Pelvic Special Tests Overview

Hello and welcome to the last lab of the class. This lab will cover all of the pelvis special tasks. So today what we're really going to be focusing on is learning the special tasks that allow us to assess the sacroiliac. joint in particular. You have an online lecture that relates to SI joint pathologies and dysfunction, and you certainly have the online lecture relating to the SI joint or the pelvis anatomy. I suggest that you review both of those prior to coming and looking or going through the special test for the SI joint. It will make more sense in terms of the movements that I will be describing. So today what we're going to start with is the isokinetic prone test, or a better way to say it is the ipsilateral prone kinetic test. As the name describes, the patient is going to be in a prone position. So we can see here the patient is in a prone position, right? Stomach is down towards the table. And this will become instrumentally important, you guys, when we're actually testing the patient. This test in particular is used to test for a posteriorly rotated ilium. So in order to perform this test relatively well, you have to know how to palpate one anatomical landmark. That anatomical landmark is the posterior superior iliac spine. So in lab, what we'll get used to doing is pulling the patient's shirt up and asking, of course, if they're comfortable with that. So I can see that my patient is wearing a sport bra, so most often what I'll do is tuck the shirt underneath the sport bra so it doesn't fall down into the palpation region. And then if you have a patient who's wearing high-waisted pants, right then what we'll do is just tuck those pants down in the into the undergarment region right so now we've exposed the low back region and we're actually ready to perform the prone isokinetic test So what I'm going to do is on the side that I suspect has the SI joint pathology, I'm going to first and foremost locate the PSIS of the patient. So you can tell that knowing how to palpate the pelvis anatomical structures becomes extremely important, you guys, when we're assessing or performing special tests for the sacroiliac joint in particular. So once my hand is on the PSIS of that patient, I'm going to apply a little tiny bit of pressure. Now, the next thing I'm going to have the patient do is I'm going to have her flex her knee to 90 degrees. So she's got her knee at 90 degrees. We can see that there. I have my hand on her PSIS. And then what I'm going to have the patient do is push her heel up towards the ceiling or lift her limb off of the table, right? And we've seen this maneuver before with the glute max and hamstring testing, right, you guys? So hand is on the PSIS. And I have my patient do is. is lift that heel up to the ceiling. And what I'm looking for, and what you guys probably won't see in this video, is a cranial or a superior movement of that PSIS. So can you take your leg down to the table one more time? I'm gonna have that patient lift up, and what I want you to see is what we want to see is for my thumb to move superiorly or cranially. What we'll see in a posteriorly rotated pelvis, remember posterior rotation means pelvis is rocked in this position. When that patient goes to extend that hip, what we'll see is one of two things. Go ahead and extend. The thumb will stay there or it'll rock inferiorly because that pelvis is stuck in a posteriorly rotated position. So again, a positive test is one in which the thumb doesn't move superiorly, so it stays here and it's stuck, or it moves inferiorly because the pelvis is rocked into a posterior position. We're not necessarily looking... for any pain. It's more so what movements do we feel or do we not feel? So I hope that makes sense, you guys. The prone ipsilateral test is used to assess a posteriorly rotated ilium. A positive test would be one in which we don't feel the thumb move towards the skull, right, you guys? And if we don't feel that movement, then we suspect that the patient has a posteriorly rotated ilium. Now, without that said, with all of these tests, if I haven't said this enough over the semester, we're always testing that bilaterally, right? So we always want to test both the right and the left side. Most often, we're going to test the non-pathological side first to see out how it's behaving. and then we test the pathological side next. That concludes the ipsilateral prone kinetic test. So the next series of tests that we are going to use to assess SI joint dysfunction, there are two. The first one is called the passive extension and medial rotation on the ileum test. Say that three times fast. And then the second one is called the passive flexion and lateral rotation of the ileum. Sacral test. So let's start with the first one, the passive extension medial rotation of ilium on sacral test. This is a special test that is used to assess a posteriorly rotated ilium. right so let me show you what a posteriorly rotated ilium would look like in a posteriorly rotated ilium we would suspect that the pelvis is rocked into this position right you guys you get that part yes so when we perform the passive extension and medial rotation test we're usually standing behind the patient but our lab sheet says that we can stand in front of the patient because you certainly can what i've learned in clinical practice is that it's actually easier for me as a clinician to stand behind the patient to get a good grip on the pelvis. But in lab, I'll let you choose what works best for you. So for the passive extension and medial rotation test, what we're going to do is we're actually going to rock the pelvis into an anterior position. So we're going to rock it in this direction, right? The opposite direction of the actual fixation. I hope you guys get that, right? So right now what we're doing is we're performing a test for a positive posterior rotation. And in order to perform... that test we have to take the pelvis in the opposite direction so we're going to try to force it into an anterior rotation does that make sense i hope so if it doesn't make sense we'll clarify it in lab you guys but i just want to be clear this patient has a posteriorly rotated pelvis right so if it's stuck there what we want to do is try to rock that pelvis into an anterior position so going back to the test you The patient has a suspected posterior pelvis. What I'm going to do is two things. With one hand, I'm going to put that on the ASIS of the patient. With the other hand, I'm going to put it on the sacrum. And