Pelvic Locomotor Dysfunction: A Clinical Approach

Copyrighted Material

I A Clinical

�LU�"T'"·.o

'Proach

G. DeFranca, DC

Director Boylston Chiropractic Office Boylston, Massachusetts

with J. Levine, DC Director Center For Neck and Back Pain l\1.assachusetts

J-JU�'''''''''

AN

Copyrighted Material

Library of Congress Cataloging-in-Publication Data

DeFranca, George G. Pelvic locomotor dysfunction: a clinical approach/ George G. DeFranca, with Linda J. Levine. p.

cm.

Includes bibliographical references and index. ISBN 0-8342-0756-7

1. Pelvis-Diseases-Chiropractic treatment. 1. Levine, Linda J. TI. Title. [DNLM: 1. Joints-injuries. 2. Lumbosacral Region-injuries. 3. Movement Disorders-physiopathology. 4. Pelvic Pain-physiopathology. 5. Joints-injuries-case studies. 6. Pelvic Pain-rehabilitation-case studies. WE 750 D316p 1996] RZ265.J64D44 1996 617.5'5-dc20 DNLM/DLC for Library of Congress 95-47220 ClP Copyright © 1996 by Aspen Publishers, Inc. Al! rights reserved.

Aspen Publishers, Inc., grants permission for photocopying for limited personal or internal use. This consent does not extend to other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale. For information, address Aspen Publishers, Inc., Permissions Department, 200 Orchard Ridge Drive, Suite 200, Gaithersburg, Maryland 20878.

The authors have made every effort to ensure the accuracy of the infonnation herein. However, appropriate information sources should be consulted, especially for new or unfamiliar procedures. It is the responsibility of every practitioner to evaluate the ap­ propriateness of a particular opinion in the context of actual clinical situations and with due consideration to new developments. The authors, editors, and the publisher calmo! be held responsible for any typographical or other errors found in this book.

Editorial Resources: Jane Colilla Library of Congress Catalog Card Number: 95-47220 ISBN: 0-8342-0756-7

Printed in the United States of America 1

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2

3

4

5

I dedicate this book to my three beautiful and Jes­ me to look curiosity. I hope this

reminds them

of the many values that I have including perseverance, honesty, self sacrifice, and

It is my wish that

they will grow to

these same val-

ues in their own lives .

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ble of Contents

Foreword .... ... ... .. ... ... .. ... .. ... .. ... .. .. . .. ..... .. .. .

ix

Preface ....................................................

xi

Acknowledgments

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Introduction ........................ ...................... Chapter

xv

xvii 1

1 8 21

Articular Innervation . .. . . . .. .. . .. .. . .. ..... .. ..

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Topographical

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Anomalies and Variants ...............

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2-Func tion

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PubicSymphysis ... . .... . . . .. . . . ...... .. . . . ....

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HipJoint . ... . ....... ..... . . . .... . ... . .........

69

Standing Posture and

..... ........ .

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Motions During Gait .. .. . .. . .... . . . ...... .......

75

Sacroiliac Joint .. . ... ..... ...

Sacral Motion with Respiration ...................

76

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76

Lif tin g Mechanics . . ....... ..... .. .. . ..........

79

Literature Review of Pelvic

81

Menstrual and Pregnancy-Induced

Motion. . . ... ....

v

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vi

PELVIC LOCOMOTOR DYSFUNCTION

Chapter

3-Clinical Assessment: The

... ........ .....

89

Case Histories .. . .... .. , ,. ." .. , .... , ........ ,

90 98 99

Linda J. Levine and George G. DeFranca .

Listen! .. .... ..... .....

The

,..... ... the History ....

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l<:>;;:irl('\""

in Mind

To

Clues in the

to the

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,

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"

of Tissues .. ,.

Diagnosis. Conclusion .,.. ,

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119 129

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Chapter 4--Clinical Assessment: General Considerations ....

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VertebralSubluxation The "Five Nevers" .. . . .

Lumbar Versus Pelvis

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Irritability. .. . .... . ..... ...... ... ... ... .

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of Motion ............................... ....................

PlayfJoint Signs .....

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.. . ... .

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...... ... . ..........

"

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Join t Compression with Passive Testing . . . .. . .. .

Selective Tissue Tension "

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andSkin Length-Strength and Movement Patterns .....

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Inequality............... . . ... . . ... ,

Chapter

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5-Examination ...................................

Standing .........

Prone ....... .

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Radiographs ... . .......... ... . .. . . . .... .

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ErythrocyteSedimentation Rate ......... .. ..... . Chapter

6-Mobilization .................. ................

General Considerations ...... . ,

Mobilization Facilitation Mobilization

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133

134 135 136 136 136 138 139 140 141 143 145 146 147 153 162

163 190 196 217 224 242 243 247

247 248 251 251

Table

vii

7-Manipulation .................................

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291

What Happens When a

292

Is

Grade VI Mobilization ..... .... . ............. .

296

What About the Audible "Crack"? .. ......... . .

297

Slack Removal .................................

298

Contraindications ............ .................

300

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SacroiliacJoint Manipulative

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Joint Manipulation......................... .

8-Inflammation, the Soft

302 313

and General

Treatment Considerations ...................

Inflammation and

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323

........................

324

Tissues...............

326

TissueStructure and Function. ...................

327

Treatment .............

336

Conclusion .......... . ............ ...........

340

Immobilization and Clinical Considerations

.

Chapter

290

What Characterizes a Manipulable Lesion? ........

9-Treatment of Structures

yoras,cUll and Soft Tissue .

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Treatment of

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PainSyndromes.........

Treatment of Tendon and

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344 344

Lesions........

376

Shortened Muscles ............

380

Miscellaneous Conditions .......................

387

Conclusion ........ ... .... ... ..............

393

Treatment of

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Chapter IO-Clinical Considerations ........................

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Treatment

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Abnormal Movement Patterns and Treatment ..... .

395 396 402

(Chains) ................

404

Lesions ........... ...

406 409 409 411

Somatovisceral Reactions ....................... .

415

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417

Prevention. ... . ..... ... .. . . . .... ... .. ..

418

or "Flat-Back" Syndrome. . . . ... .

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viii

PELVlC LOCOMOTOR DYSFUNCTION

Chapter ll-Stretching and Exercise

422

Linda f. Levine

General Aspects of

422 424

Passive '"'....�+,. ... Range-of-Motion

..

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..

Exercises ..... ..... ............. Frrw'\T'lro('t>r,tnrp

Exercises. . ... . ... ..

447

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MiscellaneousStretches ........................ Appendix A-Case Follow-Ups ............. ................ Index

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464 464 467 489

Foreword

A Clinical Approach

Pelvic Locomotor

is the first text solely

dedicated to joint and muscle dysfunctions of the pelvic and Dr DeFranca should be commended for compiling such a rAtr"",h highly readable, and easily understood book. In addition, he has written that does not overwhelm the reader

with a

substance of this very important

maintains the

The

clinical assessment and UH.".'''. cussed and fully referenced. The and function and

part of the

discusses anatomy

the groundwork for the clinically oriented second on exercise is very apro-

Dr Levine's

half of the book. In pos in the discussion of

these disorders and

information in this regard. Dr DeFranca's style of writing instills interest and excitement to any nr:�rt,hi-'n"r

involved with treating these conditions and his book is a prac­ illustrations used bring

tical contribution to the reader's library. The

the material more fully to life and enhance understanding of the various concepts presented. This book fully

U"�'\..L":>"<:;",

iliac joint movement,

years of

writing and

also raises the consciousness of the reader to the key role that sacroiliac dysfunctions play in lower back and leg pain SVIldrorrtes.

and hip

joint

Anyone who has

and has

the rela­

relief afforded to and ogy. As this dysfunctions,

pain knows that the sacroiliac

is a common etiol-

brings to light the importance of pelvic and world-renowned back pain

cuss this population of

at their conferences.

ix

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joint

will soon dis-

X

PELVIC LOCOMOTOR DYSFUNCTION

Fin ally,

'-'<::'.1(;".1;:><.",

chiropractic and

and students can go to this "sure to be-

practitioners, come" classic on the

and hip joint

how to help the millions of

this book so aptly describes .

and learn

-Leonard "John" Faye, DC, FCCSS (C) Hon

Copyrighted Material

Preface

Sit down before fact as a child. Be conceived notion . Follow humbly you will learn nothing. -Thomas Huxley 17 years ago, I was abruptly in troduced to

considerable low back and leg pain . Little

I know then that this chance

encounter would change the direction of my life . I was ferent diagnoses by practitioners of

several difMost of them finding of

a great deal of concern and attention on the an L-5 spondylolisthesis that I

joint

that caused me to suffer

thanks to a wrenching football

In

my

My treatment was

workup was at best . All I knew

was that I was unable to play After 3 months of pain, my

went to a chiropractic doctor at the insistence

was identified and corrected

carne to know as sacroiliac Dr Herman Cohen of

I was amazed at my rapid

New

recovery and ability to return to

while thankful for what seemed a

fortuitous meeting with a man who understood Why was it by chance that I

the

joint dysfunction.

treatment? What about the

L-5 spondylolisthesis, I should cause some pain .

did the bed rest, hot packs, medications,

and exercises I was told to do fail? What about other people with similar problems experiencing similar results missed by numerous others formed the basis for my

failure? Why was my problem

whom I sought help? These questions this book . The book's purpose is to draw

xi

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xii

PEL VIC LOCOMOTOR DYSFUNCTION

and to cause

area

the body and its

pain: functional disturbances of the pelvic joints

and muscles. in the musculoskel-

It seems ironic that structures so etal

as the

as to

joints would receive such little pain and disturbances of the locomotor

their importance in

B eing placed between the

to

and trunk, they must

and locomotion. The

most

,... """".•.

insert near them. The extreme support they necessitate.

daily are evidenced by the powerful

Surely the potential for injury and dysfunction is and its role in the

of pelvic joint

Yet the

of back pain are too often overlooked.

functional examinaTo the detriment of the

tion of these most important structures is

patient subject to clinical bias and unawareness, a ease, lumbar facet

of disc dis-

arthritis, muscle spasm, or even stress is

ten bestowed. As a result,

re-

hot moist

peated lumbar

and bed rest continue to no

avail and will persist in doing so until other possibilities are entertained. Other possibilities should include the examination and treatment of funcand their related structures. The aim of

tional disorders of the pelvic this book is to

to the more common disorders

related to this area. By functional ri"clwd'orc

to disorders in which the anatomi-

cal

devoid of pathological

but

the tasks for which they are or trauma, the

whatever reason, be it use,

For

function poorly.

Pelvic joint dysfunction pertains to loss of normal function due to a lack of mechanical play within the joint in The term pelvic joints

to

two sacroiliac joints, the

physis joint, and the

joint. The sacroiliac

have received more attention tion and the role they attention in this book. The

much controversy

in back pain.

loskeletal

they are

more

joints are included in this discussion due to with the pelvic

their biomechanical since no joint is an

H::I"alULlll".

In addition,

from the rest of the muscu-

entity

the related soft tissue structures and their assessment

are also considered. At the risk of """"HULl'1'- too restrictive in

I have limited this work to

This is not to exclude the importance of nor is it to foster a reductionistic

Copyrighted Material

xiii

the clinical

thinking. It is

and

in back

the pelvic

The

of

and hip joint, amphiarthro­

and the sacrococcygeal and symphysis pubis joints, dial, react the same way to use,

dysfunction, and pathology as do This

similar structures found elsewhere in the musculoskeletal holds true for

ligamentous, and other tissues fotmd in the trigger

region. functions found in the

will

and joint similar to those found in the same

the knee or shoulder. the common clinical

that affect the pel-

functional locomotor disturbances. Accordingly,

vic

are discussed at length, with less attention

joint and muscle

given to the less commonly seen discuss

The first nvo

and function of the Chapter 3

with clinical comments interspersed where focuses on the clinical

followed by a discussion on general 4 and 5 re-

of assessment and the examination process in 6 and 7 are concerned with a variety of manual

were written to em-

Two

used to h'eat �

��

tissue structures, as well as the clinical considerations of their treatment, are

8.

9 discusses the

by myofascial

treatment of the soft tissue friction

for muscle

shortening. Chapter 10 discusses various clinical observations associated with vic locomotor disturbances. It is followed by Dr Linda Levine's chapter on and exercises. an

is included to illustrate

tions and their management.

Copyrighted Material

clinical

Acknowledgments

me in the

for

deserve more credit than is provided by the mere mention of father,

names. I am greatly indebted to my me

because it was his influence that career; to Marie

the wonder-

for allowing me the freedom to undertake this

my

endeavor and for the support and understanding that I needed to work on this

and to the late

McM

MD, whose

and

input aided greatly in the initial phases of this book. I am

for her

indebted to Linda J. and

hours of honest the contributions she has

and in addition to

to this book. I am also indebted to Len

whose teachings have influenced me and my clinical reasoning on a profound level; to my sister Carol DeFranca, DC, DABCO, for her artistic touch and

I am forever in

loving

and to my sister Diann

who was instrumental in much

script typing and conversion to

disks.

