Pelvic Complex

The pelvis is the link between the upper torso and the lower extremities. In addition, it is the area of location of the center of gravity as well. The greater functional significance of the pelvic girdle is its role in maintaining the mechanics of the walking cycle. It is one structure that is often underestimated in its capacity and if appropriately addressed, can help diminish back pain and radicular pain.

Its close relationship to the lumbar spine is the essential gist of this chapter in addition to the role of the sacrum.

OSSEOUS ANATOMY

The pelvic complex consists of three bones and eight joints. The sacrum which is placed in the center is formed by the fused elements of S1 to S5. It articulates superiorly with the lumbar spine and inferiorly with the coccyx.

They are termed the lumbosacral and sacrococcygeal joints, respectively. Laterally, the sacrum articulates with the ilia or innominate bones to form the sacroiliac joints.

The two innominates are joined anteriorly by the symphysis pubis joint.

The sacrum is a triangular structure which has a broad upper surface and a tapering, narrow inferior surface. The upper surface of the sacrum is called the sacral base.

Inferiorly, the lateral edge of the sacrum that appears prominent to palpation due to the curved ends are the Inferior Lateral Angles (ILA). The sacral base and the inferior lateral

angles of the sacrum are the two main bony landmarks that the clinician incorporates to diagnose a sacral dysfunction. On the superior surface, just lateral to the midline are two articulating facets, which articulate with the inferior articulating facets of the fifth lumbar vertebra to form the lumbosacral joints.

The ilia or the innominates are two in number and placed laterally on either side of the sacrum. The superior and anterior aspect of the innominates have a curved projection which are the anterior superior iliac spines (ASIS). Anteriorly and inferiorly is a palpable bony landmark just lateral to the groin area which is slightly higher in the male.

These are known as pubic tubercles. The superior aspect of the innominate is a curved structure and this area is called the crest of the ilia. These crests taper posteriorly and medially and curve inwards forming a pal-pable depression inferiorly. These are known as the posterior superior iliac spines (PSIS).

The greater clinical significance of the pelvic complex originates at the lumbosacral junction. Most dysfunctions of the pelvic complex are viewed as dysfunctions at the sacroiliac joints and may be erroneous. As most times dysfunctions of the sacroiliac joint are caused by a dysfunction that occurs at the lumbosacral junction. The reason being that the lumbar spine is one that determines the mechanics of the sacrum at the lumbosacral joint which in turn determines

Pelvic Complex 89 the mechanics of the ilium or innominate at

the sacroiliac joint. Hence, the clinician should always remember that when addressing dysfunctions of the pelvic complex, first consider mechanics at the lumbosacral joint prior to addressing the sacroiliac joint which are mechanically two different areas but complimentary in causing a dysfunction. A more logical explanation to this can be gleamed when the walking cycle is described.

The next area that warrants attention in the pelvic complex is the symphysis pubis.

This is an articulation that possesses move-ment and technically is an anterior attachmove-ment of the innominate with relevance to its posterior attachment which is the sacroiliac joint. Hence, a dysfunction in this area can contribute to dysfunctions in the sacroiliac joint posteriorly. Overall, one should under-stand that the sacroiliac joint that receives attention in a pelvic complex dysfunction could essentially be a secondary effect or be accentuated by dysfunctions either at the symphysis pubis or more often the lumbo-sacral joint. Thus, when addressing sacroiliac joint dysfunctions, it behooves us to also address the lumbosacral and symphysis pubis joints to globally address the problem in sight.

LIGAMENTOUS ANATOMY

Much of the integrity of the sacroiliac joint depends upon ligamentous structures.

Iliolumbar Ligament

The iliolumbar ligament has been described in Chapter 10 on Lumbar Spine. The lower fibres of this ligament extend inferiorly and blend with the anterior sacroiliac ligaments.

They limit anterior translation of the 5th lumbar vertebra and posterior rotation of the ilium.

Posterior and Anterior Sacroiliac Ligaments

The posterior sacroiliac ligaments have three layers. They are the short interosseous ligaments which are the deep layers and they run from the sacrum to the ilium. The intermediate layer runs from the posterior arches of the sacrum to the medial side of the ilum. The long posterior sacroiliac ligaments blend together and course vertically from the sacral crest to the ilium. Inferiorly, the posterior sacroiliac ligaments blend with the sacrospinous and sacrotuberous liga-ments. All fibres of this ligament limit posterior separation of the sacroiliac joint. The short fibres limit posterior rotation, internal rotation of the ilium and anterior movement of the sacral base. The long fibres limit anterior rotation of the ilium.

