Pelvis

Bony palpation - Anterior aspect

The patient is standing; the physiotherapist is sitting in front of them
-> palpate the ASIS with our thumbs
-> palpate the iliac crest with 4 fingers
-> our thumbs remain on the ASIS, and we turn the other 4 fingers down to the greater trochanter
-> then leave your 4 fingers on the greater trochanter, turn your thumbs down to the symphysis pubis (women only)-> palpate gently

Bony palpation - Posterior aspect

The patient is in standing position, the physiotherapist is sitting behind them
-> palpate the PSIS with thumbs, 4 fingers on iliac crest
-> thumbs remain on the PSIS, and 4 fingers are turned to the greater trochanter
-> then turn your thumbs on tuber ischiadicum-> If PT does not feel well, ask the patient to flex hip and knee

Trigonum femorale - borders

• Proximal: lig. inguinale
• Lateral: m. sartorius
• Medial: m. adductor longus

Trigonum femorale - Palpation

Starting position: patient lying supine, non-tested leg extended, with the heel of the side being tested on the opposite knee.
Place the palm on the distal medial part of the femur-> ask the patient to press the knee into the hand

Lig. Inguinale

The ligament is examined with 2 fingers perpendicular to it-> below it, at about the midpoint of the ligament, the femoral artery passes.

The patient may feel pain if there is a hernia in the lower abdomen or if inflammation is observed in the inguinal region

M.Sartorius

Apply resistance to the distal and ventro-medial end of femur
-> ask the patient to push your thigh into my hand.
• Palpate between ASIS and pes anserinus.

Adductor muscles

Palpate the muscle belly from proximal to distal

M. Tensor Fascia Latae

Starting position: the patient lies on his side, with the upper lower limb in flexion and internal rotation, knee in extension

M. Rectus femoris

Starting position: the patient is lying on his back, untested side in flexion, tested side in neutral position. It is important that the patient does not rotate their feet, the toes pointing towards the ceiling.

Apply resistance on the anterior and distal part of the femur againt flexion-> Palpate from AIIS to patella.

Lig. Sacrotuberale

Starting position: the patient lies supine, untested side in neutral position

Ask the patient to pull the tested knee towards his abdomen and hold it-> by holding this position we palpate tuber ischiadicum and tilt our fingers to medial dorsal direction-> we palpate perpendicular to the ligament

M. Rectus abdominis

Starting position: the patient lies supine, both lower limbs in flexion

Weplace our two palms on both sides of the linea alba, ask the patient to raise his head, chin close to the sternum-> we feel the isometric contraction of the muscle under the palms

M.Tractus iliotibialis

Starting position: Side lying, The lower upper limb is in flexion, Pelvis should be in the middle position! The lower lower limb in flexion, hips (45°) and knees (90°), and the upper lower limb is in neutral position.

Resistance is not required.

With 2-3 fingers palpate the entire length from the trochanter major to the knee
Pathological: painful trigger points, pain due to shortening.

M. Gluteus medius

Hip is in neutral position
Apply resistance to the lateral and distal part of the femur against abduction

M. Gluteus maximus

Starting position: prone, The patient's lower limbs are in neutral position

Apply resistance to the posterior and distal end of femur against hip extension
To deactivate the function of hamstrings, the muscle is tested in 90° knee flexion

Hamstrings

Starting position: prone, tested knee is in 90° flexion

Resistance on the posterior and distal surface of tibia against knee flexion
We can also examine it in isolation:
• M.Biceps femoris-> with tibia external rotation
• M.Semis-> with tibia internal rotation

N. Ischiadicus

Starting position: prone

Draw A line: trochanter major- tuber ischiadicum, midpoint below distal margin of gluteus maximus-> we put gentle pressure on it

M. Piriformis

Starting position: prone, draw lines-> PSIS- trochanter major-> ASIS- tuber ischiadicum at intersection palpate deeply, perpendicular to gluteus maximus

Physiological: uncomfortable
Pathological: shortening of the muscle can cause piriformis tunnel syndrome, caused by compression of the ischiadic nerve passing under (or even puncturing) the muscle. Symptoms may include radiating pain in the lower limb, easily confused with disc herniation.

Paravertebral muscles (lumbar region)

Starting position: prone

We place our two palms on either side of the lumbar spine
We ask the patient to raise his head-> under our palms we feel the isometric contraction of the muscle

Gillet test

Examination of pelvis nutation in an open kinetic chain.

The physiotherapist is in sitting behind the patient and the patient is standing in front of PT
The thumbs are placed on both PSIS, the thumb on the non-tested side is slid onto the processus spinosus of the S2 vertebra.