I am most thankful to my Dubovick,

Wheeler, and Kristal

their much

and tolerance of

ways,

which afforded me an environment in

in which I

work Mike

I would like to thank DC, for his photography and

Gorman, DC, for his patience in

holding the various positions until we got them Viteritti,

for his

that the

of

be

and ma­ to elucidate the often

Hc,,"'.nrac

between

and I thank Dominick Fiore, DC,

for providing me with references concerning

xv

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5.

Introduction

At the tum of the centu.ry, the sacroiliac joints were considered a common source of low back Barr's milestone

on

touched off the era

the

and even sciatica.1,2 However, Mixter and low back and leg

discs II

disc theory" as the cause of low back

Hence, medical interest was diverted away from the sacroiliac Unfortunately,

to it was diminished.

and attention

cause of low back

a similar reputation of clinical

sacroiliac joint

with the proximal tibiofibular and acromioclavicular For a long time it was held that sacroiliac joint movement was negligible, if and that whatever movement was there was insignificant. It was of muscles directly and actively moved the

thought that no one How could a

that did not move be of

let alone

one whose function was not directly affected by any set group of muscles? Yet the sacroiliac joint does move, and there are muscles that either directly or piriformis,

Clinical interest is shifting back to

pelvic

ders are a common occurrence in clinical and

the

that can influence the joint. What about muscles? maximus, and

pain. Low back and

pain are

"... ,.".-1-•.-" ....v,""'''v.

however, sacroiliac joint

bar radicular

mon cause of low back,

and proximal n""�""rir\r thigh

is loosely called

sciatica." It is actually a misnomer, since the sciatic

nerve is not

and

to the site of pain distribu-

tion. Focus needs to be shifted away causes of low back many

the less common, although more From their

with low back and leg

of tending to

syndromes, Bourdillion and

Day state: "The sacroiliac joint appears to be the

xvii

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greatest cause of

xviii

PE LVIC LOCOMOTOR DYSFUNCTION

back

of motion is small and difficult to describe but, when pain can be precipitated."�(p229)

normal joint

is lost,

Although the prevalence for sacroiliac joint dysfunction in the general population is not known, many authorities rence. Of the last 100

its common occur-

seen for low back

36 were

in my own

treated for sacroiliac joint

tion. Bernard and Kirkaldy-Willis5 found sacroiliac joint lesions to be the etiologic factor in 23% of over 1200 patients in a chronic low back pain clinic. Barbor6 and Bourne7 have conducted studies are the cause of low back

iliac

that sacro-

50% to 70% of the time. chil-

dysftmction is often found in

Sacroiliac and

prolonged sitting posture encountered in school.

dren. This is due to

Low back pain in children is more common than is are often

attributable to

and leg off as

the body would we are

as

The same pains that are called

pains" in children are called ''I'm getting old" pains in adults. Mierau et studied the children between

ofsacroiliac

hypomobility in 403 school-aged

6 to 17 years, and "a high of association was found and LBP."8(p83) Those (ages

joint dysfunction constituted 29.9% of the 6 to

and 41.5% of the secondary schoolchildren (ages 12 to 17). When

asked about a history of low back 26.3% of the entire student body ::: 403) positively for prior occurrence. 83.1% of those

with a

of low back

were found to have sacro-

iliac joint Sacroiliac joint involvement in ankylosing psoriatic

and

Reiter's syn-

bowel disease is well

these processes are associated with actual tissue ogy

although not rare, are seen less often than the

dysftmctions discussed in this text. The reader is works on the

and muscle to more com-

This does not relieve us of the obligation to be as well as other

aware of and rule out such

the aim is to shift our focus of attention to functional disturbances of the structures. Bear in mind that pathologies can masquerade as joint and muscle dysfunctions and need to be differentially diagnosed. Pelvic

dysfunction, particularly sacroiliac joint

exacerbate lumbosacral

rr"�O'<>n

of an L-5 transverse process with the ilium or sacral ala. Attention is usu­ ally

to the anomaly, and patients are made to feel as if they will

,,,,,.,,,,,,,,. have a "bad" back because

were born with a "defect." In actu-

Copyrighted Material

Introduction

ality, the body has been

xix

happily with the anomaly for

considers it a normal part of the anatomy. Sacroiliac joint dysfunction can force

at the anomaly, which, as in any other joint, and inflammation. Sacroiliac joint

may react with

the irritated anomaly calms down, and har-

lation is usually

mony is restored. At times the anomalous joint itself becomes dysfunctional and needs to be manipulated. It is also

pelvic

that

lower back

that is often attributed to sacroiliac

owing to the

that occur within the

themselves.<J.-13 This is an

What is the basis of one's assessment of the locomotor to consider because the correctness of the

important

in the assessment

rests upon its answer. A fundamental tional disturbances of the locomotor

func-

is to appraise the cardinal

function of the tissues in question. The locomotor

mov-

is a

dynamic structure that needs to be examined as such. Anatomical tomography, magnetic resonance

studies (X-ray,

are important and useful; but they lack the ability to yield information regarding the functional integrity of the locomotor

We are not

with bones that simply" go out of

some treat-

ment to "put them back in place" Unfortunately, 90% of the time and

in dealing with the clinical

investigation of lower back pain is spent looking for conditions that acAn examination of the

count for 10% of the extreme pain, even

to

in

conservative treatments,

usually reveals negative neurologic and orthopedic findings. Add to this X-ray, computerized tomography,

resonance

and you have a very tion does not daily with the fact

mess. This situa-

clinician who

in the trenches

battle of lower back

90% of the problem when

The

with lower back

is one of

to overt structural disease or pathology.

aberrant function as

when confronted

in

How many clinicians scratch their

with a patient who suffers from severe low back pain yet exhibits negative Again, one needs to

findings on clinical

"What is the

basis of assessment?" Are we matching the basis of our assessment with the

of the part in

tion to move through

For

and joint play

joints of motion. The

testing of their ability to move correctly through these parameters is there­ fore

to diagnosis and effective treatment. How can this funcstatus be surmised from

or

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resonance

PELVIC LOCOMOTOR DYSFUNCTION

XX

to fall

A

states

The first incorrect

to two incorrect

that if all "high-tech" testing is negative for a particular problem, then the does not exist. Unfortunately, most high-tech testing, being better is poorly suited

able to detect structural pathology and advanced to reveal the more

seen problems of

Conseare

quently, patients with functional disturbances of the locomotor

told that their test results are negative and that nothing is wrong. As a are left to fend for themselves and hope their away. It usually does not, and they find themselves

will

to

methods of treatment or even psychotherapy. The second incorrect assumption is that if a defect is visualized on highresolution

tomography or

such as then it must be

As stated

source of

for

of

function. Second, false-positive results are common with these dures. In a study conducted by Weisel et aI, 35% of an asymptomatic paresults

had their

tient

had no in 52% and disc

of asymptomatic

They sug-

with low back pain may be coinciden-

that tal. X-ray

correlate poorly with the

tients. Patients who are in the most perfectly good-looking X-rays. radiologically is that

In

touched, and

what

Living patients or

magnetic resonance im-

on how we live in modern

us

that we often suffer from to the in some cases level surfaces amounts of

little variation in contour,

tive opportunities for the mobile foot to exercise itself. Many of us fail to partake in the locomotor

active

forfeiting the benefits

from mov-

cardiovascular and pulmonary

Copyrighted Material

Introduction

enough

tend to eat foods that in some cases seem

functions.

partake in even a mini-

to sustain Hfe, let alone health. Most mal amount of

exercises

tissues and to loosen

joints. If one observes the animal

becomes

to

apparent that after

to stretch its

taut, shortened it

down, an animal will arise by the way, in exten-

and limbs

to much

sion. If all this is not enough, we subject "J""'F.''"'U'

xxi

and

has

stress, which

soma and psyche. of traumas that

we expose ourselves to a

Throughout our

these do not heal to full func-

contribute to locomotor disturbances. tional capacity. Consequently, yesterday's

especially if improp-

diagnosed and treated, become the morrow in the

and to-

legacies

and

joint

of

trigger all this abuse from with an efficient

tern,

nervous

<.:,,,"rPlrTI

and again to maintain order. Unfortunately, the or to

either to

The result is excessive or inadequate

reE,pc,nses, with functional abnormalities ated for months, if not years. For tight

perpetu-

a muscle that is shortened and

injury may reciprocally inhibit its

creating an imbal-

ance of tension across the articulation they affect.

imbalance can exist

for years, creating further adaptive or maladaptive responses, all mediUnfortunately, this adaptive process contin-

ated by the nervous ues long after the

inherent problem in just

a patient's

problems of dysfunction. tion and

and ignoring the under-

from most musculoskeletal con-

low back pain,

ditions,

This is the

from the initial trauma has

But although the inflammahas been

may have subsided, the insult to the

neurologically

to be

other inflammatory

contribute to dysfunction and a greater pos-

of recurrence.

again. Soft tissue fibrosis and

in addition to

signs of inflammawill aid

and

the

parts linked through kinematic in physiologic as well as

need to mainof compen-

tain

The

reactions

pelvic ring, with its articulations and related soft tissues, lends itself

Copyrighted Material

xxii

PELVIC LOCOMOTOR DYSFUNCTION

to such reactions. the

between the trunk and lower readily to their constant dynamic

must

or else manifest itself in dysfunction. As such, the pelvis can be the site of painful

reactions from distant or local

Hans. For

particularly

joint

joint, can be

silent in

foster

sacroiliac

joint dishlrbances due to compensatory mechanisms. Just as often, pri­ can be painful or silent and cause symptomatic

sacroiliac or hip joints. Remarkable as it

to

in

hypermobile lumbar facet

to have a

it is common

elsewhere. For

to

sound, it is not uncommon

for the midthoracic or upper cervical

painfully for a

to

pelvis. Treatment directed solely at the painful area often misses the mark. Local lesions do not remain isolated islands of biomewhen

causing the clinician to be led

to the muscu­ "cries of wolf" via painful secondary reac­ tions commonly results in misdirected therapy. An appreciation should be for the body's

and therefore to hurt some-

to

where other than the

lesion's site. One must pay astute attention

to the "whispered"

of the locomotor

for they are com-

municated to the aware and observant clinician in the form of subtle soft minute

tissue

''-LlVH''' '

yet they confound those

movements, and reflex

"shouts" of direction.

enced hands that blunder

a hurried examination mind closed to or ignorant to conclude that nothing is

can wrong, that a lesion

not exist, or worse, that the

is in need of

psychological counseling. Some practitioners employing manual methods cling to outdated to which manipulation simply

"bone-out-of-place" bones back into

the often-touted examination

of a posterior innominate bone is used as an indication to late the innominate back into what is thought to be a normal position. Yet in this author's

to be sure, in the

of countless

corrections based on abnormal bony suIt in the

of the bony

innominate remains posterior and probably will if that is where it needs to be for that

Symmetry is not the rule in human structure. Bony

Copyrighted Material

Introduction

are

�

m

differ in size

iliac

from side to side. Posterior and are often difficult to

accurately. On the other hand, one cannot just because

�discrim�ately manipulate

are restricted or fixis create a

ated and feel that all one has to do to achieve health � a pop that frees up a restricted

Some people exist very nicely even and muscle

they harbor asymptomatic for a place to

like an accident

that are

n"""f"',t>"

than to

Manual treatment is more analogous to ing" a

a

or

muscle. The nervous system is the of the com-

mediator of function. Prudent assessment and V".,A"A�J

"crack-

There is much more �volved than

mechanical

of the neuromusculoskeletal

both known and

xxiii

and the confusing ways,

in which it manifests dysfunction are needed.

With clinical consciousness shifting toward the examination and treatment of

and with studiesl6-21 now demonstrating the value of

joint

in low back

patients,

the

nec-

essary to assess functional disturbances will become

REFERENCES articulations from an anatomi­

RBA, A consideration of the cal,

Boston Med

f. 1905;152:592-634,

2, Abel AL Sacroiliac strain. Br Med f. 1939;1:683-686. of the intervertebral disc N Engl J Met!, 1934;211:210-213.

3, Mixter WI, Barr JS, 4. Bourdillion JF, Day EA.

& Lange;

Manipt/lation. 4th ed. Norwalk, Conn:

1987. 5. Bernard T,

W,

low

characteristics of

l't:'"IJ��!U/Oll

back pain. Clin Ort/wp. 1987;217:266-280. 6. Barbor R Back

Br Met! f. 1978;2:566.

