Diagnosis of the Pelvis

00:00 Diagnosis of the pelvic somatic dysfunction. So in order to diagnose the pelvis, we need to first establish whether or not there is a dysfunction present, if there's a problem at the SI joint and if there is a problem where is the problem located. Is it located on the right or left side? So one of the tests that we could perform to diagnose the pelvic somatic dysfunction is to perform a standing flexion test. So to perform a standing flexion test, what we're going to have is the patient to please stand up for me. You're going to face away from me. I'm going to get eye level with the PSIS and I'm going to place my thumbs underneath the PSIS here. I'm going to have the patient slowly bend forward to try to touch his toes and I'm noticing the PSIS and seeing if one goes first and further as he bends forward. "And come back up," and we're going to slowly just repeat that. "Go ahead and bend forward" and again I'm just following the PSIS as it goes up and I see the left side goes a little bit further compared to the right. "And come back up." So that tells us that the left side is the problem side and we should name our diagnosis for the left. Another test that we could perform is the stork test. The stork test tells us if there's an SI joint issue or sacroiliac joint issue. It could be from the pelvis or it could be from the sacrum.

01:14 It's not as specific as the standing flexion. So what I'm doing here is again I'm going to get eye level and I'm going to get at the PSIS and I'm going to place one thumb on the PSIS here on the right side and the other thumb I'm going to put on to the sacrum at the same level because I want to see if my thumb moves inferiorly as the patient picks up their leg because when your patient picks up the leg on that side the innominate should rotate posterior thus bringing your thumb inferiorly. So I line up my thumb so I could see the relationship as he picks up his legs. "So go ahead pick up your right leg" and I see that it moves inferiorly which is normal. "Go ahead and bring your leg down" and I am going to check the other side so I find the PSIS on the left and my thumb as a marker here. "Go ahead and pick up your left side" and I could see that again it does come back down. "Good." So the stork test, if it's positive, your thumb might ride higher or your thumb may not rotate posterior as the innominate supposed to rotate posteriorly. The ASIS compression test is to screen for an SI joint dysfunction. A lot of times you could do this instead of having someone do a standing flexion test or a stork test especially if the patient is bedbound or stuck in the hospital bed you don't want to get them up to have to bend down to touch their toes.

02:33 So, you're going to place your palms on the ASIS. To find the ASIS, we're going to find the iliac crest, walk away down and find the knobby protuberance in the anterior portion of the pelvis. I like to place my palms gently over the ASIS and what we're going to do for the test is to gently compress medially and a little bit down towards the table and you're trying to see if one side feels more restricted and it's a little bit harder to perform. The side that's more restricted is going to be the positive side. So here, I find that the left side is a little bit harder to push down compared to the right. So that gives me a positive left ASIS compression test. So now to diagnose pelvic somatic dysfunctions, we're going to use different landmarks to identify if there is any asymmetry to better get a sense of how the pelvis is either rotated or sheared or asymmetric.

03:31 So the first landmark we're going to use is the ASIS. We're going to find the crest, come up anteriorly and then get underneath the ASIS and compare both sides. So here, I note that the left side is a little bit more superior compared to the right and so we have a superior ASIS on the left compared to the right. If you have a positive standing flexion test on a certain side, you should name everything for that side. So here, we have a superior left ASIS. The other thing you could tell from looking at the ASIS is whether or not you have an inflare or outflare. So the innominates could kind of turn a little bit more out or turn a little bit more in. So what we want to do is to compare the distance of the ASIS to midline. So you could see if there is relatively an increase or a decrease in distance. If there's an increase in distance from midline, then that's an outflare. If there's a decrease distance from midline, then that's an inflare. So here, it does not seem like there is a tremendous inflare or outflare but the left ASIS is a little bit more superior. The next landmark that we are going to assess is the pubic tubercle. This is a sensitive area for our patients. You want to make sure that you're respectful and you let them know ahead of time that you're going to be palpating the pubic tubercle. "So, I'm going to be using my palm of my hand to find your pubic tubercle." So, I'm going to gently push the palms slowly down until I hit the bone. I start a little bit too high to make sure that I definitely avoid contact inappropriately.

05:08 I get my thumbs on the pubic tubercles bilaterally and then I compare sides. So here, you could see if there is any sort of pubic unleveling. If there is, sometimes you could diagnose specifically a pubic dysfunction. If the ASIS and PSIS are kind of in the same level and not really asymmetric but the pubic tubercles are off, then that's specifically a pubic dysfunction. But here, the pubic tubercles are fairly equal. Usually, pubic dysfunctions are due to more of a severe trauma to get an isolated restriction there. I'm going to come down to the malleoli on both sides. I put my thumbs underneath the medial malleoli and I'm going to bring my thumbs together and just to compare sides. So here, the left side is a little bit higher which follows my finding at the ASIS which was a little more superior. So typically, the malleoli will follow the ASIS. So, we have an elevated ASIS, our pubic tubercles are equal. Now we want to check the posterior landmarks of the pelvis.

06:20 "So I'm going to have you lie on your stomach." So posteriorly we could find the PSIS. We're going to follow the iliac crest posteriorly. You see these 2 dimples here. You're going to find the knobby protuberances. These are the PSIS and I want to get my thumbs underneath it to compare sides and as I get my thumbs underneath the PSIS here, I find that the left side is a little bit more inferior. So, the PSIS on the left is more inferior that tells me that statically your ASIS is higher. So we're going to use our finger models to help us with the diagnosis. Our ASIS is higher on the left, our PSIS is lower and that is consistent with a posteriorly rotated innominate. So that’s using our different landmarks and assessments to diagnose the pelvic somatic dysfunctions.