Since the pelvis is located in the center of the body, it is affected by forces acting above it, below it, and directly to it. The structure of the pelvic bones serves to handle these forces and displace them as needed for ambulation, stability, erect stature, and functional movement. This is both good and bad. Because the pelvis does all these things, dozens of structures attach or articulate with it. This fact leaves the pelvic bowl susceptible to exceptional dysfunction and injury.
Pelvic Dysfunction & Pain
Many causes and results of pain materialize throughout the pelvic area which myoskeletal massage will resolve or improve. Some of these are:
- Lumbosacral torsion
- Pelvic rotation, tilt
- Sacroiliac dysfunction
- Piriformis syndrome
- Femoral acetabular impingement syndrome
- Lower back pain
- Muscle strain or overuse
- Motor vehicle accident
- Lower crossed syndrome
- Slips and falls
- Sport injuries such as groin pulls
- Sudden axial loading of lower extremity
- Snapping hip syndrome
The pelvis is made up of three separate bones, the left and right innominates, called ilium, and the sacrum. The bones are connected via an intricate web of ligaments, which allows a small degree of mobility between the bones. Problems develop when that amount of mobility increases or decreases significantly from “normal”.
The Sacroiliac Joint
When dysfunction strikes, the bones can jam out of alignment and cause incredible pain. Most commonly, this pain develops at the sacroiliac joint (SIJ). The SIJ is both a synovial and true diarthrodial joint. Its opposing joint surfaces are covered in fibro- and hyaline cartilage and there is a joint space within, full of synovial fluid.
Approximately half the patients with SIJ dysfunction have had a serious event occur such as an automobile accident or a debilitating fall. SIJD happens more often with women, as their pelvises regularly undergo hypermobility during pregnancy.
SI Joint Movement
Even with the built-in joint space, the SI joint is actually so limited in movement that less than 4 degrees of rotation and 1-1/2 mm of translation is normally allowed. Primarily, it is the sacrum that moves against the ilium; not so much the other way round. From a myoskeletal aspect, the sacrum can move in any of six directions. The two most common motions are nutation and counternutation.
Nutation is the movement of the top of the sacrum pushing forward and the bottom pushing backward. Counternutation is the top of the sacrum pushing backward and bottom pushing forward.
Left and right rotation are the next movements of the sacrum. In this case, rotation takes place about the longitudinal axis, the centerline, of the sacrum. In this case, the top lateral edge of one side of the sacrum is what is measured in comparison with the other side. When the right top lateral edge is depressed in relation to the left top lateral edge, the sacrum is right-rotated.
And, finally, there is upslip and downslip. These occur when the ilium on one side shifts vertically, either upward (upslip) or downward (downslip) against the sacrum. For all practical purposes, this shift is a true displacement of the joint. Worse still, because of the topography of the joint surfaces being a series of near-interlocking ridges and valleys, up- and downslips rarely self-correct.
Form closure is the term given to the inherent stability of the sacroiliac joint due to both surfaces each having the ridge-and-valley topography mentioned earlier. When necessary, this joint can self-lock to provide stability for the body in the pelvis.
Apart from the joint at the sacro-ilium junction, there is also a joint where the pelvic bones come together at the pubic arch, called the pubic symphasis. The pubic symphasis is a cartilaginous joint. the two bones are coated with hyaline cartilage and joint held together by fibrocartilage. The joint is allowed approximately 2 mm of shear and about 1 degree of rotation. Movement is allowed for shock absorbancy while walking and, of course, for childbirth in women.
And, finally, the joints of the hips where the heads of the femurs fit into the acetabulum. The hip joint is a true ball and socket synovial joint. Both the head of the femur and acetabulum are coated with hyaline cartilage to allow smooth movement along the surfaces. Movement in this joint allows for 360 degrees of circumduction and 90 degrees of femoral rotation.
Ligaments & Muscles
A vast web of thick ligamentous tissue serves to stabilize the bones of the pelvis. The web serves this purpose by laying fibers of the ligaments in many different directions across and between the sacrum and innominates. Unfortunately, these ligaments serve mainly to limit bone movement away from each other (shear), not against each other (translation). Most often, it is translational movement which causes pain in the joint.
There are many ligaments involved in several areas of the pelvis, including those which stabilize the pelvis to other parts of the axial skeleton. For myoskeletal purposes, here, we’re just going to mention those involved in force closure. The long and short dorsal sacroiliac ligaments, sacrotuberous ligaments, iliolumbar ligaments, deep dorsal sacrococcygeal liagments, interosseous sacroiliac ligaments, sacrospinous ligaments, arcuate pubic ligaments, anterior sacroiliac ligaments, supraspinus ligament, and the lumbosacral ligaments. Some of these are considered accessory ligaments as they do not directly bind down the sacrum.
Many muscles attach directly and indirectly through the fascia and aponeurosis to the pelvis and act upon its joints. Among these are the abdominals; latissiumus dorsi; obliques; quadratus lumborum; multifida; erectors; gluteals; piriformis, the pelvic floor: quadratus femoris, obturators internus and externus, superior and inferior gemellus, and levator ani; the hamstrings: biceps femoris, semi-membranosis and semi-tendinosis; tensor facia lata; sartorius; adductors: gracilis, pectineus, adductor longus; and rectus femoris. The piriformis muscle is the only muscle that attaches directly onto the sacrum, and is the primary instigator in butt muscle pain.
Force closure is the term given to contractile stability of the joint by the fascia, muscle, and ligament that attach to and/or bind down the joint. Force closure is necessary while walking and one-sided loading of the lower extremities.
Myoskeletal Massage for Pelvis
Read more about myoskeletal massage here.
Myoskeletal massage is a series of protocols used to align the pelvis, sacrum, and coccyx bones to alleviate muscle dysfunction. During the course of these protocols, the patient is assessed to determine the proper alignment of pelvic bones in relation to each other and to judge the soft tissues acting on the pelvis. Dysfunctional soft tissue is then checked for inhibition and facilitation. Facilitated tissue is released and muscle spindle techniques are used on inhibited tissue to rebalance the pelvis.
These protocols may take several sessions to complete the process or it may take a much shorter time, depending on the severity of patient’s symptoms and determination of tissue and bones during the assessment.
Remedial Massage for Pelvis
Read more about remedial massage here.
When the bones of the pelvis are not yet affected in pelvic pain, Manchester-Bedford Myoskeletal‘s remedial massage protocols will be used to resolve soft tissue dysfunction. As with myoskeletal massage, a number of sessions will likely be needed to fully resolve dysfunction, particularly if cause is difficult to narrow down or if injury was significant.