7. Bourne IHJ. Back

what can we offer. Br Med /.1979;1:1085,

Mierau DR, Cassidy JD, Hamin T, et aL Sacroiliac school aged children, 9. Fast A,

J

dysfunction and low back pain in

Ther. 1984; 7:81-84.

D, Ducommun EJ, et aL Low back pain in pregnancy.

1987;12:368-

371. 10, Davis P, Lentie Be Evidence for sacroiliac disease as a common cause of low backache in women. Lancet. 1978;2:496-497. 11. Fraser DM,

backache: a

condition? Can Fam

1976;22:76-78. Sandoz RW, Structural and functional pal:holog;ies of the

Assoc. 1981;7:101-160.

Copyrighted Material

Ann Swiss Chiro

xxiv

PELVIC LOCOMOTOR DYSFUNCTION

J. Relaxation of the

13.

of pregnancy.

joints in pregnancy:

,Obstel Cynaecol Br Empire. 1940;47:493-524. 14. Weisel SW, Tsounnas N, Feffer HL, et aL A study of

incidence of

CAT scans in an

tomography: the group of patients.

1984;9:549-

55t 15. lensel MC, Brant-Zawadzki MN, Obuchowski N, et al.

the lumbar

resonance

of

in people without back pain. New Engl J Med. 1994;331:69. of vertebral manipulation and conventional

16. Nwuga VCB. Relative

treatment in back pain management Am J Phys Med. 1982;61:273-278. 17. Kirkaldy-Willis W,

JD. Spinal

in the treatment of low back

Can Fam Physician. 1985;31:535-540. S, Browne W, et al. Low back

18. Meade TW,

comparison

of mechanical

chiropractic and hospital outpatient treatment. Br Med

randomized 1990;300:1431-

1437. 19. Shekelle PC, Adams AH, Chassin MR, et at The Appropriateness of Spinal ManiplI/ation for

Low Back Pain: Indications and

an All-Chiropractic

Panel. Santa Monica,

Calif: Rand; 1992. 20. Manga P, Angus D, et al. The r.merf17WrW" and Cost-Effectiveness ofChiropractic Management

of Low Back Pain. Ottawa,

Pran

and Associates, University of Ottawa;

1993. 21. Triano

J], lVll;,-"el<.Jl

therapy versus educa-

Copyrighted Material

Chapter 1

Anatomy

Chapter Objectives •

to describe the osseous, muscular, and articular anatomy of the pelvic and hip regions

•

to discuss the importance of the thoracolumbar fascia

•

to discuss topographical landmarks for palpation

•

to discuss common musculoskeletal congenital anomalies of the pelvic region

The anatomy of the pelvis is both interesting and complex. The word

pelvis means "basin" in Latin, and the name is appropriate, for the pelvis

resembles a hollow container bearing viscera and allowing the ingress and egress of neurovascular and muscular structures.

OSSEOUS ANATOMY The osseous pelvis consists of three articulating structures forming a

three-joint complex. The sacrum, a triangular-shaped bone, is wedged be­ tween the posterior aspects of the paired innominates at the sacroiliac joints (Figures 1-1 and 1-2). The innominates meet anteriorly at the pubic symphysis, an amphiarthrosis, to complete the three-joint complex. The sacrum articulates with the L-5 vertebra above and the coccyx below .1

Sacrum The sacrum is usually made up of five fused segments that retain vesti­ gial remains of vertebral elements (Figure 1-3). It is widest at its base, and its uppermost surface articulates with L-5. The anterior aspect of the sacral

1 Copyrighted Material

2

PELVIC LOCOMOTOR DYSFUNCTION

Sacroiliac Joints

Iliac

r,

/

�, y

\ '\

\

Anterior Superior Iliac Spine (ASIS)

Symphysis Pubis

Figure 1-1

--J-�4----�!I]i

_ _

Anterior Aspect of the Pelvis Posterior Superior Iliac Spine (PSIS)

-.---��----4- Sacrum

Coccyx

Figure 1-2

Posterior Aspect of the Pelvis

Copyrighted Material

Anatomy

3

Superior --------A Articular Facet Sacral Ala Sacral

---Ep::-:"i-�� -

__

Promontory

Transverse Ridge

L---7-_

Anterior Sacral Foramina

Figure 1-3 Anterior Aspect of the Sacrum

base is very pronounced and is called the sacral promontory. The ventral surface is marked by four transverse ridges marking the boundaries of each sacral segment. Each ridge ends laterally at the ventral sacral foramina on each side. The foramina transmit the ventral primary rami of the sacral nerves and the related blood vessels. The ridges of bone between the ven­ h'al sacral foramina provide origin for the piriformis muscle. Dorsally, the spinous processes of the first four segments are retained as the median sacral crest (Figure 1-4). The first sacral segment is the largest and still bears functi onal superior articular processes that face dorsomedially to articulate with the inferior articular processes of L-5. The remainder of the articular processes form the intermediate sacral crest that is located just medial to the posterior sacral foramina in the form of four small tubercles aligned in sequence, The transverse process of the first sacral segment and its costal element fuse to form the large sacral ala wing. The rest of the transverse processes fuse with their costal elements to form the sacral lateral mass. The lateral sacral crest, being just lateral to the posterior sacral foramina, marks the legacy of the transverse processes as an inter­ rupted line of tubercles. The inferior articular processes of the fifth sacral segment remain as the sacral cornua. The fifth segment's spinous process

Copyrighted Material

PELVIC LOCOMOTOR DYSFUNCTION

4

defect

and lamina fail to fuse in the midline and thus form a known as the sacral hiatus. The bony, nonarticular inferolateral

of

the sacrum is termed the inferior lateral angle. Viewed laterally, the sacrum exhibits a ventral concavity The sacroiliac articular facet can be seen on the lateral mass, formed by the coalescence of the processes of the first and second sacral ened to the

of the lateral and transverse

The joint's surface is lik-

of a side-lying letter

the shorter limb being

and contained within the first sacral

alad, vertically

The caudal, more horizontal limb is borne The facet's gross

resembles that of an

ear and hence earned the name auricular

Posterior to the joint sur-

third sacral face proper is a

as the attachment site for the pow­

erful interosseous Inn ominate Bone The innominate bone is formed by three fused bones and conveys a no other known object;

that

the early anatomists chris-

Superior

'If���--- Articular Facet

Median Sacral

Auricular

Crest

Surface

Lateral

Posterior

Sacral

Sacral

Crest

Foramina

"-..;:,-�: 1-4 Posterior View of the Sacrum

Copyrighted Material

Anatomy

5

Articular Process Spinous Tubercle

Sacral Promontory

Interosseous

Auricular Surface

Note articular facet and

tened it

attachment

"nameless" (Figures 1-6 and

innominate,

shaped bone formed by the fusion of the

ilium, acetabulum on its

which meet to form the

which in Latin means 1Ia little saucer for

ULf'rUD'UnlrrL

outvvard, and forward to articulate with the The

ilium is identified by its iliac spine,

crest whjch posteriorly in an in

concave medially in front and concave terminates at the nn"""lnr",

posterior s uperior iliac

Viewed laterally, the

the prominence of the

as a convex arch the ilium is broad,

iliac crest

The lateral

convex anteriorly and concave

The anterior superior iliac

marks the most anterior

ilium and serves as attachment for the lateral part of the Below this is the anterior inferior iliac anterior inferior

A shallow groove

from an eminence and allows the

,"_'J�_'''''_

tendon. superior iliac spine is the large protuberance on the most of the ilium. Just with the lower surface of the ilium is smooth,

is the

posterior inferior iliac

of the sacroiliac joint. The internal and concave. Posteriorly lies the au-

Copyrighted Material

6

PELVlC LOCOMOTOR DYSFUNCTION

Iliac Crest Ilium

Anterior Superior Iliac Spine

Posterior

----'1.'-

S uperior Iliac Spine

Anterior

;'---- Posterior I nferior

Inferior Iliac -----+

Iliac Spine

Spine

Pubic

Ischial Spine

Tubercle Ischial Tuberosity

Pubis Obturator Foramen

Ischium

Figure 1-6 Innominate Bone, Lateral

which articulates with the sacrum at the sacroiliac joint. ricular area where the powerful in­ Just posterior to this is a large, terosseous sacroiliac ligament inserts. The pubic bone meets its inferior rami to form the body of bones meet to form the puThe anterior aspect of the in the midline bic 1-8). Just lateral to the pubic ramus is a rounded bor­ aspect of whose lateral gives rise to the pubic

tubercle. the most inferior of the pelvis and has a thick body, large the ischial and thin ramus. The posterior gives rise to the ischial spine, to which the atof the ischium is the taches. The upon sitting. The ramus ascends and meets with

Copyrighted Material

Anatomy

7

Roughened Area for Attachment of Interosseous Ligament Anterior Superior

Auricular Surface

Iliac Spine

Superior Pubic Ramus

Ischial Spine

Pubic Symphysis

Figure

1-7 Innominate bone, medial aspect. Note articular facet.

the inferior ramus of the pubic bone to complete the ring-shaped obturator

foramen. Coccyx

The coccyx is a small bone formed by the fusion of usually four segments (Figure 1-9). The coccyx as a whole faces up and forward with its ventral surface. Usually the first coccygeal segment remains separate from the rest. The first three segments retain rudimentary bodies, transverse pro­ cesses, and articular processes. The segments progressively diminish in size to where the last segment is represented by a small button of bone without any processes discernible. The coccyx is widest proximally at its base, through which it articulates with the last sacral segment via an ar­ ticular facet. Rudimentary pedicles and articular processes form the coc­ cygeal cornua, which extend superiorly to articulate with the sacral cornua.

Copyrighted Material

8

PELVIC LOCOMOTOR DYSFUNCTION

Interpubic Disc with Cleft

Superior Pubic

Pubic Ligament

1-8 Pubic

transverse processes arise from the first coccygeal

and

can even fuse with the sacral inferior lateral ARTICULARILIGAMENTOUS ANATOMY contains three joints: the paired, found "'TI'tp"';,,,.

and the midline

six pubopubic, Lumbopelvic The sacrum attaches to L-5 in much the same manner as other <:P(nnpnlt<: in the

"'" that the supraspinous li m""

are

at the L4-5 level.2 Additionally, the strong iliolumbar ligament attaches L-5 to the ilium. Shellshear and Macintosh3 describe five bar ligament

to the iliolum-

1-10).

Kapandji4 refers to a nects the L-4 transverse

band of the iliolumbar

that con-

to the iliac crest in conjunction with an

Copyrighted Material

9

Fibrocartilage Disc Coccygeal Cornua

Transverse Processes

Venlral

Dorsal

1-9

inferior band of ligament that attaches the L-5 transverse process with the iliac crest. Kapandji also mentions that on occasion a subdivision of the inferior band attaches to the sacrum. Luk et a15 have shown that the ili­ olumbar ligament does not exist at birth but

gradually develops near

the end of the first decade. The initial histological appearance of this ligament is muscular, with full

differentiation occurring in the

decade. It is thought that in the lumbosacral junction

to biomechanical stresses at

by

the lower a

tus lumborum muscle fibers

transformation into

the iliolumbar ligament.s Luk et al state that the iliolumbar ligament con­ the tips of the L-5 trans­

sists of two

to insert on the iliac crest.