you can't see that, but just imagine. Imagine that that's what I'm doing. So you can see how I'm kind of hugging my patient a little bit. If the goal is to see if they have a posteriorly rotated pelvis, you guys, if I'm stuck in a posterior rotation, my pelvis will not move into an anterior direction. That is why we are moving it into an anterior direction. So are you ready for this? I'm here, hand is here, and I'm going to try and rotate that pelvis anteriorly, anteriorly. And I'm getting good movement on this patient because she doesn't have a posteriorly rotated pelvis. But what we can say is that if the patient has a posteriorly rotated pelvis, you'll get no movement of the ilium into an anterior position. I hope that makes a lot of sense. Now... If the patient has a suspected anteriorly rotated pelvis, right, you guys? So it would be one that looks like this, an anterior rotation. Now we're going to have to try to drive that pelvis posteriorly to see how much movement we get, right? So now what we're going to perform on the table at the lab table is what we would call the passive flexion and lateral rotation ilium sacral test, right? So my hand positioning is pretty similar. The difference is I'm going to be rocking that. pelvis into a posterior position. Take the hands off, I'll show you just simply. I'm going to be rocking it into a posterior position because an anteriorly rotated pelvis won't want to move into that posterior position. So look at me, hand placement could be something that looks like this. It could be something that looks like this. I'll let you choose what works best for you. What I've learned is I like this position here. So my hand is still on that ASIS. My other hand is kind of going down with the glutes, if that makes sense. And I'm still on that sacrum. And what I'm going to do is try to rock that pelvis into a posteriorly rotated position, right? If I have an anteriorly rotated pelvis, I won't want to move in that direction, okay? For those of you who want to see the other hand. hand direction, hand still on the ASIS, and I'm rocking that pelvis into a posteriorly rotated position. What would a positive be for either of these tests? Well, if you have a posteriorly rotated ilium and you try to rock the pelvis into an anterior direction and you don't get movement, that's positive for a posteriorly rotated ilium, right? If you have an anteriorly rotated ilium and for whatever reason the patient doesn't rock into a posterior position, then you you have a anteriorly rotated ilium, right? Now, all of that to say, then you have to figure out what the heck am I going to do with this patient once I figure out what dysfunction they have at the SI joint. And so you have to figure that out. Do I stretch? Do I strengthen? Do we yoga? Do I do deep tissue? Do I do active release technique, right? The first step, however, to... Figuring out what's the cause of the low back pain, in particular the SI joint pain, is to figure out what's wrong or what the dysfunction is at the sacroiliac joint. That concludes both the passive Extension and medial rotation test and the passive flexion and lateral rotation test. Okay, so our next special test in this SI joint series is going to be the compression or the gapping stress test. And I want you to pay very close attention to my hands for the next four special tests because three of them are very similar. And I want you to see the differences in hand positioning. So it becomes instrumentally important to maybe pause. Look at it a little bit because as I progress down this list of special tests, you're going to be like, these look the same. But I promise you they aren't. And in lab, you'll actually feel how they stress different tendons or ligaments within the actual pelvis itself. So the first test is. is going to be the gapping or the stress test or some people call it the compression test. With this test, you want to cross your hands and you want to make sure that the hands are placed on the opposite ASIS. So an example would be. If it's my left hand, I guess I'm going on the left side of my patient. If it's my right hand, I'm on the right hand side of the patient. Do you see how there's an X being created with my hands? What I don't want you to do is this, because this is a different test. So for the compression test, for the compression or gapping test, we have to have a cross hand position. Does that make sense so far, you guys? I hope so. The next thing that we want to do is twofold. And I'm going to change my hand. hand positioning so I'm here. What we want to do in this particular position is we want to apply a downward look down. towards the patient's body and an outward push, which is why crossing the hands is extremely important. So not only am I pressing outward, but I'm also pressing downward at the same time. I need you to see that. And it's a combination movement. In other words, you guys, what I'm saying to you all is it's not two movements. It's not down and then out. It's a combination movement in which we do both of those movements at the same time. So moving back to the patient, we're here. We're going to press down and out. And what we're looking for with this particular test is whether or not they actually have pain. What we know is if they have pain with this compression test is most often that anterior sacroiliac ligament has a sprain or is loose and isn't creating stability at that sacroiliac joint from an anterior perspective. And that's extremely important. So a positive would be deep seated pain, maybe even increased laxity as you're compressing or pressing on that particular joint. okay you guys so that is the compression test the next test that we're moving in into is called yeomans for yeomans test the patient is actually going to flip over into a prone position so that patient's going to flip over And Yeomans is going to look very similar to the prone isokinetic test, but I can promise you it's a little bit different. So with Yeomans, the patient is in a prone position here. And what we're doing this time, instead of palpating the PSIS like we did in that prone ipsilateral test, we're going to place the knee at 90 degrees. We're going to get underneath that knee joint like such, and we're literally going to extend the hip. Now I'm stabilizing here, but I'm not compressing or doing anything on the joint. I want to be very clear that what I'm doing is extending the hip. And when you extend that hip, we're compressing that SI joint. And so what that patient is going to report is pain in the