Pelvic, Hip and Core Stability


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Pelvic, Hip and Core Stability

From Grégoire Lason and Luc Peeters, The International Academy of Osteopathy,

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Pelvic, Hip and Core Stability

  1. 1. Pelvic, Hip and Core StabilityLuc Peeters, MSc.Ost. – Grégoire Lason, MSc.Ost.Principals of The International Academy of Osteopathywww.osteopathy.euOsteopaths often talk about mechanical cause-consequence chains in the lowerextremities. For example: a mechanical lesion (loss of mobility) in the iliosacral jointcan influence the mobility and stability of the foot.If we look at these mechanical connections, we must be aware that a more importantissue here is that the pelvic girdle needs to be stabile and that there must be acorrect core stability.With a stabile pelvis and good core stability, lots of strains and injuries in the lowerextremities can be treated and even avoided. This is important not only for dailypatients but even more for athletes and the follow up of these athletes towardsprevention of injuries.1. Pelvic and Hip Stability1.1. Body LoadIn a standing position, the body load comes on the promontorium of the sacrum.From there the load is transmitted through the sacroiliac joints that form an arch.Weight is then taken to the hip joints.The ilia form pubic struts, which neutralize the forces on the femur.Sitting causes compression forces at the ischial tuberosities. Body SI joint weight Arch Acetabula Compression Femur Sitting Weight bearing of pelvis 1
  2. 2. Pelvic ringIn a standing position, the sacrum is loaded with the superincumbent weight. Primaryvertebral load on the sacral promontorium causes the sacrum to rotate anterior. Thisis called primary load on S1.The posterior sacroiliac capsule takes the tensile stress. This causes the caudal partof the sacrum to move posteriorly causing a counter-balancing tensile stress on thesacrospinous and sacrotuberous ligaments. Relatively, the iliac bones rotateposteriorly.The weight bearing forces join at the inferior transverse axis. Under load, the sacrumtilts anterior. The more load, the more anterior tilt of the sacrum. This induces thelumbar spine in more lordosis.This caudal gravity load on the sacrum with tensile stretch on the posterior capsuleand the sacrospinous- and sacrotuberous ligaments happens around the ITA, thuscompressing the inferior part of the SI joints lateromedially on this S3 level. Primary load force at S1 40° ITA (L3 level) Compression at S3 level = self-bracing 10° Sacrum in weight bearing (redrawn from Vleeming) 2
  3. 3. On the cephalic side of S3 (on the iliac bone) there is an ilial ridge. This prevents S3to move cranially. Ilial ridge ITA (L3 level) Ilial ridge postero-superior from the ITAAfter load bearing, the gravity line is anterior to the sacral axis. The gravity line staysposterior to the acetabula causing a general posterior pelvic tilt and creating adynamic, balanced tension on the pelvic ligaments. The posterior pelvic tilt decreasesthe lumbar lordosis.The ligamentary stability of the pelvis in the sagittal plane is maintained by a goodcondition of the posterior sacroiliac capsule and the sacrospinous- andsacrotuberous ligaments.The basic muscular balance is done by the lower paravertebral muscles and thecoccygeal muscles. Secondary the piriformis m. and the sacral part of the gluteusmaximus m. provide a counter force for the anterior sacral rotation. Posterior sacroiliac capsule and lower paravertebral muscles Sacrospinous, sacrotuberous ligaments and coccygeal muscles Ligamentary stability and muscular balance in the sagittal plane 3
  4. 4. To have an optimal functioning pelvic girdle that spreads tension equally over thejoints and capsuloligamentary structures, the correct locking mechanism (self-bracing) must be in place. Therefore the condition of the posterior SI capsule andsacrospinous- and tuberous ligaments must be optimal.Despite good condition of these ligamentary structures, they are not sufficient tomaintain a good self-bracing, thus keeping the appearance of lesions to a minimum.There is also a need for a good functioning muscular system that maintains the self-bracing mechanism intact.Three muscle slings (chains) are supposed to contribute to force closure of theSI joints: • A longitudinal muscle sling. • A posterior oblique muscle sling. • An anterior oblique muscle sling.The longitudinal muscle sling consists of the combination of the low paravertebralmuscles attaching to the sacrum, the deep layer of the thoracolumbar fascia and thesacrotuberous ligament, which is connected to the long head of the biceps femorismuscle.Tension in this muscle sling will stabilize the SI joint in 3 ways: • Contraction of the low paravertebral muscles will anteriorize the sacrum. This increased the tension on the posterior SI capsule thus leading to more force closure of the SI joints. • Contraction of these muscles will also inflate the thoracolumbar fascia leading to more force closure. • Due to the anatomical relation with the sacrotuberous ligament, the contraction of these muscles will increase tension on the ligament thus increasing the closure of the SI joint. 4