Sacroiliac The following information obtained mostly from work

the developmental anatomy was

np·,.t,..,,.rr>

Bowen and Cassidy.6

Literature Review A literature review of the sacroiliac joint is full of controversy, sion, and contradiction. Bowen and Cassidy6 review the literature in their discussion of the

anatomical changes occurring in the sacro-

iliac joint. The first researchers to show that the sacroiliac

was a true

joint with a synovium were Albinus and Hunter7 in the

1700s, al-

though Meckel was the first to write about this in an anatomy text in 1816.8

Copyrighted Material

10

PELVIC LOCOMOTOR DYSFUN CTION

Transverse Process

Figure 1-10

iliolumbar ligament and its five parts: (1) su perior iliolumbar liga­ ment, (2) anterior iliolumbar ligament, (3) posterior iliolumbar ligament, (4) infe­ rior iliolumbar ligament, and (5) vertical iliolumbar ligament. The anterior sacro­ iliac ligament is shown at (6).3

However, it was Von Luschka in 1863 who initially described the sacro­ iliac joint as a true diarthrodial articulation.9 AlbeelO in 1909 regularly ob­ served a joint space, synovial membrane, and well-formed articulation. Confirming Albee's findings in 1924, Brookell moreover described fibrous and even bony ankylosis as evident, especially in male sacroiliac joints. Sashin12 was the first to describe age-related changes, but specimens from the first two decades were not included in his study. He described degenerative changes as present early in life, more commonly in males. Upon studying 257 specimens, he observed 85% and 50% of the male and female pelvises respectively to have osteophytic changes at the sacroiliac joints in the 40- to 49-year-old group. All male specimens aged 50 to 59 years had osteophytic changes, and 60% of them had sacroiliac joint anky­ losis compared to only 14% in the female specimens. Schunke13 in 1938 commented on the anatomy and development of the sacroiliac joint and mentioned the histologic difference in the sacral and iliac articular cartilage. He observed that the sacroiliac joint cavity devel­ oped between the second and seventh months of fetal life. He also noted

Copyrighted Material

11

of grooves and

occurring in

in the ar-

hcular topography. In

Illp4 described and named an

and described

motion based on

1954, WeisP5 mapped the uneven contour of the sacroiliac joint and deby a

scribed the sacral surface as two eminences in the young adult. In 1957, Solonen published a very thorough He demonstrated distinctive variations in to mechanical

morphology

roiliac joint is inaccurate due to its casts taken of the

types that reacted

He showed how radiography of the sac-

with

His

brought to of the joint.

and dorsal

the

receives innervation from L-3 to

ventral

whereas the dorsal as-

receives it from 5-1 to 5-2. identified two drastically

In his

of sacroiliac jointS.17 When the vertebral

anatomical and

column's curvatures were pronotmced, the sacroiliac joint tended to lie shape, as

markedly bent on itself. This

and

it was called, is associated more with

states, seen more often to insta-

in women. It tends to be more mobile and therefore

interosseous liga-

bility. The increased mobility is associated with a for motion but decreased

ment

This type of sacroiliac studied and is an

joint occurred in 25% of the

of

Its mobile characteristic resembles

overadaptation to the biped that of a

synovial joint. Another 25% of the subjects demonstrated

sacroiliac

that were more

aligned and associated with

nal curves that were not termed the static

This

and was

interosseous

was shorter and

more

but less mobility. Sandoz18 commented that this type of sacroiliac

is

is closer to that of

to fixation rather than instability. Its

and resembles an amphiarthrosis more than a diarthrosis. The

50%

the

demonstrated a type

sacroiliac joint that a

was intermediate between the dynamic and the static types, between

and mobility. dissected 40 autopsy V"''-VV''_

embryonic life to the related

and com­

anatomy of sacroiliac joints from

decade.6 Their goals were to document

and to establish a common

Copyrighted Material

for understanding sac-

PELVlC LOCOMOTOR DYSFUNCTION

12

Gross Anatomy o/the Sacroiliac Joint The sacroiliac joint is considered a diarthrosis due to the following: cartiarticular surfaces, joint

joint space with fluid,

and

to move. The joint can be divided into a ventral syn-

postauricular.8

joint morphology tends to be very variable. The

ovial or

and a dorsal or

that is

vertical and anteroposterior joint planes vary,16 as do the sacral and iliac surfacesP The sacral auricular

is

than its iliac

longer and narrower. The joint smooth from birth until puberty, when

and grooves

part an irregularity to the surface. The sacral side has been by a

two elevations

WeisPs as sion. The

and caudal

displays a

that runs longitudinally throughout its length and serves

the sacral surface are a concave appearance. The iliac surface

to interdigitate with the sacral articular groove. The sacral cartilage is up cartilage is

to three times thicker than that of the iliac side. on the sacral

in contrast to the

on the iliac sur-

Both the sacral and iliac surfaces are

parallel at the first and

second sacral segments, yet course medially at about the parts.

into anterior and pears to be a

leveP6

the sacroiliac joint can be

directly

The

thin anterior sacroiliac ligament ap-

of the anterior joint

Solonenl6 and Sashinl2

1�11). the sacral and iliac

it as a thickening

structures consist of the

periosteum. The dorsal

in-

terosseous ligament and the posterior sacroiliac ligament. The deep, thick interosseous

is the main

restraint

1-11). It is attached

sacrum to the ilium

lar surface of both the sacrum and ilium. The ligament is so forcible disruption of the joint in cadaveric ments in

way and the

that on

the bony attach-

remains intact.12 The

blends

The posterior sacroiliac

the interosseous

thin structure that is

the

posterior to the auricu-

from the interosseous ligament

sal rami of the sacral nerves and related blood vessels. It

from the

intermediate and lateral sacral crests and passes cides to the

iliac

Through his

and iliac crest.l

Illi14 observed a

intracapsular I1V"Hnf'nt

which later came to bear his name. Its existence has been controversial since other researchers were not able to coruirm ("\'''0''''''

in 1990 Freeman et aP9 found its existence in 75% of

Copyrighted Material

Anatomy

13

Sacroiliac

Joint

Interosseus Ligament

Sacroiliac Joint

Anterior Sacroiliac Ligament

Sacroiliac Joint

1-11 Cross section of sacroiliac their dissections of 31 human of Illi's sacroiliac

Note massive interosseolls U5all.'C"'.

They attribute their corroboration

to their dissection approach from the inferior aspect of the Most other researchers approached the sacroiliac

from the anterior and often

the lnt·,.""',,,r><, Freeman et al confirmed the pres­

ence of a superior

ligament

from posterosuperior

on the ilium to anteroinferior on the sacrum. Its diameter ranged from 1 to

Copyrighted Material

14

PELVIC LOCOMOTOR DYSFUNCTION

8 mm. On gross observation, it

to be a dense, fibrous band of

connective tissue. On histological study, the band of tissue was ligamen­ on the sacral

directly into the

tous in naturel

surface. On the iliac

the ligament blended in with the

interosseous ligament. The

biomechanical significance is ques-

tionable owing to its small size. . Developmental Anatomy of the Sacroiliac of the sacroiliac

Embryology. Studies on the

are limited. Schunke13 states that the sacroiliac joints

and

form between the second and seventh months of fetal development. He shows how at 8 weeks the joint is

between

onto

the ilium and sacrum

the ilium ossifies and the iliac

formed in the middle layer. At 13 thickens. By

8 months, a well-developed joint cavity is

In their dissections of fetal sacroiliac joints, Bowen and to be thin and pliable, with the joint stabi­

served the anterior joint

further noted

lized mostly by the posterior interosseous

the sacroiliac joints to be especially mobile owing to their smooth and Hat was con­

articular surfaces. Microscopically, the sacral articular

three to five times thicker than that of the iliac side. The sacral were

consistent with

whereas the iliac articular

resembled a fibrocartilaginous appear-

ance, with more collagen fibers present among the chondrocytes. noted that the sacroiliac joint

First Decade. Bowen and in size in accordance with somatic

after birth. The

became

defined, fibrous, and resilient, yet maintaining much pliability. The joint smooth

surfaces retained their

and demonstrated glid­ the joint fibrous connective

tissue and an inner

only two or three cells thick. Loose are-

olar connective tissue was

just under the

and sacral surfaces maintained their

layer. The iliac and hyaline

appearances. tp"'n",o,,

grooves and surfaces, The

between the sacral and iliac

surface

length, and the sacral surface and

years see the development of

a

noticed motion to be limited to a nodding in the

Copyrighted Material

Anatomy

15

aplpe,uea thicker and stronger, in addition to LUI,.,"',U"" o>nnp;"rl"'fl

lage,

and

more

in the articular carti-

thicker. Crevices were more

on the iliac surface. The iliac surface started to roughen

and demonstrate fibrous plaques as this

and all

as 17

the middle of the third decade. but no

Fourth and Fifth Decades.

The iliac ridge was

eration was seen

observed and and marginal

prominent in Bowen and

Movement was still apparent at the

the

appeared less pliable. Plaque forma-

sacroiliac joint, and the joint tion and erosions of the articular

were

and consis-

examination at this time demonstrated

seen. of the synovium and generative

"" ,('1/,;;. ....

with more of a fibrous nature

of the articular cartilage were

fibrillation and erosion seen more on the iliac side of the

Sixth and Seventh Decades.

continued to be and started to bridge the

more pronounced. Osteophytes became

and less pliant, with the

became increasingly

joint. The joint

due to more crevices and erosions of

more

the articular

Mobility was still

but restricted. Fibrous

the joint surfaces. Microscopically, ado-Pl'lpr'::I tlr.n

was seen, articular cartilage was thinner on

and erosions and crevice formations were seen i n amounts, particularly o n the iliac side o f the joint. Amorphous, quantities in the joint space.

cellular material was seen in

Seventh and and this limited

Decades. motion

Marked bony

was

Also

to decreased

joint motion was the large amow1t of intra-articular fibrous interconnections

Articular

exhibited considerable

was

and both sides

Microscopically,

calcification was observed. The ground substance of

joint sacro-

surfaces contained more collagen. Cartilage erosions were and some even extended to the subchondral bone. The iliac side of the jOint demonstrated more advanced changes. Bowen and

found only one

"IJ'<"L'''''�'

articular bony ankylosis.6

Copyrighted Material

PELVIC LOCOMOTOR DYSFUNCTION

16

Sacroischial of the body bind the sacrum to the ischial act as a

sacrotuberous and the

counterforce

of the trunk from torquing the

sacral base anteriorly and inferiorly by

the sacral apex

The sacrotuberous ligament takes a wide perior iliac

from the

,..,,,,,te,,.,,,,·

the lower sacral transverse

nonarticular lateral

lower

of the sacrum, and the cranial part of the coccyx.

It narrows as it descends and runs laterally, only to thicken again as it inserts into the medial The

of the ischial tuberosity. from a broad base attached to the

ligament

of the sacrum and proximal a short,

band

spine. These two

Uh'AU'�'

and runs by

of

down and forward to insert on the divide the sacrosciatic notches into the greater

and lesser

On the whole, there is a marked difference in males and females after the female pelviS,

between

Strength is sacrificed

mobility in

during pregnancy.

Pubopubic The paired pubic bones meet in the midline to form the pubic symphysis, an amphiarthrosis (Figure 1-8). The oval ends of the pubic bones are a thin layer of hyaline slants obliquely anterior, shtlike

and are connected by a

of

disc. The longitudinal axis of the joint

the

from the inferior to the

A

is consistently found in the supeJ:o�)OsterlOr

joint after the first decade of life. The

this

consist of the anterior and and

anterior ligament closes

stron-

anterior

the joint and is interlaced

with fibers from the aponeurosis of the external oblique and rectus abdominis muscles. The thinner and weaker posterior pubic courses behveen the pubic bones behind the

ment runs behveen the The

tubercles and

The

"1J1C'PTliIY

the joint

ligament, also called the arcuate pubic ligament,

thick,

arch at the inferior

of the medial ends of the

bones.

The joint between the sacrum and coccyx is amphiarthrodial and analo­ to an intervertebral joint with r(l1'rp';:nr)n

Copyrighted Material

Anatomy

17

Iliolumbar Short

Supraspinous Ligament

�

Sacroiliac Ligament

I I

//

Sacrospinous Ligament Posterior Superficial Sacrococcygeal Ligament

Figure 1-12

Sacrotuberous and Posterior Sacroiliac Ligaments

(Figure 1-13). Occasionally it can be synovial, with the coccyx and sacrum freely articulating.l The sacral articulating surface is convex, whereas that of the coccyx is concave. A thin, interposed fibrocartilaginous disc is present. Corresponding to the anterior longitudinal ligament is the ventral sacrococcygeal ligament, connecting the sacrum to the first coccygeal seg­ ment. The deep dorsal sacrococcygeal ligament corresponds to the posterior longitudinal ligament and connects the sacrum to the coccyx posteriorly. Joining the margin of the sacral hiatus to the coccyx is the superficial dorsal

Copyrighted Material

18

PELVIC LOCOMOTOR DYSFUNCTION

Sacral Hiatus

Lateral Sacrococcygeal

Superficial Dorsal

Ligament

Sacrococcygeal Ligament

Ventral Sacrococcygeal

Deep Dorsal

Ligament

Sacrococcygeal Ligament

Ventral

Figure 1-13

Dorsal

Sacrococcygeal Joint

sacrococcygeal ligament, which forms the roof of the distal sacral canal.