SI joint region. So a positive Yeomans test would be one in which you extend the hip of the patient and that patient complains of pain in the SI joint region. Now let's back up a little bit. Okay. Can we do the Yeomans test and the prone ipsilateral test at the same time? Heck yes. Is it reasonable to think, okay, have the patient extend their hip, palpate PSIS, does it move cranially? That's prone ipsilateral test, right? Now, I'm passively going to move that patient into hip extension. Guess what? That's Yeomans test. So we can do some of these tests at the same time somewhat, right? Okay, moving back to the patient. Our next test on the list is called the approximation test. also called the compression test. So I like to use approximation test. In this test, the patient is in a side-lying position. So I'm going to have my patient roll over into a side-lying position. During this test, the patient is in a side-lying position. And I don't know if you guys can tell in the video, but the patient is kind of rocked back towards me at an angle. So what I'm going to do is make sure she truly is lying in a side-lying position. I'm going to find the top of that iliac crest, and I'm going to kind of get my hands in a CPR position. Do you guys see that? that. So I'm at the top of the iliac crest, making sure I'm on the actual iliac crest, and I'm going to apply a downward pressure to that. iliac crest, right? What do you think a positive would be? Increased pain, increased laxity, a positive approximation test is indicative of a sprain to the posterior sacroiliac ligament, right? So we have the compression test, which is a positive for an anterior sacroiliac ligament sprain. And then now we have this approximation test, which is testing the posterior sacroiliac ligament. Our last test in the series is going to be the squish test. And the squish test is almost the same. You guys look at me is almost the same as the gapping test, which is why I said crossing the hands on the gapping test is extremely important. So So let's move to the patient and let's go ahead and have the patient move into a supine position. What I'm going to do in this particular case in the squish test is stand at the head of my patient. And you guys can't see that head of the patient is here. What I'm going to do is stand at the head of my patient. Right. So we're already seeing a little bit of a difference between the gapping test and the squish test. So I'm standing at the head of my patient. Make sense so far. Good. Okay, so from here what I'm going to do is right, do you guys see that? Right on that ASIS, I'm going to press downward and at a 45 degree angle. So I'm pressing downward and at a 45 degree angle. A positive test, patient who reports pain with this particular test, is also indicative of a posterior sacroiliac sprain. So that concludes the four special tests that are somewhat similar. They're all testing main... mainly the sacroiliac ligaments, either the anterior sacroiliac ligament or the posterior sacroiliac ligament. And remember, those two ligaments are instrumentally important for creating stability between the, guess what, the sacrum and the ilium, right? So any laxity in those ligaments, and we have changes that occur in the arthrokinematics of the SI joint. We'll start with another set of tests in just a moment. So as we move forward into SI joint testing, the next test is going to test the sacro tuberous. ligament. And the test is called the sacroiliac rocking test. For this test, the patient is going to be in a prone position. So let's move back to the patient. Patient's going to be in a prone position. Actually, the patient is going to be in a supine position. Sorry about that, guys. So supine position with her stomach up towards the ceiling. We can see that there. What we are going to do is kind of get a little bit more intimate with our patient. So is it okay if I touch your sacrum from underneath? Okay. So in this test, what we want to do is we want to flex the patient's leg. And most often what I will do is kind of place that patient's leg on my shoulder, if that makes sense, you guys. Because this hand is actually going to go underneath to the actual sacrum. So what I usually say is, can you lift your butt up really quick? And then that allows me to get on the sacrum itself, right? Now I'm on the sacrum with this bottom hand. What I'm going to do is flex the hip and rock the sacrum all at the same time. And so I'm pulling that sacrum. sacrum down towards the bum and then I'm flexing the hip all at the same time. Hence the reason it's called a rocking. We're rocking that sacrum. A positive test would be one in which the patient has pain with that movement and that would be indicative of a sprain to the sacro tuberous ligament of the SI joint. Our next special test that we're going to perform is the sacral shearing test. So in this test the patient is in a prone position so we'll have that patient go ahead and flip over. and we'll move to the patient. The patient flips over and as the name implies, it's a sacral shearing test. So essentially what you want to do is actually have the patient scoot over towards the edge of the table just a tad bit. And for me, I find that getting on the table with the patient is a better and more effective way to actually shear on that sacrum. So just imagine. This is probably S2, S3 of my patient. I'm going to get in a CPR position, and all I'm going to do, you guys, is press down towards the ground. So literally a few kind of chest compressions on that sacrum, right? And what we're looking for is any pain that that patient might experience. If they experience pain, then it's indicative of SI joint dysfunction. For our next test, we're actually going to have the patient stand up. So the patient's going to be in a... a standing position. And this is kind of counterintuitive, right? Because for the last, I don't know, seven tests, the patient has been in a seated or in a table position. So one of the reasons I don't like SI joint tests very much because they're very not functional or they lack function, right? And now we're putting our patient in a position of function. And so what we're going to do is actually do what's called the Gillette's test or the Gillette's test depending on who you ask. So I'm going to move around the table and I'm going to have my patient turn this direction. What I'm going to do is what I did early on when she was on the table. I'm actually going to tuck this shirt into her bra like such. And then what I'm going to do is tuck