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NMT: Pelvis


Assessment:

• sacral sulcus depth: place thumbs on each side of sacrum just inside PSIS and press, tells you if sacrum is rotated on long axis relative to ilia

• Iliac crest height: drop fingerpads from waist to upper border of ilia, consider is one side is higher than the other. A posteriorly rotated ilium will appear higher at the crest, and anterior rotation will cause it to appear lower.

• PSIS levels: Measure by placing thumbs on the posterior border of the PSIS and pressing upward. If an ilium is posteriorly rotate the PSIS on that side will be lower, and vv.

• Leg length: With pt prone, stretch both legs out then compare heels or medial malleoli. A posteriorly rotated ilium will cause the leg to be shorter on that side.

• ILA – Inferior lateral angle: Palpate these at the bottom corners of the sacrum, near the apex, pressing upward. If one is higher, the sacrum is rotated laterally. The direction toward which the sacrum is rotated is the side on which the patient lies for all hip to hip adjustments, and is the direction for which the torsion is named.

• Sacral Spring P → A: With patient prone press straight down on sacrum to see if it moves freely on the ligaments. If it does not move at all, the SI joints are probably inflamed and stuck.

• ASIS Levels: These correspond in their correlations with the Iliac crest ht.

• Pubic ramus levels: Compare the pubis on each side of the midline cartilage by pressing down on the ramus on both sides at the same time. If there is a misalignment at the pubic symphysis these may feel uneven, and a gapping procedure may help the joint reset.

• Step test: The patient stands, with a chair back to hold for balance, while the doc is seated behind them. One thumb placed on PSIS, the other on the 1st or 2nd protuberance from the sacral midline. The patient slowly lifts each knee as high as it will go, while the doc tracks the movement of these two landmarks. When the knee lifted is the same side as the PSIS palpated, the landmarks should move together along a diagonal line. When the opposite knee is lifted, the bony landmarks should move apart, also along a diagonal. Any other direction of movement is aberrant and indicates SI dysfunction.

• Seated forward bend test (aka. Seated flexion test): The patient sits and the doc is positioned behind them, with a thumb on both PSIS simultaneously. The pt gradually leans forward and the doc tracks the movement of the PSISs--if a SI joint is restricted, the PSIS on that side will move first and/or farthest.

Strain/Counterstrain: Palpate the tense muscle, locating any trigger points. Maintaining contact with the trigger point, position the patient so that the muscle is in its shortest possible position. Lighten up on the pressure on the trigger point, but hold gentle pressure for up to one minute until a release is felt. Repeat on any remaining points until the muscle relaxes.

• Psoas: shorten muscle with knee up
• Iliacus: knee up
• Iliosoas: knee up
• Lumbar paraspinals: depends on which paraspinal
• Quadratus lumborum: back arched
• Piriformis: pt prone, knee bent, knee in (ext rot)
• Glut. Med.: into rot
• TFL: froggy position

Manipulation:

• P.I. Ilium prone with blocks and sidelying. Sidelying: PI side up, contact PSIS, traction upper body, drive PSIS anteriorly with thrust.

• A.S. Ilium prone with blocks and sidelying. Sidelying: AS side up, contact ischial tuberosity, traction upper body and thrust IT in line with femur anteriorly.

• Sacral Rotation sidelying: lesion side down, contact is base of sacrum, pisiform or knife edge btw PSISs, pt on side with posterior part of sacrum up, hips tilted until my force is P-->A

• Sacral sidebend – sidelying: palpate ILAs, note tilt, contact is lower end of sacral sulcus near ILA and apex, contact with pisiform, their hip at 45 degrees, traction upper body, force P-->A.

• MET: Work whatever muscle needs to be relaxed in 10 sec bouts at 70% exertion, allowing gravity to length muscle between bouts. 3x repeats.

◦ P.I. Ilium: PIR hams 1st 20% effort, MET flex hip to pull pelvis fwd, 70% effort

◦ A.S. Ilium: due to tight psoas, so have pt sit at end of table, grab knee of opp leg, lay back, do PIR at 20% effort to release (eyes up, gradually inhale while exerting, work muscle x 10 secs, then exhale, relax, eyes down, wait, lengthen, repeat 3x total), then stretch ham on shoulder 70% effort leg bent x3

◦ Sacral torsion lesions: flexion and extension torsion.
Flexion torsion = rotate and side bend to same side. Upper body face down, 90/90 position, pt force is up, let feet drop.

Extension torsion = rotate and side bend to opp side. Upper body face up, 90/90 position, pt force is down, let feet drop.

Both named for side of side bend.

Sample Questions:

1. Using the Step Test determine if an ilial lesion exists – name the lesion (either R or L, either PI or AS ilium)

2. Perform a Sacral Spring test - what lesion is present in a positive test? (right rotation lesion or a left rotation lesion).

3. Find the ILA (inferior lateral angle) and determine which lesion exists? either L or R lateral rotation

4. Using pelvic blocks and grade 2 mobilisation correct a L P.I. Ilium. Have pt lie prone, block L greater trochanter at 90 degrees and right ASIS at 45 degrees. Oscillate sacrum gently in midrange of ROM.

5. Using Grade 4 mobilization, correct right A.S. Ilium sidelying. Have pt lie R side up, knees bent, hook top foot on bottom knee, traction pts body lenthwise w/ some twist, my L hip to their R, my L hand to their R ischial tuberosity, grade 4 oscillations.

6. Correct a R sacral rotation lesion with Grade 2 mobilisation. Pt lies on L side, (posterior edge of sacrum up), tilt hips until my force is P-->A, contact sacral base between PSISs w/ my pisiform or knife edge, traction and mobilize.

7. Using a MET to correct sacral flexion around the right oblique axis. (this means sacrum is rotated and laterally bent to the R, so pt lies on R with upper body facing down, face in cradle, arms around table. Put hips/knees in 90/90 position, I sit on stool. Pt pushes up with feet vs my hand, 70% effort x 10
sec, then I wait, let legs lower, repeat push x3 total.)

8. Use MET to correct a L A.S. Ilium. LAS ilium due to tight L psoas, so have pt sit at end of table, grab R knee, lay back, do PIR to release (eyes up, hold breath, work muscle 20% effort x 10 secs, wait, lengthen, repeat 3x total), then work ham on shoulder 70% effort leg bent x3

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