PELVIS (INNOMINATE/PUBIC)

dx pelvis

standing flexion test (+ is side where thumb moves first)

pt reseats pelvis (observe anterior and posterior)

• asis compression test (+ on side with more resistance)

• locate landmarks (asis, pubic tubercles, medial malleoli. psis)

naming is based off of side of + standing flexion test

use the weird longhorn gang sign to help in naming dx (thumb is psis, index is asis, pinky is pubic tubercle)

hvla of anteriorly rotated innominate

1. Patient lies dysfunctional side up

2. Monitor medial to PSIS and flex both hips and knees up until motion is felt

3. Extends bottom leg

4. Grasp the patient’s arm that is in contact with the table and rotate their torso away from table until motion is felt

5. Drop upper leg off the table and held between the physician’s knees

6. With the patient’s arms crossed, pass the cephalad hand through the patient’s arms and stabilize caudad (thrusting) arm behind greater trochanter

7. Check lockout

8. Instruct patient to inhale deeply and exhale fully. At the end of exhalation, exert a quick, rotational, slightly downwards thrust through the iliac crest through the patient’s top leg. Greater thrust with arm on trochanter 

9. Reassess

hvla of posteriorly rotated innominate

1. Patient lies on nondysfunctional side with the posteriorly rotated innominate facing up

2. Monitor medial to PSIS and flex both hips and knees up until motion is felt at monitoring hand

3. Patient straightens bottom leg and hooks foot of top leg over the popliteal fossa 

4. Grab pt arm closest to table  and bring that arm towards you till motion is felt at the monitoring hand over the SI joint

5. Pt cross arms, weave your hand through to monitor SI joint. Thrusting arm on posterior iliac crest. 

6. Maintain sufficient rotation localized to level of the somatic dysfunction

7. CHECK FOR LOCK OUT.

8. Instruct patient to inhale deeply and exhale fully. At the end of exhalation, exert a quick, rotational thrust through the dysfunctional ilium in an anterior superior direction (LIKE YOU’RE PUNCHING/HUGGING YOURSELF)

9. Reassess

hvla of superior innominate shear

Abd IR

1. Grasp the tibia and fibula above the ankle on the side of the innominate dysfunction

2. Abduct and internally rotate the hip and leg until movement is felt at hip

3. Leaning back gently to provide an axial traction and instruct the patient to inhale and exhale. Provide more traction with each exhale

4. Repeat this 5-7 times

5. On the last exhalation tug on the leg

6. Reassess

hvla of inferior innominate shear

1. Pt lies with dys side up

2. Standing in front of the patient, monitoring the lumbosacral junction

3. Flex the legs and knees until motion at the lumbosacral junction

4. Induce rotation towards you by pulling pt’s arm

5. Extend the bottom leg and place the foot of top leg over the popliteal space of other leg

6. Tell pt to box their arms. Stabilize the trunk while monitoring the sacroiliac joint on the side of the dysfunction

7. Firmly contact the inferior aspect of the ischial tuberosity with the caudad forearm

8. Provide a cephalic thrust through the ischial tuberosity parallel to the table toward pts head (basically straight up to the pt’s head)

9. Reassess

met anteriorly rotated innominate

1. Pt is supine.

2. Sit on edge of table.

3. Pt’s ankle (side of dysfunction) is placed against your shoulder.

4. Hold onto thigh above knee.

5. Monitor PSIS on dysfunctional side (not shown in image)

6. Flex leg up until motion is felt at PSIS (this is the barrier)

   1. Pt resists by pushing leg down against your shoulder

7. Flex leg further

   1. New barrier is when movement is felt at PSIS again

8. Repeat 3-5 times + passive stretch

9. reassess (reseat pelvis right before), can look at ASIS and possible compression test

met posteriorly rotated innominate

1. Pt is supine.

2. Raise table as needed.

3. Drop leg (ischial tuberosity of dysfunctional side) off table. Instruct pt to hold onto edge of table with opposite hand. PT FOOT SHOULD NOT TOUCH FLOOR

4. Hand on opposite ASIS to stabilize.

5. Push leg DOWN (hand above knee)

   1. Pt resists by pushing leg back up

6. Repeat 3-5 times + passive stretch

met superior innominate shear

Abd IR

1. Pt is supine.

2. One hand holds heel and the other cups the bottom of the foot of side of dysfunction.

3. ABduct leg until hip is loose packed (feels loose) + internally rotate leg. Add traction by pulling leg toward yourself.

