Pelvis What type of joint is the sacroilliac? What type of joint is the Symphysis Pubis?

At what angle are they? Modifed plane synovial joint / fiborous syndesmosis Cartilaginous plane joint with disc 30* from S2 on saggital plane 30* on horizontal Ligaments of the SI joint Long Posterior SI lig (limits anterior pelvic rotation) Short posterior SI lig (limits all pelvic & sacral movment) Posterior Interosseous

How are the SI ligaments unique? How is the joint capsule protected? Groups of muscles that support the pelvic girdle

Unlike many ligaments in other joints which are designed to provide axis of movement, these are also designed to maintain posture indefinitely without becoming painful. Sacro-tuberous & sacro spinous ligs prevent excessive nutation Inner Group: TA, Diaphragm, Multifidus, Pelvic Floor mms Deep Longitudinal: Erector Spinae, TLF & Hamstring mms & sacrotuberous lig Superficial Posterior Oblique system: Lat Dorsi, Gluteus Max & TLF Anterior Oblique group: Internal & External Obilques, the contralateral adductora & abdominal fascia in between Lateral System: Gluteus Med & Min & Contralateral adductors Innermost: Multifidus, TA, Diaphragm & pelvic Floor Force coming up the leg, car crash stepping off a kerb, falling off your bum

Causes of SI lesions?

SI pain pattern

Deep, dull, undefined, unilateral pain (doesnt cross midline). Agg: Walking, rolling over in bed, weight bearing, flexion or extension of the pelvis Can be in buttock, posterior thigh, iliac fossa. It does not commonly extend beyond the knee.

Where do SI regions tend to refer?

Physical Signs

TTP over joint line Possible LLD Pevlic Rotation Possible guarded gait Altered SI Motion from side to side

Orthopaedic Tests

Belt test (relieve pains, useful to differentiate from lumbar pain) Marching test Flexion/ Fascial Pull Test 2

How does pubic symphsis pain appear? Apart from Illiac Crest, PSIS & ASIS where else should you palpate?

Local and increases with any movement involving adductor or rectus abdominus mms The ischial tuberosities

Lee uses SI exams to assess equal stiffness of movement rather than mobile hyper mobile Other tests SI Gapping test SI rocking knee to shoulder Prone with hip ext Sitting forward flexion Femoral Shear Supine, knee slightly bent, push down length of femur Can measure leg ,length from ASIS to medial malleoli What structure can refer pain to the SI joints? Which structures can the SI joint refer pain to? Meralgia Paresthesia LSp, Hip LSp, Hip, Thigh,long the Superior gluteal or Obturator nerve pressure or entrapment of the lateral cutaneous nerve of the thigh as it passes under the inguinal ligament near the ASIS. Caused by seat belt in car accident, pregnancy stirrups, hernia Lies in TA mm, can be compressed by spasm of muscle. Pain occurs in superior aspect of anterior thigh also scrotum or labia Hockey Players syndrome . Pain on ipsilateral hip extension & contralateral torso rotation.The 3

Ilioinguinal Nerve

pain may radiate to the groin scrotum, hip and back

Indirect Inguinal Hernia Is an inguinal hernia that results from the failure of embryonic closure of the deep inguinal ring after the testicle has passed through it. Like other inguinal hernias, it protrudes through the superficial inguinal ring. It is the most common cause of groin hernia. Can occur at any age

Direct hernia

a type of inguinal hernia, which enters through a weak point in the fascia of the abdominal wall. Males are ten times more likely to get a direct inguinal hernia. Tends to occur later in life as abdominal wall weakens Anatomy A direct inguinal hernia protrudes through a weakened area in the transversalis fascia near the medial inguinal fossa , an area defined by the edge of the rectus abdominis muscle, the inguinal ligament and the inferior epigastric artery. These hernias are capable of exiting via the superficial inguinal ring but, unlike indirect inguinal hernias, they cannot move into the scrotum. Risk Factors the abdominal walls weaken with age, direct hernias tend to occur in the middle-aged and elderly. Additional risk factors include chronic constipation, overweight/obesity, chronic cough, family history and prior episodes of direct inguinal hernias.

