Pelvis Bracket anatomical and physiological concepts of position & movement Assess dysfunction using percussion and palpated sense of ease & bind Five segmental levels of sacrum Although fused, dysfunction is still expressed segmentally

Sacro-pelvic Examination Standing: Percussion over lumbar spine & sacrum Sidelying: Palpate for ligamentous thickening and changed tension down the line of the S/I joint Feel for bands of muscular tension through gluteal area Repeat on other side Correlate central percussive findings with ligamentous and muscular tension bands

Examination Supine & Sitting Patient lying supine, knees flexed: Rotary scan through pelvis & spine using hand on side of knee to guide rotation Move palpating hand down a segment as the rotation is reversed Confirm findings with patient sitting using trunk to rotate Single leg or both legs One knee flexed check for asymmetry Reverse legs (still palpating the same side)

Then Repeat on Opposite Side - Each side is a separate problem Order of Testing Scanning Standing - percussion Sidelying - soft-tissue test of ligament and muscle Supine scan - one side at a time Analysis of segment Check supine both legs two directions (equivalent to testing rotation sitting) Check sitting and treat if necessary Test each leg separately in both directions Then Repeat on Opposite Side - Each side is a separate problem

Examination Objectives Examiner can scan the sacro-pelvic region using: Percussion, standing; Local pressure palpation of ligamentous and gluteal muscular tissues, sidelying; Spinal rotation supine, introduced from below, and confirm findings in the seated position using motion testing through the shoulders/trunk Examiner can mark location of a major finding and apply motion tests to compare local response to inversion/eversion of each leg singly

Distinguishing sacral from innominate lesions Sacro-pelvic lesions can have the following components: Sacral/axial only Sacral/axial plus lower extremity Lower extremity only Lower extremity problems can be: Unilateral Bilateral Resisting in the same direction Resisting in opposite directions

Functional Treatment of Pelvis Sacral Dysfunction Resistance to spinal axial rotation Compliance throughout inversion/eversion of individual legs No need to involve legs in manipulation Do sitting or sidelying as thorax/lumbar Innominate dysfunction one side (compliant one side only) Treat with patient sidelying and affected leg on top Treat as if the sacrum is made of mobile segments

Disturbed responses in inversion/eversion tests Resistance/Compliance in contra-lateral leg What eases ant/post translation? (test sitting) Ease in post. translation - treat prone (on elbows if necessary) Ease in ant. translation - treat supine (on elbows if necessary) Control ipsilateral and palpate contralateral leg Prone - stand by ipsilateral leg Supine - stand by contralateral leg Two directional cues Both legs compatible (same as) axial rotation Legs both resisting the same movement

Legs compliant with axial movements (legs different from each other) Functional approach Position patient according to findings - elevated hips or shoulders Treat with both legs together Legs over shoulder Legs over operator’s knee Legs over operator’s arm

Ease/bind same in both legs Use an articulatory/muscle energy approach as more practical than a functional technique Resistance to inversion in each leg Patient supine actively inverting both legs against operator’s fist Operator rotates legs towards resistance of axial rotation Resistance to eversion in each leg Patient supine actively everts both legs while operator grips knees between hand and forearm

Summary of pelvic tests Findings Treatment Approach Axial resistance only Treat seated (or supine) Resistance in ipsilateral leg only Treat lying on contralateral side Sacro-pelvic disturbance: One direction compliant Position and then treat limb identified Both limbs compliant with axial rotation Use functional approach through both legs Both limbs resisting same movement Direct technique confronting sacral resistance