We ask the patient to pull their legs to the abdomen (there should be a minimum of 90° hip flexion)-> on the tested side, the thumb will move with the PSIS in a caudal direction with a maximum of 1 cm. • If it does not move or is less than 1 cm-> hypomobility

• If it moves more than 1 cm-> hypermobility
• Pathology if the SIPS moves cranially, this may indicate scoliosis, pelvic torsion, or limb shortening.
• Weperformthe assessment on both sides!

Gillet test: Nutation

pelvis inlet narrows, outlet expands

Gillet test: Counternutation

pelvis inlet expands, outlet narrows

Anterior rotation of ilium on relative stable sacrum

Starting position: side lying, 45° hip flexion, knee in 90°

The physiotherapist stands behind the patient in an offensive position and looks towards the patient's head. Our near body fingers are placed on the superior surface of the ASIS, the heel of palm of the other hand is on the caudal surface of PSIS-> We push PSIS towards cranial, we pull ASIS towards caudal!

Phys.: pain-free. Same degree of displacement on both sides; springy end feel

Posterior rotation of ilium on relative stable sacrum

The physiotherapist stands behind the patient in an offensive position and looks towards the patient's leg. Our near body fingers are placed on the caudal surface of the ASIS, the heel of palm of the other hand is on the cranial surface of PSIS-> We pull ASIS toward cranial and push PSIS toward caudal!

Sliding the sacrum in cranial direction

Starting Position: Prone

PT is standing in offense position, looking cranially, the palm of our near hand is on the apex of the sacrum, the fingers are facing cranially, the other palm stabilize the iliac crest
-> We move the sacrum cranially (the force is added gradually)

Sliding the sacrum in caudal direction

the palm of our near hand is on the basis of sacrum, the fingers are facing caudally, the other palm stabilize the ischial tuberosity
-> We move the sacrum caudally (the force is added gradually)

Sliding the sacrum anteriorly

PT in kneeling position the examination table or standing next to the edge of the examination bed, looking towards the head, palm on sacrum body, forearm perpendicular to bed, the other hand stabilizes the ASIS-> Gradually compress the sacrum towards the table (the force is added gradually)

M. Tensorfascia latae (hip flexion, abduction, internal rotation)

Starting position: Side lying, upper lower extremity is examined, hip 20° flexion, internal rotation

3: raise your leg toward the ceiling
4-5: resistance on the lateral and distal part of femur against abduction

2: the patient is supine, 20° flexion and internal rotation are created passively, PT supports the movement, holds the weight of the limb-> ask the patient to move the leg to the side

M. Sartorius (hip flexion, abduction, external rotation, knee flexion)

Starting position: supine, lower limbs are extended (old), untested in flexion (young)

3: place the heel of the test side on the knee of the untested side!
4-5: resistance on the distal medial surface of the femur and distal medial surface of the tibia against the movement

2: the physiotherapist holds the weight of the limb and follows the movement
OR create flexion and external rotation in hip passively, heel is placed on the opposite ankle and ask the patient to slide your heel towards your knee, follow the movement

M. Gluteus maximus (hip extension, external rotation, abduction, adduction)

Starting position: prone, place a pillow under the abdomen, stabilize the pelvis, 90° knee joint flexion in the lower limb on the tested side (hamstrings function switched off)

3: raise the lower limb towards the ceiling
4-5: resistance on the distal and dorsal surface of femur against hip extension

2: side lying position, upper lower limb hip in a neutral position with 90° of knee flexion, PT holds weight of limb and follows the movement (stabilize the pelvis if its needed)

M. Gluteus medius (hip abduction, flexion, internal rotation, extension, external rotation)

Starting position: Side lying, upper lower limb in neutral position, when performing the test, pay attention to avoid compensation (hip flexion, trunk lateral flexion), stabilize the pelvis

3: raise your leg toward the ceiling
4-5: resistance to the distal lateral surface of the femur against the movement

2: supine position, untested side lower limb in flexion (pulled on his feet), tested side lower limb in neutral position, physiotherapist holds the weight of the limb while following the movement

Adductor muscles

Starting position: supine, untested in flexion and is placed in an abduction (pulled on his feet), tested side lower limb in neutral position
OR side-lying position (lower limb is tested, upper limb is pulled to the chest)
When performing the test, pay attention to avoid compensation (hip rotation)

3: lift your leg up and adduct
4-5: resistance on the distal and medial surface of femur against movement

2: supine position (same position), PT holds the weight of the lower limb, follows the movement (adduction)

Sacral Apex Pressure test

The anterior ligament and the SI joint surface are tested.

Method: patient is in prone position, one hand on the body of sacrum, fingers facing cranially, the other hand crosses it
-> gradually increasing the force to push the sacrum anteriorly.

Positive: pain in the SI area or deep in the abdomen

Gapping test

The anterior ligament, posterior joint surface are tested.