Functions of the SI joint

1. transmit the weight force of the upper body to the hips and lower extremities provide a biaxial pathway. 2. transmit the reaction force from the ground via the lower extremities to the lumbar spine. 3. aid locomotion by dampening the movements from both above and below coping with torque and momentum. 4. support the pelvic viscera and their supporting tissues as well as allowing for the expansion of the pelvis girdle in labour.

How does the SI ligamentous system supprt these functions? Functions in SI joint

This ligamentous system not only restricts the movement but its fibres run in every direction & so is capable of dissipating the forces into areas capable of resolving them.
*Aid in parturition *Aid in locomotion *A dampening system *A static as well as a dynamic proprioceptive role

Why is the sacrum an Inverted key-stone

If the sacrum sat on top of the ilia, the weight bearing force would simply push it into the ilia and prevent even small movements. With the inverted key stone the sacrum is always falling away from the ilia.
pelvic rotation, tilt, lateral pelvic displacement, knee flexion, hip flexion and ankle-knee interaction.

What are the major components of locomotion?

What movements are required of the pubic symphysis?

Shearing , rotation

Where is the axis of the sacrum? Where does the ilio-lumbar ligament run?

S2 from the TP of L5 to both the iliac crest and the anterior sacro-iliac ligaments. This ensures that all pelvic movements will be integral to L5 movements and encourage follow on movements of each other. The ilio-femoral ligament is the strongest hip ligament, controlling extension to a maximum of 15 degrees and allowing weight transmission through itself in locomotion, as the lower limb goes from toe-off on one foot to heel strike of the other. Its tension is important as it helps to control the forces going through the pelvis. In O/A every range in the hip is reduced to some degree, extension is obviously the first to be lost. The spine attempts to compensate for this by extending more, the SI joint may be the 1st joint to be symptomatic. During running, walking and even during the minor weight shifting that occurs while standing and sitting muscle power and weight bearing forces are transmitted from the spine and trunk to the legs via a number of distinct but complementary pathways. This division of labour not only facilitates locomotion but protects against injury, especially injury to the articular chain from the L/S via the SIJ and pubic symphysis to the hips. Thus, a patients symptoms may arise from damage of the articular chain but the cause may be from the failure of these complementary pathways.

Which is the strongest hip ligament?

What happens to ROM in OA?

What is the force transferance system?

What are the 4 main force transference systems?

1. 2. 3. 4.

The articular and peri-articular structures of the pelvic bowl The superficial thoraco-lumbar myo-fascial structures. The deep thoraco-lumbar myo-fascial-ligamentous structures. The Ventral (anterior) myo-fascial-ligamentous structures.

Describe Superficial Force Transference system

Superficial Force Transference System = from the upper extremity (via latissimus dorsi, the rib cage and iliocostalis thoracic muscle) to the superficial layer of the TFL. (fibres cross the mid line at LS region where they become dense). Over the SIJ region the TLF blends deeply with the gluteus max muscle and fascia which continues with the ilio-tibial tract and on the lateral aspect of the contra-lateral knee.

Describe the Deep Force Transference system

The deep system - from the lumbar spine, the deep and intermediate layers of the TLF and multifidus to the medial bands of the sacro-tuberous ligament, (blending with the ipsilateral biceps femoris). (blends with lumba erector spinae: longissimus lumborum and iliocostalis lumborum This continues on to the fibular head and the crural fascia encasing the calf muscles, aiding support of the foot arches.

Describe Ventral Force Transference System

Ventral Force Transference System - from the abdominal obliques across the lower linea alba via

the inguinal ligament to the rotator and abductor muscles and fascia of the hip. This links in with the posterior systems via the fascia of transversus abdominus.