Discerning the Pelvis

By Deborah Currier,SPTA, LMT

Staff In-Service

November 5, 2015

• Upslip: The innominate slips up the sacrum

• Anterior Tilt: Tight hip flexors and trunk

extensors:

• Lordodic curve with a ‘belly’

• Must have core issues

• Shortened quads --> cramp (too short muscle trying to

work)

• Posterior Tilt: Tight hip extensors and trunk

flexors:

• Flat back, or kyphotic low back

Upslip ° Anterior Tilt ° Posterior Tilt

• If only one is present

• Core stability may be only slightly

destabilized.

• If 2 or 3 are present

• Core is usually compromised

• Hip takes over the work of the core for

stabilization with non-uniform effort

Four Basic Puzzle Pieces

• Illiac Crests: Are they level?

• PSIS’s: Are they level?

• PSIS with Movement:

• Flexion, lateral flexion, Gillet’s

• Do they remain level or go up? hypomobile

• Do they go down? normal movement

• Leg Length Discrepancy (LLD):

• Which one is shorter?

• How do they move sitting to supine?

Illiac Crests

• Assess from the back

• Move the shirt up so can observe landmarks

and movement in the back

• Come in from the lateral waist – 2nd MCP joints

level?

• Are they level?

• Higher side Upslip and/or posterior rotation

possible

• Lower side Anterior rotation possible

PSIS’s

• To find:

• Just below the Dimples of Venus

• Where the thumbs naturally land from

the iliac crest assessment

• Feel for movement while they march

in place

• Are they level?

• Higher side Upslip and/or posterior

rotation possible

• Lower side Anterior rotation

possible

PSIS’s with Movement• Flexion, Lateral Flexion and Gillet’s

• Thumb not moving, moving up, or moving away from the other indicates that the innominate is not moving against the sacrum in the SIJ Hypomobile SIJ

• Thumb moving down or towards the otherindicates innominate is moving against the sacrum preferred

• Observe the back during motion• Hinges during movement ( especially lateral

flexion)• Will see a hinge rather than a smooth curve along

the spine

• Rotated spine• Paraspinals often raised on the side of the rotation

and depressed on the contra side

• L rotated thoracic spine caused tight R paraspinals. He laterally deviated R during flexion, higher IC, hip ER

Leg Length Discrepancy (LLD)Why the leg moves with tilts and upslips?

• Posterior tilt moves innominate so its joint surfaces move forward and locks onto the femoral head ‘speed bump’

• Anterior tilt moves innominate so its joint surfaces move backwards and away from the femoral head ‘pot hole’

Use distraction to feel for movement in hip joint making the leg ‘shorter’ or

‘longer’

How much movement? • Less than a thumb’s width

• Start with a quick assessment of bilateral hip ROM

• More than a thumb’s width: Think pelvis• Shorter upslip and/or posterior tilt

• Longer anterior tilt

Leg Length Discrepancy (LLD)• Watch (out the ‘tops’ of your eyes) as the

person goes from sit to supine• If go down on an elbow – makes assessment

invalid

• Modified LLD• Start in hooklying

• Bridge from supine

• Look at knees for femur length (longer/shorter)

• Helpful after TKA or hip replacements

• Chronic conditions often have one side with an anterior tilt and the other side with a posterior tilt

• After a couple of weeks the body compensates

Edge Pieces• Posture

• Sway back: Anterior tilt

• Flat back: Posterior tilt

• Tight/Cramped Muscles

• Quads: Anterior tilt

• Hams: Posterior tilt

• Walking: Lose balance, hip gives out, hip feels weird, trip up the stairs

• Think hip flexors and trunk extensors (anterior tilt)

• Sit to Stand (especially when start standing up)

• Pain, “ugh”

• Think hip extensors and trunk flexors (posterior tilt)

• SLS:

• Tendency to lose balance medially – anterior tilt

• Tendency to lose balance laterally – posterior tilt

• Pre-Piriformis Stretch:

• If symptoms worsen, may need to correct innominate/upslip

• Upslip:

• Tight QL

• More distinct crease on one side at the waist visible in low back

PatternsBoth the illiac crests and the PSIS’s indicate the

possibility of an upslip and/or a rotation

Pattern 1:• Iliac Crest higher with ipsi PSIS level or higher

• LLD: Ipsi LE remains shorter than contra LE in

sitting & supine upslip

• Ipsi LE moves thumbwidth+ shorter to contra LE to supine

upslip and posterior tilt

Pattern 2:• Iliac Crest higher with ipsi PSIS level or higher

• LLD: Ipsi LE longer than contra LE in sitting, AND

• Ipsi LE becomes shorter to contra LE in supine AND

• Contra LE does not get shorter upslip & posterior on ipsi

Pattern 3: • Iliac Crest higher with ipsi PSIS level or higher

• LLD: Ipsi LE is longer than contra LE in sitting

• AND Ipsi LE is longer in supine upslip and anterior tilt

• OR Ipsi LE is shorter in supine upslip and posterior tilt

Self-Mobilization for Upslip

• If an upslip is suspected – correct it first

• Then re-evaluate LLD to determine if concurrent rotations are also present

• Sit in a chair with a back

• Feet evenly on floor

• Buttocks all the way back so they sit against the back of the chair

• Dowel under contra ischial tuberosity

• Dowel made from a rolled towel

• Sit straight and relaxed for 3-4 minutes

• Lets gravity encourage the upslippedinnominate to slide down along the sacrum

Self-Mobilization for Tilt

Standing

• Standing with something to hold onto for balance

• Step up with foot on the side with the anterior tilt (or contra to the posterior tilt) onto a low bench/stair

• Lean backwards

• Lunge so that the groin goes towards the floor 5x

• Knee flexes no more than 90 degrees

• Pushes pelvis into posterior with the extension.

Prone: POE, press ups

• Stretches hip flexor

• Encourages normal functional motion between L5/Sacrum

Manual ApproachesAnterior Tilt• In prone

• One hand stabilizes contralateral innominate laterally along the SIJ border

• Not on the SIJ

• Other hand pulls straight up (skyward) on the ASIS

Posterior Tilt• In prone

• One hand stabilizes contralateral innominate laterally along the SIJ border

• Other hand pushes down (into the table) on the innominate laterally and inferiorly

• With the direction of the plain of the joint

• Whole joint capsule get stretched

Other Treatment

Key Factors to Retaining Pelvic Alignment

1. Log roll

2. Core stability and engagement

3. Hip ROM and strength should be balanced

bilaterally

4. Requires life-long commitment to 2x/week

exercise or will get weak and re-injure

Thank You Cheryl!It has been a wonderful internship!

ReferencesBasheer, A., MD. (nd).The Sacroiliac Joint: To fuse or not to fuse. Retrieved from:

http://www.slideshare.net/AzamBasheer/si-joint-fusion-azam-basheer-md

Neumann, D.A. (February, 2010). Kinesiology of the hip: focus on muscular actions. Journal of

Orthopedic Sports Physical Therapy. 40(2):82-94. doi: 10.2519/jospt.2010.3025.

Parent, C., PT (September-November, 2015) Personal conversations.

Physiopedia. (nd). Leg Length Discrepancy. Retrieved from: http://www.physio-

pedia.com/Leg_Length_Discrepancy