  5. 5. Paravertebral muscles + thoracolumbar fascia Sacrospinous- and sacrotuberal ligs. Biceps femoris m. Longitudinal muscle slingThe posterior oblique sling is the coupled function of the latissimus dorsi muscle andthe gluteus maximus muscle. Both muscles function as synergists. Contraction willdirectly optimize stabilization of the SI joints. 5
  6. 6. Latissimus dorsi m. Gluteus maximus m. Left Right Posterior oblique slingThe anterior oblique sling consists of the external and internal oblique muscles aswell as of the transverse abdominis muscle (connection via rectus sheet).Muscle contraction of this sling also increases the SI stabilization (self-bracingmechanism). External and internal oblique m., transverse abdominis m. Right Left Anterior oblique slingFor example sitting with the legs crossed reduces strongly the tone of the anterioroblique sling. This is because sitting with crossed legs increases mechanically the SIcompression and friction. Reducing this muscle tone diminishes this compressionand friction.A good stability of pelvis and hips means: • Line of gravity between the inferior transverse axis of the SI joint and the acetabula. • Good, harmonious ligamentary tension. 6
  7. 7. • Good harmonious muscular balance. • Correct anatomical angulation of the hip. Secondary load force at S3 Posterior pelvic (ilial) tilt around the hip Anterior sacrum tilt around the ITA Gravity line and weight balance1.2. The HipThe capsular thickenings form a spiral around the hip. In extension these fibresbecome taut with the result that the head of the femur is held securely in theacetabulum and the joint becomes "locked" or "close-packed" - the position ofmaximum stability and firmness for the hip.All the major joints (hip, knee, ankle) become close-packed at full extension and thiscoincides with the limb becoming a rigid, vertical, weight-bearing pillar. This is clearlythe essential prerequisite for standing upright on two legs i.e. the adoption of bipedalstance.When standing erect the centre of gravity passes behind the hip joint. This shouldresult in hyperextension at the hip. It is especially the iliofemoral lig. that withstandsthis extension. 7
  8. 8. Iliofemoral lig. withstanding extension in standing position1.3. Leg Length DifferenceIf there is an anatomical leg length difference, the left and right ligamentary tension isdifferent. Although the body can compensate, this anatomical leg length differencewill reduce the stability and mechanical resistance to avoid lesions.Not every leg length difference however is anatomical. A pelvic torsion can cause anapparent leg length difference.Importance of hip- and pelvic stability: they are the basis for the core stability.2. Core StabilityCore stability means the ability of the lumbo-pelvic-hip complex to prevent buckling ofthe vertebral column and to return it to equilibrium following perturbation.Coordination and co-contraction of muscles provide spine stiffness. In other words “itis the ability to control the position and motion of the trunk over the pelvis to allowoptimum production, transfer and control of force and motion to the terminal segmentin integrated kinetic chain activities”. (Kibler et al 2006)Core stability can also be described as the possibility to continually andinstantaneous adapt to changing postures and loading conditions. It ensures theintegrity of the spine and provides a stable base for the movements of theextremities. The core also absorbs forces transmitted through the lower extremityduring activity.The hip and the lower extremity can be seen as mobile structures but the mobility ofextremity movements depends on the core activity. Core muscles are active beforethe initiation of extremity movements. “Proximal stability before distal mobility”. 8
  9. 9. “Core stability may provide several benefits to the musculoskeletal system, frommaintaining low back health to preventing knee injury” (Willson et al 2005).Core stability in practice: 1. Lumbo-pelvic-hip complex: good symmetrical mobility and local hip and pelvic stability. 2. Good muscular balance (in length, tone and strength) in the three planes: a. In the sagittal plane: i. Rectus abdominis m. ii. Transverse abdominis m. iii. Erector spinae m. iv. Multifidus m. v. Gluteus max. m. vi. Hamstrings. vii. Co-contraction of these muscles causes trunk stiffness, raises the intra-abdominal pressure and provides a stable core. b. In the frontal plane: i. Glut med., glut min. m. ii. Quadratus lumborum m. iii. Hip adductors. c. In the transverse plane: i. Hip rotators. ii. Trunk rotators 3. Stabilizing corset effect of the thoracolumbar fascia. Abdominals 9