The anterior sacroiliac ligaments prevent anterior separation of the sacroiliac joints.

Sacrotuberous and Sacrospinous Ligaments

The sacrotuberous ligaments run from the inferior lateral angle to the ischial tuberosity above the sacrospinous ligament, which runs from the inferior lateral angle to the ischial spine. These two ligaments contribute to the formation of the greater and lesser sciatic notches, which are divided by the sacrospi-nous ligaments. The sacrotuberous ligaments limit anterior and posterior rotation of the ilium as well as sacral flexion. The sacro-spinous ligament limits posterior rotation of the ilium and sacral flexion.

MUSCULAR ANATOMY

The musculature of the lumbar area are interdependent with the musculature of the pelvic area and hence, are described together.

This is for the fact that the mechanics of the two regions are essentially interdependent as well.

The musculature, as in the cervico-thoracic complex, are classified as postural and phasic.

Their primary functions are as described in the principles of management for they support alignment during function and absorb shock of activity. Their specific actions from an anatomical perspective is obvious, but their individual functions relevant to manual therapy is worth knowing.⁶ The phasic and postural muscles are as follows:

Phasic

• Hip Adductors/Quadratus Lumborum

• Hamstrings Phasic Musculature Abdominals

The primary function of the abdominals is described as the walls of a cylinder. This cylinder wall effect helps to contain the abdominal contents. By doing so it decreases the lever arm of the lumbar lordosis and minimizes its vulnerability to an anterior shear. Thereby it maintains the lordotic curve.

This function prevents two possible dysfunctions. Theoretically, as the lordosis increases, the sacrum has a tendency to flex.

If this is exaggerated due to weakness of the abdominal musculature, the risk of flexion

dysfunctions of the sacrum arise as in a flexed sacrum or sacral anterior torsions. When the sacrum flexes the lumbar segments move in the opposite direction and are at the risk of extension dysfunctions (ERS). Hence, strong abdominals help to prevent the above described dysfunctions.

The forward head and protracted shoulders posture is seen in patients with upper quarter pain. A weak abdominal wall is described as a contributing feature to this condition. A more caudal position of the sternum and chest results from a weak abdo-minal wall. This results in a compensatory forward head and protracted shoulders posture. Hence appropriate management of patients complaining of upper quarter pain would include attention to the abdominal mechanism.

Gluteus Maximus

The gluteus maximus attaches to the fascia lata. The fascia has a hip and a knee attachment. Tension in the tensor fascia lata enhances stability at the hip and knee. This brought about by effective contraction of the gluteus maximus.

The gluteus maximus is also an important pelvic stabilizer. On weight bearing, with the foot on the ground, contraction of the gluteus maximus results in a posterior rotation of the pelvis. Hence weakness can result in anterior rotation dysfunctions of the innominate.

The posterior moment creates a flexion moment at the lumbosacral junction. Flexion of the lumbosacral articulation decreases the lumbosacral angle and anterior shear stresses between the L5 and sacrum. Hence, the gluteus maximius should be strengthened for routine stability of the lumbopelvic complex and specifically for anterior innominate dysfunctions.

Pelvic Complex 91 Gluteus Medius

Weakness of the gluteus medius is described as causing a ‘Trendelenburg’ gait. Due to weakness of the this muscle, the pelvis on the opposite side tends to drop and Hence, has a tendency to increase stresses on the lumbar facet joints and the sacroiliac joints.

The patient has a tendency to lean to the same side of the weakness and Hence, the stance time on the weak side tends to increase.

This has a tendency to exaggerate the torsion position of the sacrum on that side resulting in torsional dysfunctions.

Hence, as a routine for lumbar stability and specifically following correction of a sacral torsion, strengthening of the gluteus medius is recommended.

Quadriceps

Efficient contraction of the quadriceps is required in low back rehabilitation. This muscle should have sufficient girth in order to exert a ‘pushing’ effect to amplify tension within the fascia lata to enhance stability.

The rectus femoris, being a flexor of the hip tends to cause an anterior rotatory moment of the pelvis and an extension moment in the lumbosacral junction. The management principles are the same as the iliopsoas and is described in the next section.

Quadriceps strength is also essential for execution of proper body mechanics.

