Osteopathic Evaluation and Treatment of the Hip/Pelvis

by Tyler Cymet, DO, FACOFP

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    00:00 Now, we're going to start going through the tests.

    00:02 You'll have a separate video, a very short 30 seconds to a minute on each test.

    00:08 Hip drop test, the patient is instructed to bend one knee while keeping both feet flat on the ground. That's it.

    00:16 You look at the curvature in the back and you look at the level.

    00:19 So the physician should take note of the fluidity of the motion, the amount of motion, as well as motion of the lumbar spine curve whether it gets more lateral or whether the muscles are tight and they're not moving at all.

    00:33 Do you see compensatory movement or smooth fluid movement or are you noticing some area that your eye is pulled to because the pelvis isn't moving right or isn't moving at all? Notice which side. Is it the bent-knee side or the other side where you're noticing the abnormality? That's the hip drop test.

    00:54 We'll do a short video on that.

    00:56 So note the amount of drop of the iliac crest and repeat on both sides.

    01:02 Compare the right and the left side and note the bending of the lumbar spine and whether or not it is equal.

    01:09 The iliac crest that drops more is the side of restricted side-bending.

    01:14 The Adams forward bending test, I call this the scoliosis screen.

    01:19 We do this for most kids. It's looking whether or not the student or the person has a curve of the spine and what happens when they bend over.

    01:29 This can be done from behind or from in front of the patient.

    01:32 We're saying for this test and for conformity, we want to do it in front and have them bend forward and you look at both sides for symmetry.

    01:45 The patient will bend forward and you'll notice whether or not they have a hump forming on one side or if they had an apparent curvature if it goes away.

    01:54 Again, you're looking to see if there's a difference between the right and left side in the area of the rib cage.

    01:59 You're looking for a rib hump, and you're looking to see how the body responds to motion.

    02:05 So if a patient has what looks like a twisting and maybe a small curvature of the spine, having him bend forward will tell you if it's structural and not going away and the body is going to have a hump, or whether it's functional and it goes away when they move and bend because the patient is just a little twisted, maybe a little weak, maybe a little tired and it is not a chronic scoliosis pattern.

    02:32 So with the scoliosis screen, observe the gait and the stance in horizontal planes, observe the standing flexion test.

    02:40 You can do a seated flexion test as well to confirm and to take the sacrum out so the patient can't compensate or hide something by doing something themselves to their functioning or their motion.

    02:54 The osteopathic diagnosis here is first check the pelvis and to take the pelvis out of the equation by having him seated.

    03:03 You may want to check the medial malleoli length as well, the iliac crest length. Check the ASI levels, the pubic symphysis levels and the tibial and femoral length differentials.

    03:15 This will tell you whether the issue is going to be pelvis or whether you have a spinal scoliosis.

    03:22 You want to put them prone. Again, you are checking the pelvis and sacrum here. You check the spring test of the sacrum.

    03:29 Then you have them get up on their elbows to check the sphinx test.

    03:33 You want to check levels of the posterior superior iliac spine.

    03:36 You want to check the sacral sulci for deepness and equality.

    03:42 You want to check the ilias, the bone hips, and check the lumbar spine.

    03:48 I usually touch the spinous processes when generally not tender.

    03:52 It's a good start and less sensitive.

    03:54 Then I go to the transverse processes to check for motion, tenderness, bogginess, tonicity of the muscles.

    04:01 If there are abnormalities here, you may want to consider a muscle energy treatment of the pelvis in order to take the pelvis out and get back to evaluating each area of the body individually.

    04:15 Muscle energy of the pelvis here could be the anterior iliac dysfunction.

    04:22 It could be posterior iliac innominate pelvic dysfunction.

    04:25 You could have abnormality of the pubes.

    04:30 You can have a pubic shear or discrepancy in the two sides of the pubic bone.

    04:36 You can have a pubic ramus that's elevated, or you can have a superior iliac innominate pelvic shear as well, or a lumbar mechanical abnormality.

    04:51 Other ways of treating the issue would be a facilitated positional release with a lumbar superficial muscle that's hypertonic being relaxed. You may want to extend the lumbar spine and treat the somatic dysfunction, or you want to treat lumbar flexion somatic dysfunction.

