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SUBJECTIVE EXAMINATION

History:

specific and surrounding events that may have contributed to the


development of the symptoms
mode of onset sudden or insidious
was there an element of trauma
previous episodes / previous treatment and response
is the problem a consequence of pregnancy/delivery
family history of pelvic girdle pain

Location of the Symptoms:

localized or diffuse pain/dysesthesia


quality
radiation into the lower extremity

Aggravating Factors/Movements/Posture:

pain intensity
pain behavior specific movements/postures that provoke or relieve the
pain
pain pattern intermittent vs. constant, 24 hour period, sleep disturbance
do certain movements or postures aggravate the symptoms
aggravating activities eg. running what part of the running or gait cycle
effect of prolonged sitting, standing, walking, stair-climbing, rolling over in
bed, getting in and out of a chair or car, transitional movements

Relieving factors:

Medication / General Health / Diagnostic Imaging:

Occupation / Leisure Activities:


current level of activity
requirements for sport and work

Psychosocial Factors:

coping strategies, pain beliefs, avoidant behaviours, fear or


movement

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
OBJECTIVE EXAMINATION
ACTIVE RANGE OF MOTION

Forward Bending in Standing (Lee 2011)

relative intersegmental mobility spinal segments should flex


symmetrically
paravertebral fullness should be equal left and right
pelvic girdle should anteriorly tilt symmetrically over the femoral heads
no intrapelvic rotation or torsion should occur
note any unlocking of the SIJ and the timing at which this occurs
note amount of lumbar flexion during the first 1/3 of forward flexion,
pelvic girdle pain patients emphasize lumbar flexion as compared to low
back pain patients who tend to maintain a lumbar lordosis (van Wingerden et
al 2008)
note amount of hip flexion pelvic girdle pain patients may show
significantly limited hip motion at maximal forward bending (van Wingerden et
al 2008)

Backward Bending in Standing (Lee 2011)

relative intersegmental mobility of the lumbar spine spinal segments


should extend symmetrically without hinging or shifting note any
positional changes of the lumbar vertebra at end range extension
pelvic girdle should posteriorly tilt symmetrically on the femoral heads
no intrapelvic rotation should occur
note any unlocking of the SIJ and the timing at which this occurs

Lateral Bending in Standing (Lee 2011)

note the apex of the curve and the lateral translation of the pelvic girdle
spinal segments should side flex symmetrically
a small amount of intrapelvic torsion should occur
note any loss of control

Body Twist

note the apex of the curve


intrapelvic torsion should occur eg. with right body twist, right innominate
posteriorly rotates and he left innominate anteriorly rotates, the sacrum
rotates to the right

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
LOAD TRANSFER / FUNCTIONAL TESTS (weight-bearing)

One Leg Standing Test

This test examines the ability of the low back, pelvis and hip to transfer load
unilaterally (load transfer control test) as well as examining intrapelvic mobility
(ability of the hip to flex, lumbar spine to rotate and pelvis to rotate).

Hip Flexion Phase:

With one hand, palpate the innominate at the inferior aspect of the PSIS and at
the iliac crest on the NWB side. With the other hand, palpate either the median
sacral crest at S2 or the ILA of the sacrum on the same side. The patient flexes
the ipsilateral hip- note the posterior rotation of the innominate relative to the
sacrum. Compare the amplitude and the quality of the motion to the opposite
side. Remember that this is not just a test for the SIJ but for the lumbopelvic hip
complex.