these down just a little bit. From here, what I want to be able to do is to find the PSIS on each side. So I'm going to look and I'm going to find PSIS for both sides of that particular patient. And now what I want to do is just number one first. Let's just. assess are we level in terms of PSISs and it looks like it on this particular patient. The next thing that I'm going to have the patient do is flex their knee to their chest, right? And so go ahead and bend your knee to your chest. And what you're looking for is what we see here in this image. So we're going to go back. And maybe we can zoom in so you can see thumb movement. Go ahead and bring that back down. So what we're going to do is have that patient flex. And as she flexes, what we're looking for is this inferior movement of the thumb. Do you guys see that? Bring it back down. See how that thumb is flexing? thumb goes back to a neutral position, bring it back up. We're looking for an inferior movement of the thumb, right? Because as that hip flexes, what's happening to the pelvis? It's moving into a posterior rotation, right? A positive, I'll create a false positive. really quick would be one in which the thumb moves cranially or moves up towards the cranium or superiorly right or one in which go ahead and move up the thumb doesn't move at all right so that would be considered a stuck SI joint or an SI joint dysfunction One other test that we can do is called the standing flexion test. So I'm actually going to have the patient move back just a tad bit. Perfect. She is going to bend down and touch her toes. And when she does that, what I'm looking for is forward movement of my thumb towards her cranium. So we actually want that to happen, right? Come back up. Again, standing flexion test. When she flexes, we're expecting that thumb to move up towards the cranium. Make sense? What's a positive? One. one in which the thumb stays in its position, one in which the SI joint doesn't move as cranially as the other side, right? Those would all be indicative of a stuck or a fixed SI joint pathology. For the next test, we're going to have the patient get back on the table. And we'll be performing the Gaines lens test. In the Gaines lens test, the patient is going to be seated or laying in a supine position. She is going to move. move to the edge of a table. So we'll go here for sake. And then what we're going to have the patient do is drop their limb, the injured limb off the edge of the table. So far, so good. You guys, are you tracking there? I'm going to move to the same side of the table that the patient's leg is dropped on. And what we want to do is have the patient come off just a little bit more because we want to be able to rock that hip into extension. So in this position, what we're going to do as clinicians is place our hand about four finger widths up. above that superior pole of the patella. And what we're going to do is literally rock that hip into extension. Do you see that? I'm rocking that hip into extension. A positive gain zones test would be one in which the patient reports pain as you're rocking that hip into an extension moment. Very similar to a prone ipsilateral test. Very similar to a yeoman's test. Just another way to perform a pain-provocating SI joint. test. Another test that we can use is Lager's test. So the patient's going to come back to the center of the table. Patient is still going to be in a supine position as we can see here on the actual examination table. What we're going to do is take the leg up. or the hip into flexion, the knee into flexion, 90-90, right? And then what we're going to do is laterally rotate. Do you guys see that? Laterally rotate the hip, and then we're going to apply a pressure through the femur. So this hand right here is applying a posteriorly or a downward force. to the femur while the femur is in external or lateral rotation. And what you're looking for there is whether or not that patient has pain. And if they have pain in the SI joint, then you suspect some sort of SI joint dysfunction. For our final test, we are going to do the sit to stand test, or I think what we call it is the sit and reach test. Your textbook might call it the long sit test. I don't know, some sort of sit test, okay? In this particular test, I'm going to be focused at the patient's feet. So I'm actually going to have the patient slide that direction on the table. And we are going to be focused in on... the patient's feet. So one of the things in the long sit test, I think I got it right this time, is you want to take your fingers, these fingers, index and thumb, and you want to place them on the malleoli of each. ankle. Does that make sense so far? What we are doing is we are comparing the level of those hands. Does the medial malleolus match up on both sides? Does the lateral malleolus match up on both sides, right? So again, you want to be at the tip of the hand. of those malleoli and what you're looking for is whether or not the patient has a leg length discrepancy. So once we identify what those malleoli look like in a laying position, one thing that we have to do is rock the patient into pelvis neutral. Okay, so I'll do that again. Rock the patient into pelvis neutral really quick. Do a quick assessment to see if one limb is longer. In this particular patient's case, I can see that Bree's right leg is a little bit longer when we look at the alignment. You may not see that, but you'll see it in lab. So we have a longer limb on the right side. Okay, what we're going to have that patient do is sit up from that position. Of course, it requires abdominal strength. So come on up, patient. We're going to have the patient sit up. And what we want to look at is whether or not that limb gets shorter, which it did. Okay, again, I can confirm it. Patient, give a thumbs up to the video. the camera that it happened. It happened. Okay. So here's what happens. Lay back. If we have a limb that is longer when they're laying, that gets shorter when they sit up, that is an anteriorly rotated pelvis. So we have an anteriorly rotated pelvis on the right side. If we have a limb that is shorter, right? When they're sitting or laying and it gets longer, longer when they sit up, that is a posteriorly rotated pelvis. So this concludes all of the special tests for the pelvis. I know I talked a little bit fast during these segments, but feel free to pause, to rewind, to engage with this content. I will see you all in lab where hopefully we can actually apply what you just watched. Thank you so much for viewing.

