CHAPTER 12
The Pelvis and
Sacroiliac Joint
Introduction
From the 19th century onwards, the use of manipulation to balance the bones and soft-tissue structures of pelvis and sacrum regions has increased progressively (Lee, 2004). Today, a variety of manipulative procedures are used as a first-line treatment for lower back, hip, pelvic and buttock pain that radiates from the lower extremity, specifically the pelvic bones and the sacroiliac joint (Laslett, 2008). Practitioners of manual therapy believe that a great majority of patients can be made immediately pain-free by applying manipulation. They claim that this can be achieved following a simple manual correction of abnormalities in the pelvic and sacrum regions, such as a perceived anterior rotary subluxation of the ilium or a nerve entrapment due ligamentous injury in the pelvis (DonTigny, 2007).
The therapeutic goal of these practitioners is to apply a procedure that is well tolerated by the recipient and yields the best result. They primarily aim at addressing any specific dysfunctions in the region, restoring mobility and function by adjusting malalignment of bony and soft-tissue structures, and strengthening the surrounding muscles (Childs et al., 2004). In addition, they usually utilise two general manipulation approaches for manual correction of pelvic and sacroiliac abnormalities: high-velocity, low-amplitude thrust (HVLAT) and low-velocity, low-amplitude thrust.
However, manipulation should be avoided if an absolute contraindication or a red flag for serious pathology is identified (Rivett, Thomas and Bolton, 2005). Appropriate care should be taken if a relative contraindication to manipulation is present, so that the patient is not exposed to an undue risk of injury. Furthermore, because adequate knowledge and skill, extensive experience and sound clinical reasoning play an important part in preventing incidence of adverse events following manipulation, practitioners should have an appropriate training and education before they start applying manipulative procedures to their patients (World Health Organization, 2005; Ernst, 2007).
Therefore, this chapter is written to describe the various joints of the pelvis and sacrum, the range of motion in these joints and appropriate special tests to diagnose serious pathology in the regions. In addition, this chapter will also describe some of the common injuries to the pelvis and sacrum, and the red flags for manipulation.
Joints
In human anatomy, the pelvis is interposed between the lower spinal column and the lower extremities. It includes the pelvic girdle (the two coxal bones), the sacrum and the coccyx. Each coxal bone results from a fusion of three bones – the ilium, the ischium, and the pubis – and is firmly attached to the axial skeleton because of its articulation with the sacrum, the sacroiliac joint (McCann and Wise, 2014). The pelvis is divided into the false and true pelvis separated by an oblique line known as the pelvic brim. The pelvis functions as the site of attachment for the lower limbs. It also protects the internal reproductive organs, the urinary bladder and a portion of the large intestine (OpenStax, 2013; Standring, 2008).
Table 12.1 The joints of the pelvis and sacrum | ||
Joint name | Description | Function |
Acetabulofemoral joint | •A synovial, ball-and-socket joint formed by joining the head of the femur with the acetabulum of the pelvis •Involves articulation between the lower limb and the pelvic girdle •Responsible for linking the lower extremity with the axial skeleton of the trunk and pelvis •Also known as the hip joint | •Supports the body weight in both dynamic and static postures •Helps to maintain the balance of the body |
•A true diarthrodial joint that is characteristically different to other diarthrodial joints •Involves articulation between the sacrum and the pelvis (ilium bones) •Usually formed within the sacral segments of S1, S2 and S3 •Has fibrocartilage in addition to hyaline cartilage •Is a less mobile, well-innervated joint and is therefore very strong and stable | •Serves as shock absorber for the spine •Helps transmit the weight of the upper extremity to the pelvis and legs •Provides stability to the spine and pelvis •Helps to maintain the body balance during walking (push-off phase) | |
Lumbosacral joint | •A cartilaginous, multifunctional joint that connects the lumbar spine with the sacrum •Involves articulation between the vertebral bodies of the last lumbar vertebra (L5) and the first sacral segment (S1) •Consists of several interconnected components, including a disc between the two articulating vertebral bodies and two facet joints | •Provides a strong and stable base for the vertebral column •Permits the trunk of the body to twist and bend in almost all directions |
Sources: Cereatti et al. (2010); Forst et al. (2006); Vleeming et al. (2012); Lin et al. (2001) | ||
Range of Motion
The hip muscles exert three degrees of freedom on three mutually perpendicular axes. These movements include the transverse axis (flexion and extension), the longitudinal axis (lateral and medial rotation) and the sagittal axis (abduction and adduction) (Schünke et al., 2006). A substantial motion, in fact, takes place at the external pelvic platform. Movement of the pelvis upon the hip joints is relative to the femur. Coupled movement of the hip and pelvis plays a significant role in establishing lordosis and kyphosis in the lower spine (Vleeming and Stoeckart, 2007).
Table 12.2 Estimated normal range of motion of the hip | |
Movement type | Range of motion |
Flexion | 115–125° |
Extension | 0–15° |
Abduction | 30–50° |
Adduction | 30° |
Lateral Rotation | 30–40° |
Medial Rotation | 40–60° |
Source: Seidenberg and Childress (2005) | |
In contrast, the range of motion in the sacroiliac joint is small (Forst et al., 2006). Although the medical community has for years held fast to the notion that the joint is motionless, except in the presence of disease or pregnancy, several empirical studies have demonstrated presence of a screw-axis motion at the sagittal plane of the joint (Fortin, 1993; Sturesson, Selvik and Udén, 1989; Sturesson, Uden and Vleeming, 2000).
Range of Motion at the Sacroiliac Joint
•Less than 4° of rotation
•Up to 1.6mm of translation
Source: Adapted from Sturesson et al. (1989, 2000)
Common Injuries
A major injury to the pelvis and the sacrum is often caused by a fall, motor vehicle accident, violent activity or sports trauma. These injuries are common in all populations, including male and female, the very young and the old, and participants of numerous sports (Larkin, 2010).
Table 12.3 Common injuries to the pelvis and sacrum | |
Injury | Characteristics |
Pelvic fracture | •A break of one or more bony structures of the pelvis, including the hip bone, sacrum, and coccyx •Often caused by some type of traumatic, high-energy event, such as falls from height, motor vehicle accidents or crush injuries •Severity range from low-energy, relatively benign injuries to high-energy, life-threatening fractures •Represent 3% of all skeletal fractures in the United States |
Sacroiliac joint dysfunction | •Generally refers to pain or discomfort arising the sacroiliac joint structures •Characterised as aberrant position or abnormal motion in the region, either too little or too much •Often results from some type of traumatic event, such as a direct fall on the buttocks, motor vehicle accident or a step into an unexpected hole •Common symptoms include lower back pain, buttock pain, hip pain, groin pain, sciatic leg pain, frequent urination and transient numbness |
Hip dislocation | •Usually results from a traumatic injury, a high energy directed along the axis of the femur •Can be anterior, posterior or central •May occur with associated injuries, such as fractures of the femoral head or neck •Often occurs because of motor vehicle accidents (about 70% of cases) •Occurs predominantly in the posterior region (about 90% of cases) |
Sources: Furey et al. (2009); Langford et al. (2013); Laslett (2008); Fortin (1993); Vleeming et al. (2012); Kovacevic, Mariscalco and Goodwin (2011); Seidenberg (2010) | |
Red flags help to identify serious pathology in patients with chronic pain. If a red flag symptom is found in a patient, the practitioner should prioritise sound clinical reasoning and exercise utmost caution, so that the patient is not placed at risk of an undue adverse event due to manipulation.
Table 12.4 Red flags for serious pathology in the pelvis and sacrum | |
Condition |
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