    05:10 FPR is one way of positioning a person, giving them time to reset their proprioceptive sense and their use of the muscle.

    05:20 Now, we're going to go into the causes of short leg syndrome.

    05:24 We've already said that short leg syndrome is not a short leg.

    05:28 It's a disorder of the sacrum or the pelvis.

    05:30 It's usually a mechanical disorientation, disuse, or just not working right.

    05:38 So we're going to go through them one by one.

    05:40 One common reason for a short leg syndrome is when you have the anterior innominate rotated.

    05:47 To diagnose an anterior innominate rotation you want to do a standing flexion test.

    05:53 You can have them drop a hip and you see if the curve is good or changes, and what happens to the PSIS.

    05:59 If you want to make the diagnosis though, you lay them supine and you check the ASIS on both sides.

    06:05 You see how much motion you have, how free the motion is if things are moving right.

    06:11 Then, you'll check the medial malleoli and see if the side where you have the ASIS abnormality is equal or if it's lower on that side.

    06:22 You want to see if the leg on the other side is compensated, if it's shorter.

    06:27 If you have the right side of the innominate moving forward, the left side of the innominate would move backward, the left leg would be shorter or apparently shorter and the right leg would be longer. That's the diagnosis.

    06:38 The treatment of an anterior innominate is to put the person prone.

    06:45 Then to find the hip motion, move the hip slightly off the table on the same side of the dysfunction, monitor the ilio-sacral junction or the sacroiliac junction and move the thigh. Check the motion. Spring the sacrum and see if you can return the motion that way.

    07:09 By using gravity and having the patient's weight pulled down and holding the sacrum, you're going to help create motion and move things.

    07:20 Use your monitoring hand to support the patient's knee.

    07:25 Have the patient push their foot forward to fatigue some of the muscles and to ease motions.

    07:32 So when you're talking about the flexors, you're talking about the rectus femoris, the lateral, intermediate, and medial muscles of the hip flexors as well as the iliopsoas. Use those muscles, provide some support, and monitor the sacrum as you do it.

    07:50 Repeat several times. I usually go three to five seconds each time.

    07:54 Make sure that you get some stretch or additional motion each time.

    07:58 Then you recheck to make sure that you have returned the leg to the proper orientation. You now have equal leg lengths.

    08:07 So for the anterior innominate rotation, to continue the treatment, the patient can be supine as well. You want to get on the side of the dysfunction, the side that isn't moving.

    08:19 You can rock it, monitor it by putting your hand medial to the PSIS so you're not causing tenderness because the posterior superior iliac spine is going to be somewhat tender. There's a problem there.

    08:31 It's not moving. That's got an abnormality.

    08:34 You see how far you can move it.

    08:36 When you hit the barrier and it can't move anymore, that's where you're going to start the treatment.

    08:42 Ask the patient to push against you using their own muscles.

    08:46 Again, this would be the opposite now.

    08:48 So now you're using the hip extensors. The semimembranosus, the semitendinosus, the gluteus maximus are all going to be engaged to extend and to help bring the leg back to equal leg lengths.

    09:02 Have the person push for three to five seconds.

    09:06 Repeat several times. As long as you continue to get increased motion, increased activity, you're doing well.

    09:14 So that is the first. That's anterior innominate rotation.

    09:21 Other causes for apparent short leg syndrome.

    09:26 This is number two. You can have a posterior innominate.

    09:30 We're seeing which one is stuck, which one isn't moving.

    09:34 So if you have the right innominate moving forward and the left one moving posteriorly, both of those are problems.

    09:40 Which one is the restriction that needs to be evaluated on exam? If you do a standing flexion test and you noticed that the posterior is the one not moving, that's the one that's going to be treated and that's what you're diagnosing.

    09:56 In the supine position, you'll notice the ASIS is going to be superior and posterior.

    10:02 You'll notice that the medial malleolus on the same side is going to be higher. On the opposite side, it's going to be lower.

    10:10 The short leg is going to be on the side of the problem.

    10:15 So the leg on the same side is going to be shorter.

    10:18 Again, the treatment now for the posterior innominate.

    10:23 We're going to put the person prone and lie on their stomach.

    10:26 You're going to go in the opposite side of the problem and use your weight and gravity to help induce motion.

    10:34 You're going to use your hand to monitor the posterior superior iliac spine.