Analogous to the intertransverse ligaments are the lateral sacrococcygeal ligaments, joining the transverse processes of the coccyx to the inferior lat­

eral angle of the sacrum. Femoroacetabular

The hip joint is anatomically and functionally linked to the pelvis and, as such, needs to be considered. The pelvic bowl rests on the femoral heads through the femoroacetabular joints. This joint is a large ball-and­ socket diarthroidal articulation that is powerfully supported by very strong ligaments and a deep articular coaptation. The acetabulum is a cup­ shaped depression on the lateral aspect of the innominate bone formed at the union of the ilium, ischium, and pubic bones (Figure 1-6). It faces later­ ally, inferiorly, and anteriorly and receives the rounded head of the femur. The margin of the acetabulum is enhanced by the fibrocartilaginous la­ brum. The interior of the acetabulum is lined by a horseshoe-shaped piece of articular cartilage for articulation with the head of the femur. The deeper aspect of the acetabular fossa is nonarticular and surrounded by the horseshoe-shaped cartilage. The bony acetabulum, labrum, and articu­ lar cartilage are notched inferiorly at the acetabular notch. This notch is spanned by the transverse ligament, which affords continuity to the ac­ etabular shape. The notch allows the transmittal of neurovascular struc­ tures into the acetabulum. The roundfemoral head articulates with the acetabulum. It makes up two thirds of a sphere and has a pitted indentation called the fovea located be-

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Anatomy

19

low and behind its center. The fovea affords attachment for the

of

the head of the femur, the biomechanical function of which seems to be called the

head and forms

the

The neck of the femur a

with the shaft of the fe-

of

mur in the frontal plane. In the horizontal plane, the neck forms a 15or decli-

degree angle with the femoral shaft, called the angle the femoral head is

nation.

medially, superiorly, and

the

and femoral head both face

standing, the anterior aspect of the femoral head a small surface area for weight An increased or decreased

of inclination is rpt.prr·Ari

A

with an increased angle of a decreased angle is called whereas retroversion

toe-out "n""A,"r�mr'A

a

effects of version on the attitude

of the lower

fue hip

and

to be in its functional position The

trochanter is a large

of bone at the union of the

femoral neck and shaft

and laterally. It abductor muscles. The

for the

ment and

and small lateral rotators the

insert on the

trochanter,

femoris, which inserts below on the trochanteric crest. On

the

is the lesser tro-

side of the femoral shaft and slightly

chanter, a smaller bony

that serves as insertion for the ilio­

psoas muscle. support around the hip consists of

The

to limit

tilting in the erect from the rim of the

The capsule acetabulum and labrum, runs

O Vlc"",,'"

like a sleeve with the

femoral neck, and inserts on the intertrochanteric line in mal to the intertrochanteric crest behind. Three extracapsular

to their

exist and are named

attachments. The iliofemoral

also referred to as

Y

ment of Bigelow, originates from underneath the anterior inferior iliac spine

and

downward in the shape of an inverted Y to attach to the around the femoral neck, the 1at-

femur. Both limbs of the eral limb

trochanter and the medial limb

near the lesser

tightens in extension and

rotation. The ischiofemoral ligament acetabulum and runs

and

just behind and below the to insert on the femoral

where it meets the

on extension and

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20

. ,------

PELVIC LOCOMOTOR DYSFUNCTION

( \\

Iliofemoral Ligament (Y Ligament of Bigelow)

\.1:

Iliopectineal Bursa

Pubofemoral Ligament

Figure 1-14

Joint, Anterior

internal rotation. The pubofemoral ligament arises from the

bone near

the acetabulum and attaches to the femur near the lesser trochanter. It functions mainly to limit internal rotation. ments around the hip joint

all the major liga-

with internal rotation.

Question for Thought •

In terms of range of motion and gait, what would you to see clinically if

fibrosis and

were to oc-

cur in the hip joint?

tTl117.W1'110fthe head afthe femur, also called the ligamentum

arises

from the nonarticular acetabular fossa near the acetabular notch and runs

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Anatomy

21

Iliofemoral ligament

Ischiofemoral

Synovia! Sac

figure 1-15 Hip -_.. _--

Joint, Posterior

-----

-_ .. _-_._-

to the fovea on the femoral head. Its function seems a means for neurovascular structures to

than

synovial fluid over it. MUSCULAR ANATOMY

Pelvic j oint and muscular dysfunctions commonly occur (uu;uva,y

and and

of the muscles

An understanding of the to the pelvis is essential in

pelvic locomotor disturbances.

Abdominals

Anteriorly, the abdominals consist of four muscles: the two obliques, transversus abdominis, and rectus abdominis. The external oblique arises

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22

PELVIC LOCOMOTOR DYSFUNCTION

from the lower eight ribs and descends in its lowest and posterior part to and insert into the lateral run the front half of the iliac crest (Figure 1- 16). The middle and run medially and downward to end in an that inserts onto the bone between the pu­ bic symphysis and pubic tubercle and ends in the midline as the linea alba. Its lower medial border is folded upon itself to form the inguinal ligament and extends between the anterior and iliac tubercle. it causes trunk flexion. Unilateral contraction causes latside. It is innervated eral flexion and rotation of the trunk to the the ventral rami of the lower six thoracic nerves. The internal oblique arises from the lateral two thirds of the inguinal ligament, a of iliac crest near the anterior iliac the middle third of the intermediate line on the iliac crest, and of the thoracolumbar crest and fascia. It arches medially and to insert onto the midline linea alba. Its middle and lateral fibers run upward to insert into the lower three ribs. It functions bilaterally to flex the trunk. unilatsynergistically with conerally, it rotates the trunk tralateral external oblique, and laterally bends the trunk to the same side. The transversus abdominis originates from the lower six rib cartilages, thoracolumbar anterior three fourths of the internal of the iliac crest, and lateral third of the Its fibers run to insert into the linea alba abdominal viscera. The rectus abdominis from the fifth, sixth, and seventh costal and xiphoid and descends to insert on the along its length It is and intersections. It strongly flexes the trunk, the xiphoid and symphysis. For the most part, the abdominal muscles are innervated the lower six or seven thoracic nerves. The internal oblique and the transversus abdominis also receive innervation from the L- 1level. Iliopsoas

from the ventral of the lumbar of the 12th thoracic and lumbar It enters the and traverses in front of ligament. It over the tendinous and receiving most of the iliacus the joint capsule, tendon This blend tendons inserts onto the lesser trochanter of the The psoas receives its innervation from the three lumbar nerves.

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Anatomy

u

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23

24

PELVIC LOCOMOTOR DYSFUNCTION

-

-� >

Psoas Minor Muscle

Iliacus Muscle

Figure 1-17

The

Psoas Major, Psoas Minor, Iliacus Muscles

iliacus is a large triangular muscle that originates from the internal

surface of the iliac bone and descends to combine mostly with the psoas major muscle. However, some fibers continue on to insert directly onto the femur just below and in front of the lesser trochanter. The iliopsoas is a strong hip flexor and assists in lateral femoral rotation. It has powerful effects on the lumbar spine due to its attachments. Unilateral contraction bends the spine ipsilaterally and rotates it contralaterally. Kapandji4 notes

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Anatomy

25

that its attachment to the summit of the lumbar lordosis causes trunk flex­ The iliacus receives ion relative to the pelvis and accentuates the innervation from the femoral nerve. The psoas minor muscle is a small muscle originating from the T-12 to L-1 disc. It inserts near the iliopubic eminence in the form of a long, slen­ der tendon. Its presence is and therefore its function seems in-

Lower Back Region

from the posreceives attachments from muscles The terior aspect of the trunk and Even the upper is linked to the pelvis via the latissimus dorsi muscle attaching to the thoracolumbar fascia. TIlOracolumbar Fascia

This expanse of connective tissue is cally located to afford insertion for a variety of trunk muscles.21 The thoraconsists of from the intercolumbar fascia nal oblique, transversus and latissimus dorsi muscles. In the lower the thoracolumbar fascia into three (Figures 1-18 and 1-19). The posterior layer covers the attached medially to the lumbar and sacral erector spinae muscles, Df()(e'SSt�S and ligaments and laterally to the aponeurotic expanse of the abdominal muscles and latissimus muscle. The middle of the fascia covers the surface of the lumborum muscle and attaches H"CU.'.UH pf()(e:SSE�S and below to the iliac crest. Laterally, it jOins with the posterior thus investing the erector muscles. The anterior layer of lumborum muscle. the fascia covers the anterior surface to the anterior of the lumbar transverse It is attached to the posterior and middle layers and the apoprocesses and neuroses of the transversus abdominis and intemal muscles. The and middle join laterally to form the lateral raphe, a dense union tension can Because the abdominal muscles insert into its lateral the lumbar be generated within the thoracolumbar fascia to help abdominal muscle contraction.22-25 Hukins et aF6 discuss how and middle of the fascia restrict radial or the erector during active contraction. was found to which in tum increase the axial tension within the muscle almost increased the muscle's extensor moment proportionally.

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PEL\:lC LOCOMOTOR DYSFUNCTION

26

]

Erector Spinae

Thoracolumbar Fascia

Transversus

Psoas Lumborum

1-18 Thoracolumbar lumborurn muscle.

Abdominis

cross section. Note lateral

the anatomy of the thoracolumbar

of

Bogduk and

how it can exert an "antiflexion" effect on the lumbar to the lateral raphe via

spineY Approximately 57% of the force

abdominal muscle and latissimus muscle activity is transferred to the lum­ bar

the thoracolumbar fascia.28

to its fi­

fascia transfers this force so as to on)Ce:SSE�S and therefore resist lumbar flexion.29

phenomenon has been termed the gain of the thoracolumbar fascia24 and is one of three ways the thoracolumbar

can stabilize the lumbar the L-4 and L-5

in flexion. The second way is to the ilium by fibers of the

tachments are tensed in flexion and assist the et al23 have termed the third

ligaments.

columbar fascia the hydraulic amplifier mechanism. As to the research of Hukins et

tioned with

restriction of the radial

", ..,nfl,,",'

it involves the

of the

of its retinacular function.

in tum, increases the extensor

moment of the erector spinae muscle group. The

of the above information comes to

sider the function of the trunk muscles and

me-

which are covered in the next Questions for Thought .. What is the

between the abdominal

the

latissimus .. How can this information be used in a low back rehabilitation

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Anatomy

27

Erector Spinae

Trapezius

Muscle

Muscle

11 th Rib

Latissimus Dorsi Muscle

External Abdominal Oblique Muscle

Thoracolumbar Fascia

Internal Abdominal Oblique Muscle

Serratus Posterior Inferior Muscle

Figure 1-19

Posterior Trunk Muscles

Erector Spinae In the past, it has been customary to think of the back muscles as one large mass arising from the sacrum and ilium from a common aponeurotic origin and traveling cephalad to various attachments on the spine and ribs. However, recent studies involving the anatomy and innervation of the lower back muscles have helped elucidate the arrangement of these

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28

PELVIC LOCOMOTOR DYSFUNCTION

muscles.29-32 These new

make it reasonable to view the origin and

insertion of the erector

in a manner opposite to what conventional

lLlI"lll't:

has consists of the iliocostalis lumborum and the

erector

thoracis and forms the muscular, bulging

in the

low back. Each of these muscles is subdivided into a lumbar and thoracic on their cephalad origin. The lumbar part of each muscle emanating from the lumbar vertebrae. The thoracic arises

thoracic vertebrae or ribs.29.J2 The

muscle consists of

that the erector

lumbar and thoracic

repre-

in. the anatomical and biomechanical under-

sents a major standing of this region.

iliocostalis lumborum is innervated

the lat-

derives its

eral branches of the lumbar dorsal rami. The

llmervation from the intermediate branches of the lumbar dorsal rami.

Lumbar Part of the Longissimus The lumbar longissimus consists of five slips of muscle originating from the medial

of the lumbar transverse processes

1-20). These

lumbar fascicles insert into the ilium near the The tion during

rota-

contraction. Contracting unilaterally, it serves to flex to the same side. Owing to its

laterally the lumbar at a mechanical action is not as

iliac

functions mainly to impart posterior

to as t hat of

it is and its extensor

axial multifidus.

Lumbar Part of the Iliocostalis In contrast to the longissimus, which attaches at the medial aspect of the transverse, the lumbar

from the

transverse

of the lumbar

Thus, its fascicles are

to those of the longissimus,

that

SImI-

are more laterally placed.

The fascicles insert into the iliac crest just lateral to the

superior

iliac spine. Unilateral contraction will cause lateral flexion of the lumbar with the transverse processes providing a

mechanical advan-

Because of their attachment to the tips of the transverse processes, the fascicles are at an

to produce axial rotation, but the amount

produce is overshadowed by the indirect action of the oblique ab­ dominal muscles rotating the trunk via the thorax. Contracting bilaterally, the lumbar iliocostalis fascicles exert a posterior the lumbar

along with a

lower levels, due to the more horizontal inclination

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rotation through at

Anatomy

29

Figure 1-20

Longissimus muscle, lumbar part. On the left, the five muscular fas­ cicles are drawn. The lumbar intermuscular aponeurosis (LIA), formed by the lum­ bar fascicles of the longissimus, is shown. On the right, the attachments and span of the fascicles are shown. Source: Adapted from Clinical Anatomy of the Lumbar Spine by N. Bogduk and L.T. Twomey, p. 79, with permission of Churchill Livingstone, © 1987.

Thoracic Part of the Longissimus The thoracic part of the longissimus originates from the transverse pro­ cesses and ribs from I-I to I-12 and inserts onto the spinous processes of L-3 through S-3 and along the sacrum on a line ending just medial to the posterior superior iliac spine (Figure 1-22). The long ribbonlike tendons fonn the bulk of the erector spinae aponeurosis and cover, but are not at­ tached to, the lumbar fibers of the longissimus and iliocostalis. Contract­ ing bilaterally, they increase the lumbar lordosis acting through the erec­ tor spinae aponeurosis. Unilateral contraction can cause ipsilateral lateral flexion.

