Assessing and Treating the Pelvis
Altered function and alignment in the pelvis can cause pain and pathology to arise in other body parts such as the foot, knees, thorax or neck. These distal pathological changes can come about even without the presence of Pelvic Girdle pain.
Movements of the Pelvis
Pelvis Nutation & Counternutation:
Sagittal plane motion at the SI joint is called either nutation or counternutation. The word nutation means to nod similar to the idea of the slight tilting or nodding of the earth on its axis in the study of astronomy.
Movements in the Pelvis is Important for all areas of functional movement; imagine walking with a rigid pelvis. When one limb flexes whilst the other extends — it would be impossible to move without the pelvis rotating independently on each other.
Note that in any movement — the pelvis may nutate on one side and counternutate on the other.
Nutation is defined as a relative anterior tilt of the sacral base (upper flat surface of the sacrum that articulates with L5. It is considered a relative motion as it requires the sacrum to rotate anteriorly in relation to the ilium rotating posteriorly.
Counternutation occurs when the sacral base tips posteriorly in relation to the ilium. Therefore, it may occur when the sacrum rotates posteriorly, the ilium rotates anteriorly, (or both).
Assessing Pelvic Position and Relationship to Base of Support
Pelvic Alignment in Anterior Posterior (AP): Look at Manubriosternal Junction (Sternal Angle, Angle of Louis) & Top of Pubis Symphysis and compare which sits Anteriorly or Posteriorly to one another.
Pelvis Relationship to Base of Support: Greater Throchanter over Anterior Aspect of Lateral Malleolus.
Rotation of Pelvis in (Transverse Plane): Therapist flat Hands on ASIS from Behind.
Pelvic Tilt (Anterior Posterior): Relationship between ASIS — PSIS.
Neutral Pelvis Range is usually an 11–14deg Anterior Tilt
Lateral Pelvic Tilt: Hook finger on bottom of ASIS and Compare to Top of Innominate.
Sacral Rotation: Start midline of the sacrum and palpate distally to sacral hiatus, then move laterally to find both inferior lateral angles. Palpate which inferior lateral angle is deeper.
Pelvis Correction
Firstly consider the Pelvis positional Relationship to:
- Where is the Pelvis in Space (Rotation, Tilt [Anterior & Lateral])
- Where is the Pelvis relative to the Base of Support
- How are the Three Bones of the Pelvis in relation to each other.
Correcting Pelvic Alignment:
Lateral Tilt: By decompressing the Pelvis above the femurs (By gentle decompression). Larger decompression on one side.
Transverse Pelvic Rotation: De-rotate or Unwind the pelvis with your hands until ASISs are level. Then correct for Base of Support.
Pelvic Compression's: Bilateral Anterior/ Posterior, Asymmetrical Ant/Posterior to alter force closure.
Get the patient to then Lift Each Foot once whilst correction is applied to get the lower limbs to adapt to the correction.
Regular Stance:
Ideal: Both Sides of Pelvis stays in slight Nutation ; Should not be in counter nutation.
No asymmetrical compression on the pelvis from musculature (Common in Athletes that do asymmetrical sport)
Single Limb Stance:
Ideal: Thorax and Pelvis remains nutral over Base Of Support/ i.e not shifted to one side.
Optimal in Pelvis for transferring load Should be: Slightly Nutated (Not Moving into Counternutation)
Example of what happens normally in Single limb stance: When you stand on your left leg — the Left pelvis should be experiencing weight transfer. It should not go into counternutation.
The right side should posteriorly rotate.
Direction of the innominate and sacrum moving at the same time in the same direction signals no unlocking and excessive compression.
Stepping Forwards:
Ideal/ Optimally If stepping forward on Right: The pelvis as a unit should move forward in space over the base of support. Left side of pelvis should maintain control/ remain in neutral. Right innominate should be free to rotate relative to the sacrum (For hip flexion), Pelvis should rotate transversely to the Left and thorax rotates to the right.
When landing on the Right foot; the Right pelvis should then stabilize and NOT go into counternutation.
Sub-optimal Scenario: Someone who steps forward on right: If their Pelvis rotates transversely to the Right — it makes it harder for Right lower limb to move to the right.
The Relationship between the Pelvis and Knee
In stance or Stepping: Compare sides of knees (Medial Joint Lines, Condyles, Joint Spacing, Tibia on Femur Rotation)
Treating the Pelvis via Correction
Motion Analysis/ Palpation of Pelvis: via an SI Joint Glide: Palpate Sulcus between sacrum and innominate and Place Anterior Posterior (AP) Pressure on the ASIS to move the Innominate on the sacrum — You should feel the Innominate drop relative to the sacrum (Appreciate the End Feel, Neutral Zone, Elastic Zone).
Angle the AP pressure to produce movements at the different planes of the joint, (Palpate the: Superior, Mid and Inferior Poles)
Resistance in Neutral Zone could indicate: Neuromuscular/ Visceral Forces. It is then wise to consider which muscles may be interacting to create that resistance.
Example of Muscles that can influence of create compression on the Pelvis:
Ischiococcygeus can Compress the Inferior Pole
Piriformis can compress the Entire joint or the middle or Inferior Pole
Superficial Multifidus and Erector Spinae can compress the Superior Pole
Also consider: Psoas, Iliacus (Middle Pole), External Oblique, Internal Oblique, Pelvic Floor.
Release with Awareness:
Used for a muscle/ area with increased tone.
- Put gentle pressure on the area
- Move the joint to shorten the Origin/ Insertion of the hypertonic Muscle
- Wait for the efferent spinal cord response to the reduced afferent input from the muscle spindle — This will reduce the Muscle Tone.
- Cue the client to “Let go”, “Release”, “Soften” the muscle.
- Move the Joint in Various combinations & request the client to focus on awareness of the softening and release of hypertonicity.
- Take the muscle through a full stretch.
Adding Compression & Rehabbing Muscles:
Respond well to Anterior Compression? = Train Transversus Abdominis or De-tone Multifidus
Respond well to Posterior Compression? = Train Deep Multifidus or De-tone Transversus Abdominis
Abdominal Wall Assessment:
Palpating: Skin VS Fascia VS Muscle
External Oblique Fascia
Pelvic Floor co-Contracts with Transversus
Lumbar Muscle Assessment:
Symmetry of Muscle Tone
Longissimus Thorasis is the longest erector spinae
Superficial Multifidus Palpation
Recruitment of Deep Multifidus