I suggest that you review both of those prior to coming and looking or going through the special test for the SI joint. It will make more sense in terms of the movements that I will be describing. So today what we're going to start with is the isokinetic prone test, or a better way to say it is the ipsilateral prone kinetic test. As the name describes, the patient is going to be in a prone position. So we can see here the patient is in a prone position, right?

Stomach is down towards the table. And this will become instrumentally important, you guys, when we're actually testing the patient. This test in particular is used to test for a posteriorly rotated ilium.

So in order to perform this test relatively well, you have to know how to palpate one anatomical landmark. That anatomical landmark is the posterior superior iliac spine. So in lab, what we'll get used to doing is pulling the patient's shirt up and asking, of course, if they're comfortable with that. So I can see that my patient is wearing a sport bra, so most often what I'll do is tuck the shirt underneath the sport bra so it doesn't fall down into the palpation region. And then if you have a patient who's wearing high-waisted pants, right then what we'll do is just tuck those pants down in the into the undergarment region right so now we've exposed the low back region and we're actually ready to perform the prone isokinetic test So what I'm going to do is on the side that I suspect has the SI joint pathology, I'm going to first and foremost locate the PSIS of the patient.

So you can tell that knowing how to palpate the pelvis anatomical structures becomes extremely important, you guys, when we're assessing or performing special tests for the sacroiliac joint in particular. So once my hand is on the PSIS of that patient, I'm going to apply a little tiny bit of pressure. Now, the next thing I'm going to have the patient do is I'm going to have her flex her knee to 90 degrees.

So she's got her knee at 90 degrees. We can see that there. I have my hand on her PSIS.

And then what I'm going to have the patient do is push her heel up towards the ceiling or lift her limb off of the table, right? And we've seen this maneuver before with the glute max and hamstring testing, right, you guys? So hand is on the PSIS. And I have my patient do is. is lift that heel up to the ceiling. And what I'm looking for, and what you guys probably won't see in this video, is a cranial or a superior movement of that PSIS.

So can you take your leg down to the table one more time? I'm gonna have that patient lift up, and what I want you to see is what we want to see is for my thumb to move superiorly or cranially. What we'll see in a posteriorly rotated pelvis, remember posterior rotation means pelvis is rocked in this position. When that patient goes to extend that hip, what we'll see is one of two things. Go ahead and extend.

The thumb will stay there or it'll rock inferiorly because that pelvis is stuck in a posteriorly rotated position. So again, a positive test is one in which the thumb doesn't move superiorly, so it stays here and it's stuck, or it moves inferiorly because the pelvis is rocked into a posterior position. We're not necessarily looking... for any pain. It's more so what movements do we feel or do we not feel?

So I hope that makes sense, you guys. The prone ipsilateral test is used to assess a posteriorly rotated ilium. A positive test would be one in which we don't feel the thumb move towards the skull, right, you guys? And if we don't feel that movement, then we suspect that the patient has a posteriorly rotated ilium.

Now, without that said, with all of these tests, if I haven't said this enough over the semester, we're always testing that bilaterally, right? So we always want to test both the right and the left side. Most often, we're going to test the non-pathological side first to see out how it's behaving.

and then we test the pathological side next. That concludes the ipsilateral prone kinetic test. So the next series of tests that we are going to use to assess SI joint dysfunction, there are two.

The first one is called the passive extension and medial rotation on the ileum test. Say that three times fast. And then the second one is called the passive flexion and lateral rotation of the ileum.

Sacral test. So let's start with the first one, the passive extension medial rotation of ilium on sacral test. This is a special test that is used to assess a posteriorly rotated ilium.

right so let me show you what a posteriorly rotated ilium would look like in a posteriorly rotated ilium we would suspect that the pelvis is rocked into this position right you guys you get that part yes so when we perform the passive extension and medial rotation test we're usually standing behind the patient but our lab sheet says that we can stand in front of the patient because you certainly can what i've learned in clinical practice is that it's actually easier for me as a clinician to stand behind the patient to get a good grip on the pelvis. But in lab, I'll let you choose what works best for you. So for the passive extension and medial rotation test, what we're going to do is we're actually going to rock the pelvis into an anterior position. So we're going to rock it in this direction, right?

The opposite direction of the actual fixation. I hope you guys get that, right? So right now what we're doing is we're performing a test for a positive posterior rotation. And in order to perform... that test we have to take the pelvis in the opposite direction so we're going to try to force it into an anterior rotation does that make sense i hope so if it doesn't make sense we'll clarify it in lab you guys but i just want to be clear this patient has a posteriorly rotated pelvis right so if it's stuck there what we want to do is try to rock that pelvis into an anterior position so going back to the test you The patient has a suspected posterior pelvis.

What I'm going to do is two things. With one hand, I'm going to put that on the ASIS of the patient. With the other hand, I'm going to put it on the sacrum.

And you can't see that, but just imagine. Imagine that that's what I'm doing. So you can see how I'm kind of hugging my patient a little bit.

If the goal is to see if they have a posteriorly rotated pelvis, you guys, if I'm stuck in a posterior rotation, my pelvis will not move into an anterior direction. That is why we are moving it into an anterior direction. So are you ready for this?