4. “Bring your foot towards your shoulder without bending knee as you inhale”

   1. Traction is maintained during inhalation. (You lean back to keep the traction)

   2. Traction is ADDED at end of each exhale to reach new barrier

5. Articulatory component: thrust at the end of the last exhalation.

   1. Give a nice tug as pt coughs “on your final exhale cough”

   2. Respiratory assist method so NO passive stretch

met inferior innominate shear

1. Pt is prone.

2. Pt at edge of table, leg (on side of dysfunction) drops off table with knee bent (rests on your thigh)

3. Monitor SI joint until you get pt into position THEN move hand to monitor IT.

4. Monitor SI until movement is felt at joint, then switch hand to IT

5. Hand pushes ischial tuberosity UP

   1. Ischial tuberosity is pushed further up at the end of each exhale to reach new barrier.

   2. As they inhale, I’m resisting, as they exhale, I’m applying force to pt head for 3-5 seconds

   3. “Inhale deeply and exhale forcefully”

6. Internal rotation of hip is added by moving knee slightly under table.

met innominate inflare

1. Pt is supine. 

2. Leg (on same side as inflare) is crossed over the other knee.

3. Can stand on either side of patient. One hand on bent knee and the other on opposite ASIS

   1. Hand on opposite ASIS to stabilize or monitor ASIS on side of dysfunction.

4. Engage in barrier by pushing knee OUT (toward table)

   1. Pt resists by pushing knee in against your hand. OR BRING THEIR KNEE INWARDS

5. Leg is pushed out further each time to engage new barrier.

6. Repeat 3-5 times + passive stretch

met innominate outflare

1. Pt is supine.

2. Leg (on same side as outflare) is crossed over.

3. Can stand on OPPOSITE side (can stand on same but set up would be harder). Reach out and hold knee.

   1. Hand on opposite ASIS to stabilize (not pictured) or monitor PSIS on side of dysfunction.

4. Engage in barrier by pushing knee IN

   1. Pt resists by pushing knee OUT against your hand

5. Leg is pushed in further each time to engage new barrier.

6. Repeat 3-5 times + passive stretch

met superior pubic shear

1. Same set up as posterior innominate rotation MET EXCEPT:

   1. Ischial tuberosity stays on table (localizes to pubic tubercle)

2. Pt is supine.

3. Hand on opposite ASIS to stabilize.

4. Ischial tuberosity (on side of dysfunction) ON table 

5. Push leg DOWN (hand above knee)

   1. Pt resists by pushing leg back up and slightly medially (as if they’re trying to get back onto the table)

6. Repeat 3-5 times + passive stretch

7. Stand with your hip against pt’s hip to stabilize.

met inferior pubic shear

1. Pt is supine. You stand on opposite side.

2. Monitor PSIS on dysfunctional side.

3. Flex pt’s leg up until motion is felt at PSIS (this is the barrier)

4. Pt resists by pushing up to ceiling

5. Flex leg further

6. New barrier is when movement is felt at PSIS again

7. Repeat 3-5 times + passive stretch

met pubic compression

1. Pt is supine.

2. Hips are flexed at 45 and knees at 90

3. Make sure pts ankles are touching!

4. Push knees apart until you feel resistance.

5. Pt pushes knees back together (toward freedom)

6. Start with fist between knees, then forearm; gradually increasing distance between knees

   1. Can do with palm, then fist, then additional hand for length IF YOU FIT FOREARM BETWEEN LEGS.

met pubic gapping

1. Pt is supine.

2. Other knee against your abdomen

3. Make sure pts ankles are touching

4. Push knees together (into barrier)

5. Pt pushes knees apart (into freedom)

6. Distance between knees is decreased each time

cs of anterior pelvic points

cs iliacus

F ER (hips)

1. Pt supine

2. Stand on same side of Tender pt which is located ⅓ from ASIS to midline (straight line across)

3. Cross ankles opposite over adjacent 

4. Flex pt hip/knees bilaterally and rest legs on your thigh (FROGGY LEGS)

5. Finetune with further flexion and external rotation.

cs psoas

F St er (hips)

1. Pt supine

2. Stand on same side of tender pt

3. Tender pt is ⅔ distance from ASIS to midline (straight line across)

4. Cross pt ankles (opposite over adjacent)

5. Flex pt hips/knees bilaterally and rest legs on your thigh

6. Bring knees towards me

   1. add slight external rotation and pull knees towards tender pt slightly side bend lumbar spine

7. Fine tune with more or less hip flexion, side bend and rotation

cs low ilium

F

1. Use iliac crest to find ASIS, then move to AIIS.

2. Follow from AIIS down inguinal ligament until you feel a bulb OR feel pubic tubercle and go ½ in lateral and ½ in superior

3. Physician stands on the same side of the tender point

4. Markedly flex patient’s hip 

5. Fine tune with more/less hip flexion

cs inguinal

F ADduct Internally Rotate

1. Tender point is located on the lateral aspect of the pubic tubercle; associated with the attachment of the inguinal ligament and/or pectineus muscle

2. Standing on the same side of the tender point

3. Cross the patient’s thighs opposite over adjacent. flex hips/knees bilaterally and place legs on physician’s thigh

4. Pull patient’s ipsilateral leg towards physician to induce adduction and internal rotation of the hip

5. Fine tune with more/less hip flexion, internal rotation and adduction

cs of posterior pelvic points

we just need to know UPL5 and Piriformis

cs piriformis (posterior pelvic)

Point is between sacral ILA and greater trochanter

1. Stand on same side

2. Ask pt to move to edge of table

3. Move leg down and hold between your knees

4. Flex and ABduct leg on affected side

5. Hold just below ankle and fine tune with internal or external rotation

cs UPL5 (posterior pelvic)

Point is superior and medial to PSIS

1. Pt is prone

2. Stand on opposite side

3. Hold pt leg of the tender point above knee

4. Extend and ADduct