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30

PELVIC LOCOMOTOR DYSFUNCTION

\ Figure 1-21 Iliocostalis muscle, lumbar part. On the left, the four fascicles of the 'Iumbar part of the iliocostalis are shown. Their span and attachments are depicted on the right. Source: Adapted from Clinical Anatomy of the Lumbar Spine by N. Bogduk and L.T. Twomey, p. 81, with permission of Churchill Livingstone, © 1987.

Thoracic Part of the Iliocostalis The thoracic part of the iliocostalis arises from the lower seven or eight ribs and inserts into the sacrum and ilium (Figure 1-23). Its tendons are also long and ribbonlike and add to the lateral aspect of the erector spinae aponeurosis. By spanning the lumbar spine, they create a "bowstring" ef­ fect and with bilateral contraction can increase the lordosis.27 Unilaterally contracting, they cause lateral flexion of the lumbar spine by acting through the thorax. They also function to derotate the trunk when it is rotated contralaterally. The erector spinae aponeurosis consists mostly of fibers from the thoracic part of both the longissimus and iliocostalis muscles. Contrary to earlier concepts, the lumbar part of each of these muscles remains separate from the aponeurosis29•32 and can function independently from it.

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Anatomy

31

Figure 1-22

Longissimus muscle, thoracic part. On the left are shown the intact fibers of the muscle. The darkened areas represent the short muscle bellies of each fascicle. Note the short rostral and long caudal tendons, the latter of which form the erector spinae aponeurosis (ESA). On the right is shown the span of individual fascicles. Source: Adapted from Clinical Anatomy of the Lumbar Spine by N. Bogduk and L.T. Twomey, p. 83, with permission of Churchill Livingstone, © 1987.

Multifidus The multifidus is a deep, large lower back muscle featuring segmentally arranged fascicles originating from each lumbar spinous process and at­ taching to the mammillary processes, sacrum, and iliac crest below (Figure 1-24). In the past, the muscle was viewed in the reverse, with the muscle running from below upward and inserting onto the spinous processes. Recent studies of the anatomy and innervation patterns of this muscle con­ tend that the multifidus arises as separate bundles from each lumbar

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32

PELVIC LOCOMOTOR DYSFUNCTION

Figure 1-23

Iliocostalis muscle, thoracic part. The left depicts the intact fascicles, and the right shows their span. The caudal tendons of the fascicles collectively form the erector spinae aponeurosis (ESA). Source: Adapted from Clinical Anatomy of the Lumbar Spine by N. Bogduk and L.T. Twomey, p. 83, with permission of Churchill Livingstone, © 1987.

spinous process and radiates downward in a segmental fashion to insert on lumbar mammillary processes and the pelvis. All the fascicles arising from a given spinous process are innervated by the medial branch of the dorsal primary ramus that exits below that vertebra.3D,33 The multifidus consists of small, short laminar fibers and larger, longer spinous fascicles. The laminar fascicles run caudally and span two lumbar levels to the mammillary process. They originate from the dorsal caudal aspect of the lamina. The L-S fascicle inserts onto the sacrum just above the first dorsal sacral foramen. The larger fascicles arising from the spinous processes insert as five overlapping layers spanning three, four, and some­ times five segments below. The fascicles from the L-2 through L-S spinous

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Anatomy

33

A

c

E

Figure 1-24

F

Fascicles of the multifidus muscle.

(A)

Laminar fibers.

(8)

to

(F)

Fas­

cicles from L-1 to L-S. Source: Adapted from Clinical Anatomy of the Lumbar Spine by N. Bogduk and L.T. Twomey, p. 76, with permission of Churchill © 1987.

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34

PEL VIC LOCOMOTOR DYSFUNCTION

processes insert onto the sacrum, posterior superior iliac spine, and part of iliac crest. 34 TI1e spinous process attac1unent of the multifidus acts as a strong lever to impart posterior sagittal rotation, ie, extension, at each lumbar segment. The motion imparted at each segment is actually the rocking component of extension.32 The attaclunents of the multifidus do not afford good me­ chanical advantage to impart any considerable torque in axial rotation. However, it is thought that they function to stabilize or dampen any op­ posing flexion caused by the abdominal muscles during trunk rotation.35

Quadratus Lumborum As its name implies, the

quadratus lumborum is a quadrangular-shaped

muscle in the lumbar region. It is very important, complex, and an often­ forgotten structure in the lower back, especially with regard to low back pain syndromes. Tn re ferencing Eisler, Travell and Simons36 review the anatomy of the quadratus lumborum muscle. The quadratus lumborum consists of three layers attaching to the middle third of the iliac crest and iliolumbar ligament, the upper four lumbar transverse process tips, and the 12th rib (Figure 1-25). TIms, the fibers are oriented in three directions going from (1) the iliac crest to the 12th rib (iliocostal fibers), (2) the iliac crest to the lumbar vertebrae (iliolumbar), and

(3) the lumbar vertebrae to

the 12th rib (lumbocostal) . The iliocostal fibers are the most posterior layer and run vertically and slightly medially as they course upward to insert on the 12th rib. The diagonally running iliolumbar fibers form the middle layer and cross with the most ventral layer, the diagonally running lum­ bocostal fibers. Travell and Simons36 comment that the quadratus lumborum, owing to its layered structure and orientation of its fibers into three groups, should be thought of as three muscles when one is stretching it. The muscle appears thicker nearer its costal attaclunent and presents a smooth lateral border. The medial border appears serrated due to the interdigitations of the diagonal fibers attaching to the transverse pro­ cesses. Being sheetlike, it lies in the frontal plane just lateral to the lumbar spine and forms part of the posterior abdominal wall. The quadratus lumborum derives its irmervation from the 12th thoracic and upper three or four lumbar ventral rami. The quadratus lumborum functions primarily as a lateral flexor of the lumbar spine by either initiating bending to the ipsilateral side or control­ ling it to the contralateral side by eccentric (lengthening) contraction. Act­ ing bilaterally, the quadratus lumborum muscles extend the lumbar spine.37.38 In discussing lower motor neuron lesions, Knapp39 states that paralysis of both quadratus lumborum muscles makes walking impos-

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Anatomy

.

35

,

L- 1 lliocostal Fibers L-2 Iliolumbar L-3

Fibers

L-4 Iliolumbar Ligament

Figure

��7'"-=:::=����

}-25 Quadratus Lu mborum Muscle

sible, even with braces. This indicates the important role the quadratus lumborurn plays in stabilizing the lumbar spine while a person is upright. With the spine fixed in place, unilateral contraction raises the ipsilateral hip (hip hiking) . The quadratus lumborum also assists respiration by sta­ bilizing the 12th rib and i ts diaphragmatic attachment and is active in forced exhalation and coughing .40,4 1 The quadratus lumborum is under ac­ tive tension during sitting, lying, and walking posi tions.42 During gait, the quadratus lumborum shows increased EMG activity just before and dur­ ing ipsilateral and contrala teral heel strike. 43 Hip and Gluteal Region

The gluteal region is marked by the prominent rounded contour of the large gluteus maximus that characterizes the muscular development associ­ ated with mankind's upright posture (Figure 1-26). Having the largest cross-sectional area, the gluteus maxirnus is the strongest and most pow­ erful muscle in the body.44 It originates from the posterior aspect of the iliac crest near the posterior superior iliac spine, the erector spinae apo­ neurosis, the dorsal surface of the lower sacrum, the lateral aspect of the

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36

PELVIC LOCOMOTOR DYSFUNCTION

coccyx, and the sacrotuberous ligament. The larger upper fibers of the muscle descend obliquely and laterally to insert into the iliotibial tract with the tensor fascia lata muscle. The lower fibers insert onto the gluteal tuberosity of the proximal femur .

Gluteus Maximus Muscle

Tensor Fasciae Lata Gracilis Muscle

Semitendinosus Muscle Iliotibial Band Sartorius

Biceps Femoris

Muscle

Muscle

Semimembranosus Muscle

--"'t1�..DJJ.I..:IJ!.J

Plantaris Muscle

Popliteal Fossa

Gastrocnemius Muscle

Figure

1-26 Posterior Hip and Thigh Muscles

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37

maximus flmctions to extend and laterally rotate the

The joint. Its

fibers assist in hip abduction, and its lower fibers assist

adduction.45 The

maximus is m inimally active

normal

walking. However, its action is essential during running, jumping, walkfrom a deep squatting position. It aids i n

ing up a grade, and

plane. The gluteus maximus

stabilizing the integral role in

from the stooped position.

its insertion into the iliotibial

it lends dynamic lateral knee

It is innervated by the inferior The gluteus

nerve.

medius is the main abductor of the hip and is very efficient as lever arm (Figure

such due to its size and originates from the

It

the iliac crest, with its anterior two

thirds uncovered

maximus. It inserts into the lateral

of the greater trochanter. It

abducts the

joint. However, its an-

terior fibers assist in flexion and medial rotation of the hip joint, and its posterior fibers assist extension and lateral

a one-legged stance.

by the maintenance of a level The gluteus

minimus is the

rotation.45 This muscle is

in the coronal plane, exemplified

the

very important in

gluteal family, having a force

sister

medius. It lies deep to the glu-

equivalent to one third that of the

of the iliac crest, and in-

teus medius, originating from the serts onto the anterior surface of the essentially is a hip abductor but also the hip joint. Both the

trochanter (Figure

It

to flex and medially rotate

medius and the

minimus are inner­

vated by the superior gluteal nerve. member of the gluteal family, having

The tensorfasci£l iata is the

anteriorly on the pelvis and taken with it its shared innervation the gluteus medius and

the

gluteal nerve

}-26 through

as the gluteus

yet its lever arm is

abductor.44 It crest's

from the anterior the iliotibial band at the thirds of the thigh. In addition to hip rotate the via the Th e

lip and the

It inserts into the anterior

of the anterior

the middle and proximal it acts to flex and medially

joint. It extends the knee and

rotates the lower leg

ban d .

iliotibial band

is a thickened, tough

the fascia lata (Figure

of the dense lateral thigh

1-28). The tensor fascia lata and the gluteus

maximus insert into its proximal aspect to form the deltoid of the The iliotibial band inserts into the lateral

of the lateral tibial

on the tubercle of Gerdy. Owing to its lateral insertion below the knee

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38

PELVIC LOCOMOTOR DYSFUNCTION

Gluteus Medius

Gluteus

Muscle (Cut)

Maximus Muscle (Cut)

Gluteus Minimus

--�.........�-

Muscle

Piriformis

Sacrospinous

Muscle

Ligament

Superior Gemellus Muscle

Obturator I nternus Muscle

Inferior Gemellus Sacrotuberous

Muscle

Ligament

Quadratus Femoris Muscle Adductor Magnus Muscle

Gracilis Muscle Semimembranosus

Vastus Lateralis

Muscle

Muscle

Semitendinosus

Biceps Femoris

Muscle

Muscle

Gastrocnemius ---� Muscle

Figure 1-27

and Posterior Thigh Muscles

joint, the iliotibial band affords dynamic lateral stability, assisting the latof the knee.

eral collateral

Lateral Rotators

the Hip l a teral rotation of the

(Figure

are numerous and

n",W�'rtl

The most important of these is the piriformis muscle. It

nates from the underside of the sacrum and runs l a terally (Yr,""'I'pr

sciatic foramen to insert into the

chanter. In the normal physiologic duces l a teral rotation, flexion,

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aspect of the stance, the

a..,o"lco,.

Anatomy

I

39

I

I I \

Gluteus Maximus Tensor Fascia Lata

Iliotibial Band

\ \ \ \

/

A II

d

'I \

\ \ I

:i

�\

!

I I \ \ \ \ I I I I I

\�:::.