I'm here, hand is here, and I'm going to try and rotate that pelvis anteriorly, anteriorly. And I'm getting good movement on this patient because she doesn't have a posteriorly rotated pelvis. But what we can say is that if the patient has a posteriorly rotated pelvis, you'll get no movement of the ilium into an anterior position.

I hope that makes a lot of sense. Now... If the patient has a suspected anteriorly rotated pelvis, right, you guys?

So it would be one that looks like this, an anterior rotation. Now we're going to have to try to drive that pelvis posteriorly to see how much movement we get, right? So now what we're going to perform on the table at the lab table is what we would call the passive flexion and lateral rotation ilium sacral test, right?

So my hand positioning is pretty similar. The difference is I'm going to be rocking that. pelvis into a posterior position. Take the hands off, I'll show you just simply.

I'm going to be rocking it into a posterior position because an anteriorly rotated pelvis won't want to move into that posterior position. So look at me, hand placement could be something that looks like this. It could be something that looks like this. I'll let you choose what works best for you.

What I've learned is I like this position here. So my hand is still on that ASIS. My other hand is kind of going down with the glutes, if that makes sense. And I'm still on that sacrum.

And what I'm going to do is try to rock that pelvis into a posteriorly rotated position, right? If I have an anteriorly rotated pelvis, I won't want to move in that direction, okay? For those of you who want to see the other hand.

hand direction, hand still on the ASIS, and I'm rocking that pelvis into a posteriorly rotated position. What would a positive be for either of these tests? Well, if you have a posteriorly rotated ilium and you try to rock the pelvis into an anterior direction and you don't get movement, that's positive for a posteriorly rotated ilium, right?

If you have an anteriorly rotated ilium and for whatever reason the patient doesn't rock into a posterior position, then you you have a anteriorly rotated ilium, right? Now, all of that to say, then you have to figure out what the heck am I going to do with this patient once I figure out what dysfunction they have at the SI joint. And so you have to figure that out. Do I stretch? Do I strengthen?

Do we yoga? Do I do deep tissue? Do I do active release technique, right?

The first step, however, to... Figuring out what's the cause of the low back pain, in particular the SI joint pain, is to figure out what's wrong or what the dysfunction is at the sacroiliac joint. That concludes both the passive Extension and medial rotation test and the passive flexion and lateral rotation test. Okay, so our next special test in this SI joint series is going to be the compression or the gapping stress test.

And I want you to pay very close attention to my hands for the next four special tests because three of them are very similar. And I want you to see the differences in hand positioning. So it becomes instrumentally important to maybe pause. Look at it a little bit because as I progress down this list of special tests, you're going to be like, these look the same.

But I promise you they aren't. And in lab, you'll actually feel how they stress different tendons or ligaments within the actual pelvis itself. So the first test is. is going to be the gapping or the stress test or some people call it the compression test.

With this test, you want to cross your hands and you want to make sure that the hands are placed on the opposite ASIS. So an example would be. If it's my left hand, I guess I'm going on the left side of my patient. If it's my right hand, I'm on the right hand side of the patient. Do you see how there's an X being created with my hands?

What I don't want you to do is this, because this is a different test. So for the compression test, for the compression or gapping test, we have to have a cross hand position. Does that make sense so far, you guys?

I hope so. The next thing that we want to do is twofold. And I'm going to change my hand.

hand positioning so I'm here. What we want to do in this particular position is we want to apply a downward look down. towards the patient's body and an outward push, which is why crossing the hands is extremely important. So not only am I pressing outward, but I'm also pressing downward at the same time.

I need you to see that. And it's a combination movement. In other words, you guys, what I'm saying to you all is it's not two movements. It's not down and then out.

It's a combination movement in which we do both of those movements at the same time. So moving back to the patient, we're here. We're going to press down and out. And what we're looking for with this particular test is whether or not they actually have pain.

What we know is if they have pain with this compression test is most often that anterior sacroiliac ligament has a sprain or is loose and isn't creating stability at that sacroiliac joint from an anterior perspective. And that's extremely important. So a positive would be deep seated pain, maybe even increased laxity as you're compressing or pressing on that particular joint.

okay you guys so that is the compression test the next test that we're moving in into is called yeomans for yeomans test the patient is actually going to flip over into a prone position so that patient's going to flip over And Yeomans is going to look very similar to the prone isokinetic test, but I can promise you it's a little bit different. So with Yeomans, the patient is in a prone position here. And what we're doing this time, instead of palpating the PSIS like we did in that prone ipsilateral test, we're going to place the knee at 90 degrees. We're going to get underneath that knee joint like such, and we're literally going to extend the hip. Now I'm stabilizing here, but I'm not compressing or doing anything on the joint.

I want to be very clear that what I'm doing is extending the hip. And when you extend that hip, we're compressing that SI joint. And so what that patient is going to report is pain in the SI joint region. So a positive Yeomans test would be one in which you extend the hip of the patient and that patient complains of pain in the SI joint region.

Now let's back up a little bit. Okay. Can we do the Yeomans test and the prone ipsilateral test at the same time? Heck yes.