Starting position: supine, the PT is facing the patient's head
OR the lower limbs are bent, and the PT is facing the patient's feet.

With the forearms crossed, the two heel of palms are placed on the medial surface of the ASIS-> gently distribute lateral force on both ilium, open the SI joint ventrally, stretches, stretch the anterior ligamentous system, compression is created on the dorsal surface of the SI joint.

Positive: if deep abdominal pain occurs, the anterior ligament is affected, if back pain occurs, the joint surface is affected.

Approximation test

The posterior ligament, anterior joint surface are tested.

Method: side lying, lower limbs in 45° hip and 90° knee flexion,

Place one hand on the ASIS area with the other hand perpendicular to it, applying the force vertically, perpendicular to the table gradually.
By opening the SI joint dorsally, stretching the posterior ligamentous system, compression is created on the ventral surface of the SI joint.

Positive: if deep abdominal pain occurs, the joint surface is affected, if back pain occurs, the ligamentous system is affected.

Knee to shoulder

Examines the ligamentum sacrotuberale

Method: supine, the lower limb on the examined side is flexed in the hip and the knee and is pushed towards opposite shoulder.

It rotates the ilium posteriorly-> lig. sacrotuberale stretched

Pain: provoked by positioning, palpation of tuber ischiadicum and lig . Sacrotuberale
Diff.diag.: piriformis rigidity-> by holding the position the pain decreases (muscle problem), if it increases nerve problem (n. ischiadicus)

Flamingo - Trendelenburg test

Flamingo test: symphysis is tested

Trendelenburg test: opposite side gluteus medius is tested

Method: the patient is standing pelvis width distance, we asked them to pull the knee of the tested (Flamingo) untested (Trendelenburg) to the abdomen. Hold on if neccessary.

Flamingo: pain in the symphysis area
Trendelenburg: if the gluteus medius is weak on the side being tested (the patient is standing on it), the non-tested side of the pelvis (where the leg is bent) will drop towards the ground.

Pelvis torsion – Supine to Long Sit Up test

Supine position:
Anterior torsion: limb is longer compared to other side
Posterior torsion: limb is shorter compared to other side • The Patient moves from supine to long sitting

Sitting position:
Anterior torsion: shorter (which was longer in supine)
Posterior torsion: longer compared to other side

Femoral Shear test

The patient is in supine, PT passively performs 45° hip flexion, abduction, and external rotation on the examined side, the sole of the foot next to opposite knee is on the table. In this position the head of the femur is most centralized and fits best into the socket of joint

One hand stabilizes the ASIS on contra lateral side and the other hand grasps the femoral condyles to produce axial compression in the joint

Positive:
1. Joint surfaces affected-> hip joint pain in the groin area
2. Patellofemoral joint pain occurs-> compression
3. SI joint: stretch of ventral ligaments deep abdominal pain, compression on dorsal joint surface back pain 4. Lumbosacral transition pain occurs-> lower back pain /shear force/

Gaenslen test

Examination of SI joints and pelvico-lumbo-hip complex

Method: The patient is in supine in a transverse position, with examined lower extremity hanging below the plane of the bed (passive hip extension and knee flexion) on the test side, and the contralateral lower limb is pulled to the abdomen, patient holds this position.

The Pt pushes the non-tested side leg (flexed hip and knee joint) towards the patient’s chest, while the tested leg which is allowed to fall over the side of the examination table is pushed towards the floor

Gaenslen test Pathology

Lumbar lordosis can be increase which may cause compression on lumbar facet joints
-> complaint occurs under the rib cage

Stiffness of hamstrings
Lig. sacrotuberale pain
Symphysis pain

Extended lower limb:
SI joint pain can be felt both sides deep abdominal or back pain If a neurological cause is suspected, always do the Slump test first

Flexed lower limb:
• Patellofemoral pain– compression
• Hip joint pain- soft tissue sprain
• Compression of the knee joint surfaces
• Stiffness of hamstrings
• Lig. sacrotuberale pain
• Symphysis pain

Extended lower limb:
• Patellofemoral compression– stretching of rectus femoris + lig. patellae
• Patella moves laterally- tractus iliotibialis tension
• Shortened hip flexors (iliopsoas, rectus femoris)
• Shortened anterior ligaments and capsule of the hip
• SI joint ligament system is strained
• Radicular pain: radiating pain in the anterior thigh-> stretch of femoral nerve (L2-L4)

Patrick-Faber test

The patient is in supine, PT creates flexion, abduction and external rotation in the examined side hip, with the ankle above the untested side knee. With one hand PT stabilizes the contralateral ASIS, with the other hand, slowly and gradually pushes the distal femur toward s the table

Positive: Pain in SI region, when mobility issues happen