Figure 1-28 Iliotibial Band

function occurs when the femur is flexed past

60 degrees: the piriformis 60 d egrees, it

then causes medial rotation, extension, and abduction.44 At

mostly abducts. It is innervated by the ventral rami of L-5, 5-1, and 5-2. The quadratus femoris, obturator internus and externus, and gemelli superior and inferior are small muscles that function to rotate the hip joint laterally. The

quadratus femoris

arises from the lateral aspect of the ischial

tuberosity and inserts into the intertrochanteric area of the femur. In addi­ tion to l aterally rotating the hip j oint, the quadrahls femoris can adduct it. It is innervated by the nerve to the quadratus femoris. The obturator internus originates within the pelvis from the margin of the obturator foramen and obturator membrane. It exits the pelvis v i a the lesser sciatic notch, m akes a sharp bend below the ischial spine, and passes

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PEL VIC LOCOMOTOR DYSFUNCTION

40

to the hip trochanter.

to insert into the medial surface of the

ar<>:'''�r

obturator internus tendon is joined by the small

superior and inferior muscles as

originate from near the ischial spine The obturator

of the ischial

and

are innervated by the nerve to the obturator intern us. The inferior

is innervated

the nerve to the

femoris. In addition to laterally rotating the hip, the obturator internus and gemelli abduct the flexed The obturator externus arises from the external membrane and the bony margin

of the obturator

the obturator foramen. It travels back­

to wind around the back of the

ward and

joint and pass be­

hind the femoral neck to finally insert into the trochanteric fossa. Because of its winding course, the obturator externus can still laterally rotate the hip joint while the femur is flexed, as during sitting. It is innervated

the

branch of the obturator nerve. These small rotator muscles

to be

riorly.

their

to the rotator cuff

to stabilize the

also

and function should be addressed

treatment of painful

Adductors The hip adductors are considerable in number and are powerful (Figures 1-29 and 1-30). They help stabilize the

in the lateral

working in conjunction with the hip abductors. The erful of the adductors

is the adductor magnus. It and the ischial ramus

inferolateral as-

laterally. The most medial fibers run horizon­ tally a short distance to insert on the upper femur medial to the maxllnus attachment at the gluteal

The ischial ramus fibers run

the linea aspera and medial

to insert

line of the femur. Most of the fibers from the ischial tuberosity run inferior,

a

bercle. TItis

of the muscle is sometimes called the "third adductor."

muscle belly that inserts on the adductor tuacts to adduct the hip and powerfully extend it as

well.46 In a

communication, Travell commented on how the ad­

ductor magnus acts as a hams tring muscle due to its peculiar attachments. The adductor

is innervated

the obturator nerve and the tibial

division of the sciatic nerve. The adductor

L}',L HULL"

from the front of the

bone and de-

in the middle third of the femur. The adductor brevis arises from the outer surface of the inferior ramus of the

Copyrighted Material

A natomy

41

Sartorius Muscle (Cut) __ ___ �

Rectus Femoris Muscle (Cut)

-����L---_ Ii

Pubic Tubercle

Obturator Externus Muscle

Adductor Longus Muscle

Vastus Intermedius Muscle

Adductor Magnus Muscle

Vastus Lateralis

Vastus Medialis

Muscle

Muscle

Rectus

Semimembranosus Muscle

Femoris Muscle (Cut)

Medial Patellar Retinaculum

Figure 1-29

Deep Anterior Thigh Muscles

pubis and passes downward and backward to insert on the proximal fe­ mur between the lesser trochanter and linea aspera. The above two muscles adduct and flex the hip joint and are innervated by the obturator nerve. The pectineus is an often-overlooked adductor muscle. It arises from the superior ramus of the pubis and the bone near the pubic tubercle and courses downward, backward, and laterally to insert on the proximal fe­ mur, covering the adductor brevis. It functions to adduct and flex the thigh and is innervated by the femoral nerve and accessory obturator nerve. The gracilis muscle is a long, superficial adductor of the hip originating from the inferior ramus of the pubis and inferior half of the symphysis pubis. It runs inferiorly to insert on the proximal aspect of the medial tibia

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42

PELVIC LOCOMOTOR DYSFUNCTION

Gluteus Medius

Inguinal Ligament

Muscle

Iliopsoas Muscle Lacunar Ligament

�''''m'ff1rHf---_

Pectineus Muscle

1-I-llH+--- Adductor Longus Muscle Rectus Femori Muscle

Gracilis Muscle Vastus Lateralis Muscle

----J�:_;: Sartorius Muscle

Vastus Medialis Muscle

Ilioti bial Band

Patellar Ligament

Figure 1-30

------\'t.��

Anterior Thigh Muscles

just below the condyle. In addition to adducting the thigh, it flexes and medially rotates the lower leg at the knee joint. It is innervated by the obtu­ rator nerve. Hamstrin gs

The hamstring muscle group consists of the biceps femoris, semimem­ branosus, and semitendinosus (Figures 1-26 and 1-27). The biceps femoris forms the lateral hamstring and consists of a long and a short head. The long head originates from the ischial tuberosity and distal part of the sac­ rotuberous ligament. As it runs inferiorly, it receives the short head, which

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43

Anatomy

from the

shaft.

both form a common tendon collateral

that inserts into the fibular head and

The

head receives its innervation from the tibial portion.

the short head is innervated by the common

The semimembranosus and semitendinosus form the medial group. The semimembra nosus takes origin from the ischial tuberosity and runs inferiorly to insert on the posteromedial aspect

the medial tibial

off attachments that insert into the medial meniscus. The

semitendinosus

a common

with the biceps femoris long head.

It travels inferiorly to insert into the

of the

tibia with the gracilis and sartorius in what is called the pes a nserine tendo n. Both muscles derive their innervation from the tibial portion of the sciatic nerve. for the short head of the

muscles are biar�

therefore, their action at the hip is flex the

upon the position of

additionally, the medial and lateral

medial and lateral tibial rotation

. As a group,

extend the hip joint. This action is much more efficient with the knee extended. The biceps femoris assists lateral the knee

rotation with

and the semitendinosus and semimembranosus assist

medial hip rotation. Through their pull on the pelvis, the the trunk from a bent-forward

in

also

knees are extended. Anterior that

from the anterior

The two muscles

we need to consider are the sartorius and rectus femoris

sartorius takes

iliac spine. It then wraps

from the anterior

around the inside of the thigh and knee to insert into the don at the medial

of the

tate, and abduct the hip

1-30). The anserine tenro-

tibia. It acts to

It also flexes and

rotates the lower

at the knee. It is innervated by the femoral nerve. The rectus femoris is

the

muscle

that it acts at both knee and

and the fact Its straight head

and its re flected head of

arises from just above the acetabulum. It inserts into the superior the

It acts to flex the hip and extend the knee. Its action at the knee,

like that of the For example, with

is dependent upon the

of the

joint.

of the rectus femoris can only be accomor extension. This muscle is innervated

the femoral nerve.

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44

PELV1C LOCOMOTOR DYSFUNCTION

Pelvic Floor Muscles

The levator ani and coccygeus are two muscles that form the diaphragm and, as such, a re located in the floor of the pelvis. Their importance lies in the fact that of muscles to and the perpetuation of the pain of related to a The levator ani is a complex muscle due to its a ttachments and variously named pa rts, the p ubococcygeus, pu borectalis, and iliococcygeus (Figure and Generally, the levator ani extends between the and between the two lateral the coccyx walls. It is penIt inserts into the and female anal the structures that pierce i t, the midline, and the coccyx. It forms the majority of the pelvic and acts to support the viscera, the uterus, to add voltmtary control to continence. It is innervated by the fourth sacral and inferior rectal nerves. The coccygeus is a small muscle forming about one fourth of the and fans out to insert into from the ischial It "O(>n') on �" and of sacrum and support to It functions with the levator ani to a ttachment, i t may pull the coccyx viscera. Due to its I t derives i ts innervation and forward after the and fifth sacral nerves. As a n in animals the l! l()CCICCvg,el muscle serves to and the for tail muscle is the tail down and between the The body, a dense nodule of muscular is between anus and urethra in men and the anus and is sometimes called the central tendon the perineum; it is not tendinous. Several muscles, including the levator ani, meet and in terlace affording more structural support to the pelvic floor. Between the anus and coccyx is a similar structure called the :> ,...,-.rr,rr'il O-<'" which is actually made up of fibromuscular tissue. ARTICULAR I N N E RVATION

As the lumbar nerve roots exit the immedia tely divide into dorsal and ventral primary rami. The rami arch dorsally to innervate essentially the s tructures to the transverse This includes the dorsal the facet and their and supply ligaments. The primary rami enter the lumbar motor, sensory, and reflex innervation to the lower extremity and struc­ tures a nterior to the transverse Therefore, clinical

Copyrighted Material

A

�

B Urethra Pubococcygeus Vagina Perineal Body lIiococcygeus Puborectalis Anal Canal Anococcygeal Ligament Coccygeus

Figure 1-31

Muscles of the pelvic floor, sup erior aspect. (A) Female. (B) Male.

�

;:i :::,

�

«:::

"'" U1

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46

PELVIC LOCOMOTOR DYSFuNCTION

examination tests that assess lower and reflex and sensory muscle the ventral primary ramus. The la teral aspect of the sacroi liac rami. branches of the L-5 through S-2 form a ligament and the interosseous between the is supplied the L-3 through 5-2 nerves .1, 16 joint, the sacroiliac joint is richly supplied is innervated by several nerves Branches from the the joint. A branch from the nerve to the hip join t. receives articular branches from the obturator receives its innervation from the lower

TOPOGRAPHICAL ANATOMY FOR PALPATION

Topographically, the lower back a vast amount of anacomplex tomical territory. We are concerned primarily with the of the pelvis, of the (SIn and sacroiliac the Posterior Aspect

On level with the height of the iliac crests is the L4-5 (Figure 1-32). The PSISs are just deep to the dimples on either side of the lower back. Their size and shape can vary, and detection tissue by palpa tion can be difficult, especially if a of mark the covers them, The PSISs of the Situated small S-2 The L-5 the 51], covered At this level, by the thick interosseous sacroiliac the joint is about 3 cm deep and is inaccessible to direct However, SIJ movement can be detected monitoring the movements that occur between the PSIS and S-2 tubercle. The iliolumbar and are difficult to unless they become the L-4 and L-5 transverse processes are accessible at their

Copyrighted Material

Anatomy

47

7 2

8

9

4

,.._�-r 1 0

Figure 1-32 Palpation landmarks, posterior aspect. (1) Sacrospinalis tendon inser­ tion, (2) smaLl origin of gluteus medius muscle, (3) posterior inferior iliac spine, (4) greater trochanter, (5) piriformis muscle, (6) inferior lateral angle of the sacrum, (7) quadratus lumborum muscle, (8) posterior superior iliac spine, (9) sacrotuberous ligament, and (10) ischial tuberosity. Dorsal Sacroliac Ligament

Anterior Sac roiliac Ligament

Figure 1-33

Cross-sectional view of upper aspect of sacroiliac joint. Dou ble­ headed arrow indicates depth of sacroiliac joint's articular portion. Note in­ terosseous ligament.

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48

PELVIC LOCOMOTOR DYSFUNCTION

cephalad of the PSIS can be felt the tendons of the erector spinae muscle group as

Just lateral to the PSIS is the

insert into the

5 to 6 em infe-

medius muscle.

small origin of the

inferior iliac spine

rior and slightly lateral to the PSIS is the

(PITS). Just medial to this is the lower aspect of the SII, which is the where the SIJ can be directly lower

Inierior and medial to the nonarticular inferior lateral

the

of the SIJ can be

angle of the sacrum. The sacral cornua and interposed sacral hiatus can be of the sacrum. The ischial tu-

felt in the midline on the most inferior berosity is

found at the level of

fold in the mass of the

buttocks. An important structure to

and palpate is the sacrotuber-

ous l igament. It can be found by following its course between the ischial tuberosity and sacrum. It feels similar to a firm, taut cord. Often, with vic

dysfunction, the sacrotuberous

as

tense

and tender. The piriformis muscle is best palpated with the patient p rone, the knee and the thigh internally rotated by pulling the bent

flexed to 90

a stretch on the p iriformis. The muscle lies on line

laterally. This

trochanter and the sacrum. It can be

of the

with the

palpated at the i ntersection

two lines: one

trochanter, and the other spine

and lower maximus and may be

the PSIS and the the anterior

" '-" V ". "'.,,

It lies deep to the

to the

spasm is iden-

tified as a taut, tender band of muscle in the sciatic notch. The coccyx is palpated within the confines of the upper aspect of the gluteal cleft. The most effective rectum. With the

to palpate the

is through the

position, a lubricated,

in the lateral

gloved index finger is slowly inserted into the rectum after the external and internal anal

have relaxed. The coccyx can then be palpated

between the i ndex

and the thumb externally.