Eccentric contraction of the quadriceps helps position the back with an intact lordosis, to minimize the risk of injury during activity.

Postural Musculature

The postural muscles have a significance to dysfunction for the fact that they have a tendency to contract. Prolonged contraction can pull on their respective skeletal attachment

and cause a change in alignment. Hence, appropriate lengthening prior to strengthen-ing is mandatory to correct and minimize the incidence and recurrence of a dysfunction.

Iliopsoas

In a weight-bearing situation, contraction or contracted states of the iliopsoas can produce an anterior rotation of the ilium. This increases the lordosis in the lumbar area and predisposes the sacrum to flex as in weak states of the abdominals causing dysfunctions of sacral flexion and sacral anterior torsions.

This may additionally predispose to an exten-sion moment/dysfunction of the lumbosacral joint predisposing to an ERS.

Hence, the iliospoas needs to be lengt-hened if an anterior innominate dysfunction is identified and additionally in situations of a flexed sacrum or an ERS.

Conversly, weakness of the iliopsoas can cause the sacrum to extend predisposing to extension dysfunctions of the sacrum as in extension shears or sacral posterior torsions.

This in addition, can cause a anterior flexion moment at the lumbosacral articulation leading to FRS dysfunctions.

Erector Spinae (Superficial)⁶

These muscles have no direct attachment to the lumbar spine. However, they exert a bow stringing effect over the posterior trunk. They pull the thorax posteriorly and create an extension moment over the lumbar spine.

They also work by a lengthening contraction to control the trunk during forward bending and by a static contraction to effect the posture of the lower thorax over the pelvis, during function.

The superficial erector spinae have a profound effect on sacroiliac joint mechanics.

The inferior attachment of this muscle is on the sacrum. Its pullover the sacrum creates

a flexion (nutation) moment on the sacrum.

Hence it’s strength contributes to the stability of the sacroiliac joint.

However, being a postural muscle, exces-sive contraction of the erector spinae can increase the flexion moment of the sacrum and contribute to sacral flexion dysfunctions and sacral anterior torsions. In addition, it increases the extension moment of the lumbo-sacral junction and contributes to extension dysfunctions (ERS).

Erector Spinae (Deep)

The deep erector spinae muscle offers stability of the lumbar spine and lumbosacral articu-lation in a sagittal/anteroposterior plane.

Contraction of this muscle and consequently a contraction of the contralateral iliopsoas create a sagittal plane balance system for lumbar stability.⁶

Multifidus

This is a bipennate muscle that originates from the mallillary process of the lumbar vertebra and runs upwards and medially to attach to the spinous process of the lumbar vertebrae above.

Injury to any of the tissues in the lumbo-pelvic region may lead to excessive muscle activity or muscle guarding which is to protect the injury site from further movement.

The extensive direct attachment of the multifidus muscle to the lumbar spine makes it a prime candidate for reflex muscle guarding due to low back injury.

The muscle guarding of the multifidus can essentially cause ERS and FRS dysfunctions by virtue of their oblique attachment to individual vertebra, inhibition techniques like muscle energy techniques (MET) focus to contract or inhibit the multifidus muscle to correct a dysfunction. The multifidi also attach to the sacrum and can favor sacral extension. Contracted states of the multifidus, especially where there is muscle guarding can

attribute to dysfunctions of the sacrum in extension as in unilateral extension shears or posterior torsions.

The multifidus is considered an inner group muscle. Due to its attachment to individual vertebra it exerts a compressive force between each of them individually.

Since the lumbo pelvic unit is resistant to torsional forces on load bearing, the multifidus may be a contributing factor to spinal stability by sqeezing the vertebral together and locking them

Thus, following correction of lumbar dys-functions be it an ERS or an FRS, subsequent strengthening of the multifidus minimizes the potential for recurrence ofa dysfunction.

Piriformis

The piriformis muscle attaches to the lateral border of the sacrum and inserts into the trochanteric fossa bilaterally. By virtue of their attachment they favor sacral flexion leading to sacral flexion dysfunctions or sacral anterior torsions. Thus, causing an extension moment at the lumbosacral junction leading to an ERS dysfunction.

The sciatic nerve passes close to the piriformis and in a smaller population, through it. Hence, dysfunctional states of the piriformis can irritate the sciatic nerve causing sciatic symptoms.

Overall, being a postural muscle, the piriformis has a greater tendency to tighten and is also extremely pain sensitive. Often times it is the source of ‘deep buttock pain’

described by patients with low back pain.

