inflammatory drugs

Question 67

Describe the posture/gait/GROM for si syndrome

Answer 67

posture: normal to antalgic, unleveling of the crests/psis, gluteal folds and associated lumbar scoliosis gait: normal to protective, decreasing stance to affected side gROM: normal to painful to restricted, altered lumbopelvic rhythm.

Question 68

What is associated with a PI ilium

Answer 68

inferior and prominent PSIS, relatively deep sacarl base, medial knee pain, functionally short leg

Question 69

What is associated with AS ilium

Answer 69

superior and less prominent PSIS, lateral knee pain and functionally long leg.

Question 70

What are some tests to check SI syndrome

Answer 70

SI strech test, hibbs, iliac compression test, thigh thurst, sacral thrust

Question 71

What are some treatment options for SI syndrome?

Answer 71

Hypomobolity: manipulate, mobilize, excercise, LLI, orthotics Hypermobility: Belts, Excercise, Proliferant injections, Fusion (surgery) Inflammation: Ice, anti-inflamm drugs, PT modalities, and rest

Question 72

What is a SI strain

Answer 72

strain of the support musculature PROM is painless except for some muscle stretching pain. AROM is painful (ie. Gillets) Provocative and neurological testing is negative. Pain free adjustment

Question 73

What is a SI strain

Answer 73

injury to ligaments or joint capsule. both AROM and PROM are painful. provocative tests are painful and neurological testing is negative.

Question 74

What is facet syndrome (wrt lumbar spine)

Answer 74

Irritation of the facet joints, patient has LBP with scleretogenous radiating pain into groin, hip and butt and above knee. Area is tender to pressure, can have joint restrictions, pain mimics SI syndrome, provocative test increasing lordosis increases pain, lumbar flexion decreases pain, Kemp's test, negative neurological test.

Question 75

What is maigne's syndrome

Answer 75

facet syndrome in TL spine. most common after 40 years old. close proximity to cluneal nerves, can cause inflammation. findings: t12-L1 painful SP's TL extension restriction, painful skill rolling, hypersthesia to pin and may cause sclerotogenous pain to post iliac crest region and butt

Question 76

What is Gluteal Trigger point syndrome

Answer 76

commonly associated with SI syndrome | findings: nodule in muscle, referal myotomal pain, local twitch response, reproduction of patients pain syndromes

Question 77

What is piriformis syndrome

Answer 77

inflammation or irriation of the sciatic nerve. myofascial trigger point syndrome. 15-20% have entrapment syndrome where the nerve seperate the muscle into two.

Question 78

What is ankylosing spondolytis

Answer 78

chronic inflammatory poly arthritis characterized by progressive bony akylosis of the SI and spinal joints. SI's fuse first and progress cephalad

Question 79

What is Reiter's

Answer 79

Conjunctivitis, Urethritis, Polyarthritis. STD/STI. reaction to an infection. diagnosis made with lab tests

Question 80

What are some other (conterversial) disorders associated with pelvic adjustments

Answer 80

GI: ulcers, colic, constipation, IBC Gyne: dsynmenorrhea, PMS Urinary: bed wetting

Question 81

When the injury is acute do you want to adjust in the direction of pain?

Answer 81

no

Question 82

when do you want to start adjusting the injury

Answer 82

when it is in the reparative, remodeling states

Question 83

true or false: unstable joints generally dont benefit from asjusting, particularly in their planes of instability

Answer 83

true

Question 84

true or false: hypermobile joints dont become restricted in which case adjusting can be beneficial

Answer 84

false

Question 85

for lumbar disc herniations, when is adjusting contraindicated

Answer 85

when there is progressive neurological deficit

Question 86

Are SI adjustive complications common?

Answer 86

no

Question 87

What is meralgia parethetica

Answer 87

entrapment of the lateral femoral cutaneous nerve as it passes under the inguinal ligament medial to the ASIS causeing dysesthesia and pain along the lateral thigh. sensory impairment only, no atrophy, motor or reflex changes, commonly confused with L2-3 nerve root compression. Initiated by obesity, pressure from belt or genu ilium adjustment.

Question 88

true or false: one adjustment may clear multiple directions of restrictions at a single joint

Answer 88

true

Question 89

true or false: LS joints may be affected more when trying to adjust an SI

Answer 89

true

Question 90

What adjustments gap joint surfaces?