  10. 10. Quadratus lumborum m. Erector trunci Transverse Gluteus med. & abdominis m. min. m. Rectus abdominis Gluteus max. m. Adductors Hamstrings In the sagittal plane In the frontal plane Obliquus internus and externus Hip rotators In the horizontal planeA poor core function/stability can be caused by: • Lesion in the hip, pelvic and low lumbar joints. • Muscular weakness and/or disbalance. • Poor muscular endurance. • Fatigue. • Pain/injury – avoidance.When during activity, the muscles cannot stabilize the spine, pelvis and hips (core),the patient will be vulnerable for injury. 10
  11. 11. To illustrate this: it is recently found that patients with paravertebral musculardysfunction show increased quadriceps inhibition. (Hart et al 2005).The osteopath therefore will always evaluate the patients’ core stability by: • Testing the hip, pelvis and low lumbar joints for harmonious mobility. • Testing for equal capsuloligamentary tension. • Testing the muscular balance in the three planes (on length, tone and strength).3. BibliographyByrne D.P., Mulhall K.J. & Baker J.F. (2010) Anatomy & Biomechanics of the Hip.The Open Sports Medicine Journal, Vol. 4, pp. 51-57.Campbell J.D., Higgs R., Wright K. & Leaver-Dunn D. (2001) Pelvis, hip and thighinjuries. In: Schenck R.C., Guskiewicz K.M., Holmes C.F., Eds. Athletic Training andSports Medicine. Rosemount: American Academy of Orthopaedic Surgeons; p. 399.DonTigny R. (1993) Mechanics and Treatment of the Sacroiliac Joint, The Journal ofManual and Manipulative Therapy. Vol.1, No. 1, pp. 3-12.DonTigny R.L. (1994) Function of the Lumbosacroiliac complex as a self-compensating force couple with a variable, force-depending transverse axis: Atheoretical analysis. The Journal of Manual dz Manipulative Therapy 2: 87-93.DonTigny R.L. (2005) Critical analysis of the functional dynamics of the sacroiliacjoints as they pertain to normal gait. J of Orthopaedic Medicine (UK) 27:3-10.DonTigny R.L. (2007) A detailed and critical biomechanical analysis of the sacroiliacjoints and relevant kinesiology. The implications for lumbopelvic function anddysfunction. In Vleeming A, Mooney V, and Stoeckart R (eds): Movement, Stability &Lumbopelvic Pain: Integration of Research and Therapy. Churchill Livingstone, 2edition, Chapter 18, pp 265-278.Gracovetsky S. (2007) Stability or controlled instability? In Vleeming A, Mooney V,and Stoeckart R (eds): Movement, Stability & Lumbopelvic Pain: Integration ofResearch and Therapy. Churchill Livingstone, 2 edition, Chapter 19, pp 278-294.Hart D.L., Stobbe T.J., Till C.W. & Plummer R.W. (2005) Effect of Trunc Stabilizationon Quadriceps Muscle Torque. West Virginia University, Morgastown.Hart J.M., Kerrigan D.C., Fritz J.M., Saliba E.N., Gansneder B. & Ingersoll C.D.(2005) Contribution of Hamstrings fatigue to quadriceps inhibition following lumbarextension exercise. Journal of Sports Science and Medicine (2006) 5, 70-79.Kibler W.B., Press J., & Sciascia A. (2006) The role of core stability in athleticfunction. Sports Med, 2006. 36(3): 189-198. 11
  12. 12. Lee D. et Vleeming A. (2004) The management of pelvic joint pain & dysfunction.Chapter 34 in Grieves Modern Manual Therapy: The vertebral column. ChurchillLivingstone, Edinburgh. P. 495-506.Leetun D.T., Ireland M.L., Willson J.D., Ballantyne B.T., & Davis I.M. (2004) Corestability measures as risk factors for lower extremity injury in athletes. Med Sci SportsExerc. 36(6): 926-934.Peeters L. & Lason G. (2005) Integratie en toegepaste principes in de Osteopathie –Osteo 2000. (Ed.).Vleeming A. et al (1990) Relation between Form and Function in the Sacroiliac JointPart I & Part II Spine 15(2): pp. 30–135.Vleeming A., van Wingerden J.P., & Dijkstra P.F. (1992) Mobility in the sacroiliacjoints in the elderly: a kinematic and radiological study. Clin Biomech;7:170–176.Vleeming A., Mooney V., Dorman T., Snijders, Stoeckart R. (1995) The Function ofthe Lumbar Spine and Sacroiliac Joint Part I and II. Rotterdam Philips.Vleeming A., Pool-Goudzwaard A., Hammudoghlu D., Stoeckart R., Snijders C. &mens J.M.A. (1996) The Function of the Long Dorsal Sacroiliac Ligament. Itsimplication for Understanding Low Back Pain. Spine. Volume 21. Number 5. pp. 556-562.Vleeming A., Mooney V., Dorman T., Snijders C. & Stoeckart R., (1997) MovementStability and Low Back Pain. The Essential Role of the Pelvis. Edinburgh, ChurchillLivingstone.Vleeming A., de Vries J.H.J., Mens J.M., & van Wingerden J.P. (2002) Possible roleof the long dorsal sacroiliac ligament in women with peripartum pelvic pain. ActaObstet. Gynecol. Scand. 81(5): 430-436.Willson J.D., Dougherty C.P., Ireland M.L., & Davis I.M. (2005) Core stability and itsrelationship to lower extremity function and injury. J Am Acad Orthop Surg. 13(5):316-325. All rights reserved. © 2012. No part of this article may be reproduced or made public by printing, photocopying, microfilming, or by any means without the prior written permission of the publisher. iNeuro APP iCranialNerves APP 12