Optimal length and strength of the piriformis is essential to minimize the above described consequences.

Hip adductors/Quadratus lumborum

The hip adductors attach to the pubic and ischial rami and extend below to attach to the femur. When the foot is on the ground

Pelvic Complex 93 as in a weight-bearing position, the adductor

muscles can cause an inferior moment at the pelvis. Thus, contributing to an inferior or

‘downslip’ of the pelvis.

The quadratus lumborum attaches to the iliac crest and the lumbar transverse processes and 12th rib. In contracted or shortened states, it can cause superior translations or an ‘upslip’

of the innominate.

Hamstrings

The hamstrings, by virtue of their attachment to the ishial tuberosity control the amount of pelvic rotation during forward-bending.

Tightness of the hamstrings favors posterior rotation of the innominate. This can cause extension dysfunctions of the sacrum as in extension shears or sacral posterior torsions.

As described earlier, extension dysfunctions of the sacrum tend to cause a flexion moment at the lumbosacral articulation leading to flexion dysfunctions of the lumbar spine as in an FRS. Hence, appropriate lengthening or stretching of the hamstrings is recommended.

MECHANICS

The mechanics of the pelvis is complex owing to the several articulations working to maintain normal mechanics of a very complex function, i.e. walking. Dysfunctions of the pelvis are correlated to normalizing mecha-nics relevant to the walking cycle.⁸ If the normal mechanics of the cycle of events that occur during walking is disturbed then dysfunctions result. The mechanics that occur in the pelvic complex during normal walking is described below, however, the basic movements of nutation and contranutation will first be described.

Nutation or ‘anterior nutation’ is described as the anterior and inferior movement of the sacral base. Simply stated, despite all the controversies that exist in literature in this regard, it is considered sacral flexion.

Contranutation or ‘posterior nutation’ is when the sacral base moves superiorly and posteriorly. Simply stated, it is sacral exten-sion. In addition the sacrum has the ability to side bend and rotate as well.

The ilia or the innominates possess an ability to rotate forwards and backwards and is termed as anterior and posterior rotation of the ilia. In addition, they also have the ability turn inwards and outwards and is termed as an inflare/outflare or a medial/

lateral rotation. A superior and inferior translatory motion occurs when the opposing surfaces are flatter and more parallel.

A combination of sacral and ilial movements is what occurs during the normal walking cycle.

Walking Cycle Relevant to Pelvic Mechanics⁸

The axis of movement is the first important component that the clinician should under-stand. All movements in the human body occur in a diagonal plane as one would recollect concept of patterned motion that are taught in PNF courses. It is three dimensional and is a combination of the frontal, sagittal and horizontal axes. The sacrum functions the same way and Hence, the movements of the sacrum as a combination of flexion side-bending and rotation occur in a hypothetical oblique axis. This axis is an imaginary line drawn from the superior aspect of one sacroiliac joint to the inferior aspect of the other. For example, the line of the axis running from the superior aspect of the left sacroiliac joint to the inferior aspect of the right sacroiliac joint is the left oblique axis, and vice versa for the right (Figure 11.1).

In the normal walking cycle, the events that occur are heel strike, foot flat or mid-stance, and heel/toe off. The cycle of events that are of greater clinical significance are the ones that occur during heel strike and mid-stance and are as follows:

then L5 would rotate left and sidebend to the right.

If for any reason the mechanics described above is altered then a dysfunction would result. The reason being the stresses of weight-bearing are not evenly distributed and may be localized to the area of restriction or instability, resulting in pain. Hence, a clinician addressing mechanical dysfunction in the lumbo-pelvic complex should primarily be concerned at restoring the normalcy of mechanics during the walking cycle.⁷ The dysfunctions that may interfere with the normal mechanics of the walking cycle is described in the next section. The goal of treatment, hence, would be to identify these dysfunctions and correct them as appropriate,

If for any reason the mechanics described above is altered then a dysfunction would result. The reason being the stresses of weight-bearing are not evenly distributed and may be localized to the area of restriction or instability, resulting in pain. Hence, a clinician addressing mechanical dysfunction in the lumbo-pelvic complex should primarily be concerned at restoring the normalcy of mechanics during the walking cycle.⁷ The dysfunctions that may interfere with the normal mechanics of the walking cycle is described in the next section. The goal of treatment, hence, would be to identify these dysfunctions and correct them as appropriate,