Support Phase:

On the weight bearing side, palpate as above. The patient is instructed to flex
the contralateral hip. Note the motion of the innominate relative to the sacrum on
the weight bearing side. Especially note the movement that occurs as the weight
is transferred onto the supporting leg (initial loading) and the contralateral leg is
coming off the ground. The innominate should either posteriorly rotate or remain
still (in a posteriorly rotated position). When the pelvis unlocks, the innominate
can be felt to anteriorly rotate relative to the sacrum, an indication of failed load
transfer. (Hungerford 2004, 2007)

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Squat Analysis:

lumbar spine maintain neutral, note any spinal


segments that hinge or buckle
observe symmetry of motion and any loss of control
watch for anterior rotation of the innominate relative to
the sacrum
note the alignment of the thorax relative to the pelvis

PAIN PROVOCATION TESTS

Posterior Pelvic Pain Provocation Test (P4)


Compression
Distraction
Patrick Faber
Sacral Thrust

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
PASSIVE ROM TESTING (FORM CLOSURE)

Passive Physiological ROM


Innominate
o Anterior rotation
o Posterior rotation
Sacrum
o Nutation
o Counternutation

Neutral Zone Analysis (Lee 2011)

Anteroposterior plane Craniocaudal plane

The SIJ is capable of a small amount of translation that facilitates angular motion.
The direction of the glide is variable due to the orientation of the plane of the
joint. The results of the neutral zone analysis must be compared to the active
rom and functional load tests to determine if the joint is stiff, has increased laxity,
is fixated or myofascially compressed.

P: supine lying with the knees and hips flexed and supported
T: standing at the patients side. Palpate the sacral sulcus just medial to the
PSIS with the long and ring fingers with one hand. With the heel of the
other hand, palpate the ipsilateral ASIS and iliac crest. Apply a gently
force in an anteroposterior direction varying the inclination from slightly
medial to lateral to find the plane of the joint.
The same positioning and landmarking is used to assess the neutral zone
in a craniocaudal plane.

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Clinical Reasoning Neutral Zone Analysis (Lee 2011)

Stiff / fibrotic joint both active and passive range of motion will
be reduced compared to the other side

Increased laxity the active rom may be reduced on that side and
the passive range will be greater than the opposite side a non-
optimal bracing strategy may exist to control the joints excessive
motion

Fixated joint no movement occurs either on active or passive


mobility testing and the joint plane cannot be found history of
trauma

Compressed joint (neural system impairment) inconsistent


findings, axis of motion is altered, may be restricted in just one
plane, presence of increased muscle tone

Elastic Zone Analysis: once the neutral zone is assessed, move towards the
end of the joints range to assess the elastic zone.
End feel
o Stiff SIJ firm end feel
o Lax SIJ very little resistance and may be painful
o Compressed SIJ springy sense to the resistance that may vary
with the different speeds of the application of the force
o Fixated SIJ all movement is blocked cannot assess the elastic
zone
Reproduction of pain

Stability Testing

Vertical SI Stability

Stabilize the sacrum with one hand


and shear the innominate in a
superior and inferior direction with
the opposite hand. This can also be
done in the side lying position.

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Anterior / Posterior

The starting position is the same as the


neutral zone analysis testing find the
plane of the joint, note the amplitude of
movement and then close-pack the joint
by nutating the sacrum and posteriorly
rotating the innominate. Hold this
position and repeat the anteroposterior
glide, no movement should occur if the
articular restraints are intact. (Lee 2011)

Pubic Symphysis vertical stability

With the heel of one hand, palpate the


superior aspect of the superior ramus
of one pubic bone and with the heel of
the other hand, palpate the inferior
aspect of the superior ramus of the
opposite pubic bone. Fix one and
apply a slow, steady vertical
translation force to the other. Minimal
translation should occur and the end
feel should be firm and painfree.
(Lee 2011)

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
MOTOR CONTROL FORCE CLOSURE

Active Straight Leg Raise Test

The test is performed with patients in a supine position with legs straight and feet
20 cm. apart. The test is performed after the instruction try to raise your legs,
one after the other, above the couch for 20 cm without bending the knee. The
patient is asked to score impairment on a 6 point scale not difficult at all =0;
minimally difficult = 1; somewhat difficult; difficult =2; fairly difficult =3; very
difficult =4; unable to do= 5. The scores on both sides are added, so that the sum
score range from 0 to 10. (Mens 2001, European Guidelines 2008)

The patient can also be asked to note any difference in effort does one leg feel
heavier or harder to lift.