Is it reasonable to think, okay, have the patient extend their hip, palpate PSIS, does it move cranially? That's prone ipsilateral test, right? Now, I'm passively going to move that patient into hip extension.

Guess what? That's Yeomans test. So we can do some of these tests at the same time somewhat, right? Okay, moving back to the patient.

Our next test on the list is called the approximation test. also called the compression test. So I like to use approximation test. In this test, the patient is in a side-lying position.

So I'm going to have my patient roll over into a side-lying position. During this test, the patient is in a side-lying position. And I don't know if you guys can tell in the video, but the patient is kind of rocked back towards me at an angle. So what I'm going to do is make sure she truly is lying in a side-lying position. I'm going to find the top of that iliac crest, and I'm going to kind of get my hands in a CPR position.

Do you guys see that? that. So I'm at the top of the iliac crest, making sure I'm on the actual iliac crest, and I'm going to apply a downward pressure to that.

iliac crest, right? What do you think a positive would be? Increased pain, increased laxity, a positive approximation test is indicative of a sprain to the posterior sacroiliac ligament, right?

So we have the compression test, which is a positive for an anterior sacroiliac ligament sprain. And then now we have this approximation test, which is testing the posterior sacroiliac ligament. Our last test in the series is going to be the squish test.

And the squish test is almost the same. You guys look at me is almost the same as the gapping test, which is why I said crossing the hands on the gapping test is extremely important. So So let's move to the patient and let's go ahead and have the patient move into a supine position. What I'm going to do in this particular case in the squish test is stand at the head of my patient.

And you guys can't see that head of the patient is here. What I'm going to do is stand at the head of my patient. Right.

So we're already seeing a little bit of a difference between the gapping test and the squish test. So I'm standing at the head of my patient. Make sense so far.

Good. Okay, so from here what I'm going to do is right, do you guys see that? Right on that ASIS, I'm going to press downward and at a 45 degree angle.

So I'm pressing downward and at a 45 degree angle. A positive test, patient who reports pain with this particular test, is also indicative of a posterior sacroiliac sprain. So that concludes the four special tests that are somewhat similar. They're all testing main... mainly the sacroiliac ligaments, either the anterior sacroiliac ligament or the posterior sacroiliac ligament.

And remember, those two ligaments are instrumentally important for creating stability between the, guess what, the sacrum and the ilium, right? So any laxity in those ligaments, and we have changes that occur in the arthrokinematics of the SI joint. We'll start with another set of tests in just a moment. So as we move forward into SI joint testing, the next test is going to test the sacro tuberous.

ligament. And the test is called the sacroiliac rocking test. For this test, the patient is going to be in a prone position. So let's move back to the patient.

Patient's going to be in a prone position. Actually, the patient is going to be in a supine position. Sorry about that, guys. So supine position with her stomach up towards the ceiling.

We can see that there. What we are going to do is kind of get a little bit more intimate with our patient. So is it okay if I touch your sacrum from underneath?

Okay. So in this test, what we want to do is we want to flex the patient's leg. And most often what I will do is kind of place that patient's leg on my shoulder, if that makes sense, you guys.

Because this hand is actually going to go underneath to the actual sacrum. So what I usually say is, can you lift your butt up really quick? And then that allows me to get on the sacrum itself, right?

Now I'm on the sacrum with this bottom hand. What I'm going to do is flex the hip and rock the sacrum all at the same time. And so I'm pulling that sacrum.

sacrum down towards the bum and then I'm flexing the hip all at the same time. Hence the reason it's called a rocking. We're rocking that sacrum.

A positive test would be one in which the patient has pain with that movement and that would be indicative of a sprain to the sacro tuberous ligament of the SI joint. Our next special test that we're going to perform is the sacral shearing test. So in this test the patient is in a prone position so we'll have that patient go ahead and flip over.

and we'll move to the patient. The patient flips over and as the name implies, it's a sacral shearing test. So essentially what you want to do is actually have the patient scoot over towards the edge of the table just a tad bit.

And for me, I find that getting on the table with the patient is a better and more effective way to actually shear on that sacrum. So just imagine. This is probably S2, S3 of my patient.

I'm going to get in a CPR position, and all I'm going to do, you guys, is press down towards the ground. So literally a few kind of chest compressions on that sacrum, right? And what we're looking for is any pain that that patient might experience. If they experience pain, then it's indicative of SI joint dysfunction. For our next test, we're actually going to have the patient stand up.

So the patient's going to be in a... a standing position. And this is kind of counterintuitive, right? Because for the last, I don't know, seven tests, the patient has been in a seated or in a table position.

So one of the reasons I don't like SI joint tests very much because they're very not functional or they lack function, right? And now we're putting our patient in a position of function. And so what we're going to do is actually do what's called the Gillette's test or the Gillette's test depending on who you ask. So I'm going to move around the table and I'm going to have my patient turn this direction.

What I'm going to do is what I did early on when she was on the table. I'm actually going to tuck this shirt into her bra like such. And then what I'm going to do is tuck these down just a little bit. From here, what I want to be able to do is to find the PSIS on each side. So I'm going to look and I'm going to find PSIS for both sides of that particular patient.