    10:40 Again, you go a little bit off of it because you don't want to hurt the patient and they're going to be tender right over it.

    10:44 You check the iliosacral motion.

    10:48 Once you get some motion and you could do that with rocking, you could do that with gentle easing, That's when you know you're getting some response.

    10:56 So the doctor's hand is supposed to be on the anterior thigh supporting the leg and on the sacroiliac junction.

    11:06 Bring the thigh up, extending the leg in order to help fatigue the muscles. Use the muscles to help induce motion.

    11:15 You may have the patient push down for three to five seconds getting increased motion and increased extension each time, getting the 10 to 30 degrees of extension of the thigh.

    11:28 Repeat several times. As long as you're getting an increase in motion, keep going.

    11:32 Another way of treating this is to put the patient supine.

    11:36 I often use where the patient is most comfortable, what they tolerate, and what they'll let you do.

    11:43 If a patient is uncomfortable lying on their stomach and they start grimacing, put them on their back.

    11:48 Monitor the PSIS on the same side and the ASIS on the opposite side.

    11:55 That's the normal rocking motion of the pelvis and that's the motion you want to see.

    12:00 Bring the patient's leg off the table. Hang it off the table in order to use gravity and to help induce the extension of the hip muscles.

    12:10 Then have the patient push up trying to bring the pelvis back into alignment.

    12:16 Repeat several times until you have a return of leg length equality and leg length motion.

    12:23 Other ways of doing this, you can have the patient supine.

    12:27 Instead of doing extension, you can use a flexion technique where you will put your hand on the ASIS because you are now having the patient supine and put this on the ASIS of the dysfunctional side.

    12:44 Have the patient flex the knee for comfort and to see what kind of motion. By flexing the knee, you're taking the lower leg muscles out of it.

    12:52 They're not going to have this easier time compensating or using their body to hide the problem.

    12:59 Monitor the motion and the progress of motion in the hip, sacrum, and pelvis.

    13:05 You may want to flex the knee against your shoulder so you have more leverage and you can push.

    13:12 You can have the patient push against you.

    13:15 As long as they are using their extensor muscles, you're going to get some benefit and some loosening.

    13:21 You do three to five seconds each time as a normal muscle energy procedure.

    13:25 As long as you get increased motion, you keep going.

    13:31 Here's an extensive review of the findings you may have and how you can think about what's going on.

    13:39 A lot of what we want to instill in people is the ability to think.

    13:43 If you have the right side of the pelvis move forward, what happens to the left? What happens to the leg length? How does this affect the sacrum? So checking the PSIS, ASIS, sacrum, all those levels put together should give you a clear, coherent picture of what's going on in the skeleton and how one part is affecting the other.

    14:06 Then it's very biomechanical. If you have the right side of the pelvis pushed forward and you want to do a direct technique, you push the right side of the pelvis backward and go where they can't go to make sure you get it treated.

    14:20 So take a second, look at the test, look at the findings, and figure out the potential changes and the normal functioning and normal mechanics of the skeleton.

    About the Lecture

    The lecture Osteopathic Evaluation and Treatment of the Hip/Pelvis by Tyler Cymet, DO, FACOFP is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Hip Drop Test
    • Adams Forward Bend Test
    • Anterior Innominate Rotation
    • Posterior Innominate Rotation

    Included Quiz Questions

    1. Adams forward bend test
    2. Ober's test
    3. Trendelenburg test
    4. FABER/Patrick's test
    5. Thomas test
    1. Right superior innominate shear
    2. Left superior innominate shear
    3. Right inferior innominate shear
    4. Left inferior innominate shear
    5. Right anterior rotated innominate
    1. Left anteriorly rotated innominate
    2. Right anteriorly rotated innominate
    3. Right posteriorly rotated innominate
    4. Left posteriorly rotated innominate
    5. Right inferior innominate shear
    1. Left posteriorly rotated innominate
    2. Left inferior innominate shear
    3. Right posteriorly rotated innominate
    4. Right anteriorly rotated innominate
    5. Left anteriorly rotated innominate
    1. Hip drop test
    2. Ober's test
    3. Trendelenburg test
    4. FABER/Patrick's test
    5. Thomas test

    Author of lecture Osteopathic Evaluation and Treatment of the Hip/Pelvis

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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