Note the compensation strategies used to accomplish the task: (Lee, 2011)
over-activation of the external obliques excessive drawing
in of the rib cage
over-activation of the internal obliques lower ribs flare out
excessively
compensatory rotation through the lumbopelvic region
thoracic spine should not extend (over-activation of the
erector spinae)
the abdomen should not bulge (breath-holding valsalva)
the thorax should not laterally translate relative to the pelvis

A positive test is when either the patient or the therapist notes an effort difference
between the two sides or a compensation strategy is noted. A note should also
be made of the provocation of pelvic girdle pain.

Compression is then applied to the pelvis and the ASLR is repeated and a
change in effort or pain is noted.

Bilateral Anterior simulates force of contraction of the lower fibers


of transversus abdominis , internal oblique and the abdominal
fascia
Bilateral Posterior simulates lumbosacral multifidus and
thoracolumbar fascia
Anterior pelvis at level of pubic symphysis simulates the
contraction of the anterior pelvic floor in coordination with TrA ad
internal oblique
Posterior pelvis at level of the ischial tuberosities simulates the
action of the posterior pelvic wall and floor
Compression can be applied obliquely through pelvis (one side
anteriorly and the opposite side posteriorly)

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Assessing Transversus Abdominis

Palpate the abdomen about 1 inch medial to and just inferior to the ASIS be
sure to allow your fingers to sink into the abdomen to allow palpation of the
deepest layer of TA. Try different cues and images to try to elicit an isolated
contraction of TA. The patient is encouraged to contract slowly and gently.
Examples of some cues:
for women, gently lift your pelvic floor
imagine drawing the ASISs together
find your pubic bone in your brain, think of gently drawing your
lower abdomen up and in, pulling away from your pubic bone
When an isolated transversus contraction is achieved, a deep tensioning will be
palpated just medial to the ASISs with a flattening of the lower abdomen.

Substitution Strategies

bulging of the internal oblique muscle


spine and pelvis should remain in neutral there should be no posterior
pelvic tilt or depression of the rib cage
breath holding
restriction of the rib cage wiggle and lateral costal expansion indicates
recruitment of the obliques and / or erector spinae
may also see asymmetrical recruitment

Assessing the Superficial and Deep fibres of Multifidus

Palpate L1 with one hand and the PSISs with the fingers of the other hand.
Imagine a triangle between these 3 points. Roll transversely across this diagonal
line and note any areas of hypertonicity. Next, palpate the muscle segmentally at
each level in the lumbar spine just lateral to the spinous processes. Note levels
of atrophy or decreased resting tone. Try different cues to obtain an isolated
contraction of the deep fibres of the multifidus. (eg. imagine slowly drawing the
two innominate bones together or contract the muscles of the pelvic floor and
gently lift up and in).

Substitution Strategies

observe and palpate for activity in the global muscles thoracic


component of the erector spinae, superficial and lateral multifidus and the
superficial abdominal mm

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Global System Slings Strength Analysis

The integrated sling systems are comprised of several muscles which produce
forces. A muscle may participate in more than one sling and the slings may
overlap and interconnect depending on the task being demanded. The
hypothesis is that the slings have no beginning or end but connect to assist in the
transference of forces. The identification and treatment of a specific muscle
dysfunction (weakness, inappropriate recruitment, tightness) is important when
restoring global stabilization.

Posterior Oblique Sling (gluteus maximus, latissimus dorsi)

Anterior Oblique Sling (oblique abdominals, contralateral adductors)

Lateral Sling (gluteus med/min, TFL)

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Global Slings Length Analysis

Right Posterior Oblique Sling

Left Anterior Sling

Longitudinal Sling (erector spinae, hamstrings)

Iliacus / Rectus Femoris / TFL / Adductors

Piriformis / Deep External Rotators

Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
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Assessment of the Pelvis


Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013
Assessment of the Pelvis
Lenerdene Levesque BSc.P.T., MClSc(manip), FCAMPT
Western University 2013