Answer 90

``` SI flexion (sacral base contact) SI extension (PSIS contact with a ML vector) SI extention (kick start and sacral apex contact) ```

Question 91

What adjustments shouldn't create cavitations

Answer 91

SI extenstions (cavitation is prob due to LS rotation in setup)

Question 92

What do extension (flexion) adjustive procedures provide for the joint?

Answer 92

extension (flexion) and distraction of the joint

Question 93

What are some adjustments for extending the SI joint

Answer 93

Side posture: 1)contact ilum with hypothenar or forearm, kick start (caudad, cephalad). stances: genu-pincer or thigh to thigh (vector: PA, ML, IS) 2)contact sacrum (AI sacrum) with hypothenar or forearm. (vector: PA, LM, SI scoop) Prone: -->opposite side contact! 1) two handed: PSIS and S. apex. PSIS vector: PA IS. Apex vector: PA, SI 2) one handed is PSIS contact only 3) Genu ilium: PSIS contact and knee. vector: PA, ML

Question 94

What are some adjustments for flexing the SI joint?

Answer 94

Side: 1) Ischium contact (AS ilium): palm or forearm contact. legs: low fencer, straddle thihg, double thigh to shin, split leg (knee to pop fossa), vector: PA scoop 2) Sacrum contact (PS sacrum): -dysfunctional side up: hip flexed less than 90, cupped hand. for flexion restriction hip is flexed above 90. -dysfunctional side down: PS sacrum -- rolled over less and more. vector PA Prone: 1) two handed contact Ischium and S. base. vectors: Ischium: PA, SI and base: PA, IS. 2) one handed S. base contact only. same vector

Question 95

How do you decide between a sacral contact and ilium contact?

Answer 95

1) dr. pref 2) mechanical advantage 3) patient comfort 4) possible LS dysfucntion 5) Trial/error

Question 96

What is pelvic blocking? why is it good

Answer 96

developed as a part of SOT placing blocks under patient to induce movement., makes biomech. sense, patients can do it at home, can be used with other modalities/manipulatons

Question 97

For flex/ext where do you place blocks/

Answer 97

Extension: prone: isch tube on side where extension wanted. ASIS on other side supe: PSIS on side extension wanted, isch tube on other side Flexion: prone: ASIS where flexion wanted, isch tube other side. supe: Isch tube where flexion wanted and PSIS on other side.

Question 98

When is pubic symphysis dysfunction suspected?

Answer 98

patient complains of pain in the pubic region, and treating the SI joints isn't helping.

Question 99

What are some possible findings for pubic symphysis dysfunctoin?

Answer 99

Static palpation: pain, vertical displacement and can be seen on xray, vertical displacement is MOST COMMON. can be anteriorly displaced but this is uncommon, can be seperated (laterally) but this is less common and may be related to childbirth/preg and can be seen on xrays

Question 100

What is the motion of the pubic symphysis

Answer 100

usually around the x axis, small tranlational movements forward, backward and up and down.

Question 101

What are some adjustive setups to fix the pubic symphysis

Answer 101

Palm thigh- superior displaces pubes Hypothenar/thenar pubes: anterior (AP vector) or superior pubes (SI vector) Palm ilium- ischium: inferior pubes Pubic distracion: distract the pubes apart.

Question 102

When do we suspect coccygeal dysfuction

Answer 102

1)local pain with traumatic history (fall on butt)- anterior displacement into flexion childbirth- posterior displacement into extension 2) rectal complaints. 3)external palaptions indicating displacement 4) xrays showing displacement

Question 103

What are some adjustive setups of coccyx?

Answer 103

external: thumb on coccyx base, vector IS internal: digit-anterior coccyx, calcaneal posterior superior sacrum

Question 104

Are coccyx adjustments affective?

Answer 104

mildly effect due to recent evidence. (maigne et al)

Question 105

What are absolute contraindacations for adjusting

Answer 105

vertebrobasilar insufficiency, aneurysm, fracture, bone tumor, diabetic neuropathy

Question 106

What are relative contraindications for adjusting (based on stage and degree)

Answer 106

Arthrosclerosis, clotting disorder, advanced osteoarthrisits, Uncoarthritis, Severe sprains, Osteopenia (osteoporosis), Space occupying lesion, malingering, hysteria, hypochondriasis, Alzheimer's disease.