And now what I want to do is just number one first. Let's just. assess are we level in terms of PSISs and it looks like it on this particular patient. The next thing that I'm going to have the patient do is flex their knee to their chest, right? And so go ahead and bend your knee to your chest.

And what you're looking for is what we see here in this image. So we're going to go back. And maybe we can zoom in so you can see thumb movement. Go ahead and bring that back down.

So what we're going to do is have that patient flex. And as she flexes, what we're looking for is this inferior movement of the thumb. Do you guys see that? Bring it back down.

See how that thumb is flexing? thumb goes back to a neutral position, bring it back up. We're looking for an inferior movement of the thumb, right? Because as that hip flexes, what's happening to the pelvis? It's moving into a posterior rotation, right?

A positive, I'll create a false positive. really quick would be one in which the thumb moves cranially or moves up towards the cranium or superiorly right or one in which go ahead and move up the thumb doesn't move at all right so that would be considered a stuck SI joint or an SI joint dysfunction One other test that we can do is called the standing flexion test. So I'm actually going to have the patient move back just a tad bit. Perfect.

She is going to bend down and touch her toes. And when she does that, what I'm looking for is forward movement of my thumb towards her cranium. So we actually want that to happen, right? Come back up. Again, standing flexion test.

When she flexes, we're expecting that thumb to move up towards the cranium. Make sense? What's a positive? One. one in which the thumb stays in its position, one in which the SI joint doesn't move as cranially as the other side, right?

Those would all be indicative of a stuck or a fixed SI joint pathology. For the next test, we're going to have the patient get back on the table. And we'll be performing the Gaines lens test. In the Gaines lens test, the patient is going to be seated or laying in a supine position.

She is going to move. move to the edge of a table. So we'll go here for sake.

And then what we're going to have the patient do is drop their limb, the injured limb off the edge of the table. So far, so good. You guys, are you tracking there? I'm going to move to the same side of the table that the patient's leg is dropped on.

And what we want to do is have the patient come off just a little bit more because we want to be able to rock that hip into extension. So in this position, what we're going to do as clinicians is place our hand about four finger widths up. above that superior pole of the patella. And what we're going to do is literally rock that hip into extension.

Do you see that? I'm rocking that hip into extension. A positive gain zones test would be one in which the patient reports pain as you're rocking that hip into an extension moment. Very similar to a prone ipsilateral test. Very similar to a yeoman's test.

Just another way to perform a pain-provocating SI joint. test. Another test that we can use is Lager's test.

So the patient's going to come back to the center of the table. Patient is still going to be in a supine position as we can see here on the actual examination table. What we're going to do is take the leg up.

or the hip into flexion, the knee into flexion, 90-90, right? And then what we're going to do is laterally rotate. Do you guys see that?

Laterally rotate the hip, and then we're going to apply a pressure through the femur. So this hand right here is applying a posteriorly or a downward force. to the femur while the femur is in external or lateral rotation. And what you're looking for there is whether or not that patient has pain. And if they have pain in the SI joint, then you suspect some sort of SI joint dysfunction.

For our final test, we are going to do the sit to stand test, or I think what we call it is the sit and reach test. Your textbook might call it the long sit test. I don't know, some sort of sit test, okay?

In this particular test, I'm going to be focused at the patient's feet. So I'm actually going to have the patient slide that direction on the table. And we are going to be focused in on...

the patient's feet. So one of the things in the long sit test, I think I got it right this time, is you want to take your fingers, these fingers, index and thumb, and you want to place them on the malleoli of each. ankle.

Does that make sense so far? What we are doing is we are comparing the level of those hands. Does the medial malleolus match up on both sides?

Does the lateral malleolus match up on both sides, right? So again, you want to be at the tip of the hand. of those malleoli and what you're looking for is whether or not the patient has a leg length discrepancy. So once we identify what those malleoli look like in a laying position, one thing that we have to do is rock the patient into pelvis neutral.

Okay, so I'll do that again. Rock the patient into pelvis neutral really quick. Do a quick assessment to see if one limb is longer. In this particular patient's case, I can see that Bree's right leg is a little bit longer when we look at the alignment.

You may not see that, but you'll see it in lab. So we have a longer limb on the right side. Okay, what we're going to have that patient do is sit up from that position. Of course, it requires abdominal strength.

So come on up, patient. We're going to have the patient sit up. And what we want to look at is whether or not that limb gets shorter, which it did. Okay, again, I can confirm it.

Patient, give a thumbs up to the video. the camera that it happened. It happened.

Okay. So here's what happens. Lay back. If we have a limb that is longer when they're laying, that gets shorter when they sit up, that is an anteriorly rotated pelvis.

So we have an anteriorly rotated pelvis on the right side. If we have a limb that is shorter, right? When they're sitting or laying and it gets longer, longer when they sit up, that is a posteriorly rotated pelvis.

So this concludes all of the special tests for the pelvis. I know I talked a little bit fast during these segments, but feel free to pause, to rewind, to engage with this content. I will see you all in lab where hopefully we can actually apply what you just watched. Thank you so much for viewing.

Transcript for:Pelvic Special Tests Overview

Transcript for:
Pelvic Special Tests Overview