M "I\"H'",,'r

much information can be obtained via external palpation. For reasons, a gloved

should still be used to palpate the

the

pressure and patient relaxation combine to allow

cleft.

an

examination.

deep in

most of the coccyx can be felt

through the 50ft tissues of the Lateral Aspect

With the

of the laterally

in a

trochanter

structures can be

as a

the hollow area visible on the lateral as-

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49

midway between the with the hip flexed. The trochanter consists a line of medius and han from the greater to the iliac one can loca te these medius muscles. The gluteus minimus lies deep. The origin of the that is j ust inferior to the crest of the ilium is easily fascia lata is seen as a b ulge of muscle j ust inferior a longitudi­ The iliotibial tract is a thick band of connective tissue naUy nmning crease in the lateral of the thigh. This is best seen if the and asked to raise the straight off the table j us t a few patient is inches. region. The sciatic nerve is and the ischial

Anterior

tha t is palpated from the fron t The examiner's thumbs are allowed to contact the ASISs while the hands encircle the iliac crests. The inguinal ligament can be followed by the thumbs small bumps of to the bone the mons pubis. pubis is and the thigh ab"""',",,",,,-,-,, as a definite sulcus. With the

McBurney's Point Superior Iliac Spine Baer's Point

1-34 Palpation

Anterior

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50

PELVIC LOCOMOTOR DYSFUNCTION

ducted as in the Patrick-Fabere test position, a prominent cord of tendon toward the middle of the can be felt extending from the p ubic the adductor longus muscle. Medial to and j ust bethigh. This the iliacus muscle can be palpated low the inward and laterally. The muscle can be palpated with the of the contact 1-35). The lateral to the rectus abdominis muscle at the level the ASIS and are pressed carefully but firmly in a and medial direction. The to raise the straight off the table, thus patient is then asked its muscle to rise up to the contracting the psoas and examiner's fingers. It should feel mildly taut and painless. of the middle and lateral thirds of a line corulecting the ASIS The and the umbilicus marks point. Just below this is Baer's sacro­ 1-34). Patients with joint problems often dis­ iliac play tenderness here upon palpation, occasionally causing them to com­ of abdominal wall soreness in their history. Bourdillion mentions point as being tender in SI] infections and strains.5O The sacral promand to the umcan be palpated in slender people bony landpressure until the but bilicus using mark is C O N GENITAL A N O MALIES AND VARIANTS

The transitional areas of the are restless"51 and therefore are areas where congenital anomalies commonly manifest. The lumbosacral and pelvic areas constitute fertile ground for such occur­ functional dis­ these areas are common sites of rences. turbances. Since manual methods entail tests of movement and meticu­ of anatomic structures, the influence of anomalous lous anatomy i n clinical assessment needs to be rl-'L';.n,,, ,,,, The sacrum can with a number of different variations. Solonen observed variable of the sacrum's lateral aspect in 30 Only 5 cases (16%) were The left side was wider in 19 cases. Schmorl and Junghanns write of variations in sacral ala height.51 A and sacralized fifth lumbar lumbarized first sacral are common occurrences. The L-5 can be transitional and can form an adventitious or accessory joint the sacrum either lmilaterally or biiatspatulated transverse process of L-5 can articulate with the rt h,r,,' " " or fuse with it. In some cases, these accesmay need manual methods directed at them. sory

Copyrighted Material

Anatomy

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51

52

PELV1C LOCOMOTOR DYSFUNCTION

The sacroiliac joint is associated with accessory joint formations in ap­ proximately

30% of cases.52 Trotter53 noted a higher incidence

In 16% of dried

and

accessory sacroiliac

jOints in whites than b l acks. Ehara et aJ54 observed

13% of pelvic CT scans of 100 pa-

tients. The sacral

of the accessory joints are located on the

surface

the sacrum just l ateral to the second sacral foramen.

n"'''''', r , r,,.

iliac facets are

found on the medial

occur as small

frequently,

of the PSIS, Less

projections from the iliac

medial to the PSIS.54 It is not definite whether the

::>''r'PC'OAT'"

crease in occurrence of accessory noted arthritic

in these accessory

thought they could be a potential source of low back

as

with any o ther joint, radiographic evidence of osteoarthritis does not correlate well with subjective can be a cause of '-�LAU"V

Arthritic or not, anomalous

and need to be attended to.

syndrome can be present where an

process is associated with spina bifida occulta of the first sacral In

or iliac

ilia.58 In

exostoses are on the sacral

Hohl

or caudal

which the sacrum and sometimes lower lumbar

ron-r",,,,,,

were missing.59

The iliac artery may create an anomalous bony arch called the paraglenoid " ...,'L U.J,

enough,

which, if

and Currarin061

on

Muecke

confuse

rr"" (y�'n

and its association with rotuberous ligaments may calcify variants, Of what clinical

are anomalous

As far as the body

the anomalous structure has been part of the

is

tomic inventory since birth. The mere constitutes shaky evidence o n

ana-

of an anomalous structure t o blame the

symptoms. I t is common to observe in clinical known to exist accessory articulations or these are potential sites of dysfunction low back

can be the predominant cause

Commonly observed radiographic evidence

in these anomalous joints wear. Being joints,

movement and

are apt to become dysfunctional and

need to be examined. If such is the case, 'VL"aj'V�'"

joint can

mobilizations directed relief. But standard

Copyrighted Material

at the

Anatomy

53

joints tend to affect the anomalous

lization and manipulation of the

jOints too. More commonly, however, it is the neighboring joints and tis­ sues, not the anomaly, that create the problem. The anomalous can become

in

to

"o�, ..... ,�r'"

for dysfunctional

On the other hand, dysfunctional neighboring

boring

themselves can be causing the pain, but often the anomaly is blamed by mere

Chapter Review Questions of articulations found in the pelvic

•

Name the six

•

Describe the differences between the sacral and iliac sacroiliac joint.

•

How is a child's SIJ different from an adult's

•

Why is the SIJ considered a true diarthrosis?

•

What is the

of the anteversion of both the

and the •

•

•

! .

of the thoracolumbar fascia? What

What is the three

it can stabilize the lumbar spine during

Describe

elucidation of the lumbar

and how it

from link

What knee flmction?

are anomalous anatomical

Of what clinical

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Copyrighted Material

Am ]

l\lll"HlVnz

Chapter 2

Function

to

It is

to oneself the opinion that what one

does not exist. -Steindlerl

Chapter Objectives .. to discuss the functional mechanics of the .. to explain dynamics of the standing posture and fects thereof of

.. to describe the various

relates

and how

pelvic function .. to discuss menstrual and pregnancy changes that affect the .. to explain the mechanics of

as it relates to pelvic

the literature rA''\,,
function

of sacroiliac joint function, two things are certain: (1)

the sacroiliac joints are considered diarthrodial and therefore do move; the exact character of this movement is controversial. The made (Figure

of a

analogous to a

(2) is

motion segment

The sacroiliac joints and pubic symphysis function in concert

to yield suppleness to the pelvis. This kinematic chain of joints also includes the hip joint, the lumbosacral

and the "",,'rnrn,-r,,'cyp

the first kinesiologist, was the initial person to concept of links to the human body; he defined a

57

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58

PELVIC LOCOMOTOR DYSFUNCT10N

2 3

\

Figure 2-1 The pelvis as a three-joint

rr"��'QV

facet joints are analogous to the bral disc is analogous to the

distance between

of links is

axes. A mechanical

termed a kinematic

it can be

kinematic

or closed.

chains occur when the peripheral link is free and are the most frequently found

ends of the limbs

in the body. For example, the

are free to move without affecting more Brunnstrom2 states that the rib cage and pelvis are the only closed kine­ matic chains in the

movement occurs

In a closed kinematic

such that all links in the system are affected interdependently. Theoreti­ cally, biomechanical stresses can be spread among members of the chain, linking them in function as well as dysfunction. The pubic

and

joints are linked in another. As

at one can create

commonly occur together. In addi-

lumbar, and sacroiliac joint

a dysfunctional joint on one side may force the opposite side joint to in a painful manner. Due to their

between the trunk and lower

and and their related

due to the

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Function

59

structures are susceptible to injury and subsequent dysfunction. These can have far-reaching effects in the locomotor system. Therefore, an awareness concerning their role in locomotor disturbances needs to be developed. Undoubtedly, more research needs to be done to sift through the avail­ able information and separate fact from conjecture and error. As pointed out by Grieve,3 experimental errors due to (1) the use of cadavers for study, (2) attempts to measure joint motion in tightly coapted joints during weight bearing, and (3) failure to put the sacroiliac joints through a full range of motion need to be considered in making conclusions about the scientific evidence before us.

SACROILIAC JOINT Movement does occur in the sacroiliac joint and pubic symphysis. Al­ though small, and in some instances imperceptible, this movement plays an important role in the overall functioning of the pelvis and lower back. The pelvic joints act to afford shock absorbency and pliability to the pelvis itself. The symmetrical motion of nutation and the asymmetrical motion of antagonistic iliac rotations at the sacroiliac joints seem to be the more ac­ cepted movements and the ones most commonly worked with clinically. Controversy still exists as to the exact axis or axes of rotation found in sacroiliac joint motion. The adaptive movements the pelvis makes in re­ sponse to postural changes are important to consider. Loss of these move­ ments via dysfunction will make it difficult for the patient to perform nor­ mal daily activities. More emphasis is commonly placed on the sagittal plane movements of the ilia, that is, flexion and extension, sacral nutation/ counternutation, and the dynamic pelvic changes made during different postures when examining for and treating sacroiliac joint dysfunction. The sacrum and ilia can move in relation to each other either symmetri­ cally or asymmetrically. Relating these movements to our patients' daily activities and injuries may help us better understand their problems. Sym­ metrical motions occur when the sacrum moves correspondingly to both ilia simultaneously, as, for example, during nutation or counternutation. Both ilia can move simultaneously in relation to the sacrum in a symmetri­ cal fashion. An example is simultaneous flexion or extension of both ilia on the sacrum. Asymmetrical motion entails twisting and bending motions of the sacrum in between the ilia or antagonistic movements of the ilia in relation to each other and the sacrum: for example, posterior rotation of the right ilium on the sacrum with anterior rotation of the left ilium.

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60

PELVIC LOCOMOTOR DYSFUNCTION

Symmetrical Motion Sacral NutationlCounternutation

or

the process of going from supine to of the

forward

the sacrum nods or nutates forward and downward and the ischial tuber­ During nutation, the sacral base moves anteriorly and

osities

inferiorly and the sacral apex moves posteriorly, with motion being checked

trunk

the sacrohtberous and

position, the oppo-

from

extension or when

site motions, or countemutation, occur. This explains why a dysfunctional sacroiliac joint that is unable to accommodate to these dynamic postural alterations may a

to arise from bed or

pain when a patient

flexion the

position. Janse5 and Illi6,7 further assume

sacrum nutates on one side and countemutates on the other side so that in between the ilia. In other

the sacrum

in addition to nu­

tating, the sacrum torques or twists. Iliac Motion

WalcherS demonstrated symmetrical

motion by

the hips; flexion increased the

and

outlet, and extension

inlet. motion via the ischial tuberosities

when someone was the pelvic (Figure

while the iliac crests approximated discusses this same mechanism of

2-2A).

motion when the pelvis assumes the

posrure.

Mennellll states that the distance between the

iliac of an inch as the iliac

to three

one

the transition from the sitting to the prone position.

crests

and the

Similarly, Gillet and Liekens9 observed the iliac crests to

while the reverse oc-

ischial ruberosities to

is unable to

curred on movements to

these a person will

to

difficulty in rising from or getting into a seated position. In fact, common occurrence in sacroiliac joint of

upon

patients

from a chair. It is not sitting itself that

but the actual act of Shtresson et aP2 observed the ilia to rotate nnQt prl{"\,rl moved from

to sitting or standing.

to approximate each other consistently when

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when the subject

iliac crests were also noted from the

to sit-

Function

61

A

2-2 Changes in pelvic

of Mennell and Gillet and the Liekens in that Strachan et aID spinal traction and compression to cause sacral extension and flexion respectively. Asymmetrical Motion

or motion occurs at the sacroiliac joints such to that the sacrum moves in relation to the ilia, or the ilia move one another in relation to the sacrum.6,7,9,J3-15 Sacral Motion Relative to the Ilia

Gillet and Uekens comment that "the sacrum flexes from side to in the base moving farther than the apex. It is usually its movements, being influenced either by the lumbars if the force comes from or by the ilia if it comes from below."9(p9) The sacrum tends to follow the lumbar trunk motionp·1S It also seems to act like a lumbar motion in that it characteristics of coupled motionp,15 Rotation of the lumbar spine causes ipsilateral rota­ tion of the sacrum with contralateral lateral flexion of the sacrum.14 Lateral flexion of the lumbar is associated with lateral of the sacrum coupled with minimal and inconsistent sacral rotation.13

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62

PELVIC LOCOMOTOR DYSFUNCTION

Gillet and Liekens9 while the

between the ilia

is

position. For to the trunk

when left rotation

sways to the right,

while the to lean right.

causing the entire lumbar

induces a right lateral

z-axis rotation) to the sacrum. sacnun rotates with the lumbar rotation). In addition, the

the

left

iliac crest moves and posteriorly, but minimally.

while the left iliac crest moves

Figure 2-3 demonstrates the ability of the sacrum to rotate between the ilia, as visualized on a CT scan. describe sacral motion

Gillet and Liekens9 the ilia in response to lateral When the

localized

between

to the

is sitting, the left shoulder is

spine.

strongly toward the

right hip to bend the lumbar spine to the left (Figure

The sacrum can

be observed to follow the sway of the lumbar

and to tilt to the

z-axis rotation) between the 1:\vo ilia. The two ilia slant a

letter "M,t! with the 1:\vo verti-

cal lines of the letter representing the ilia. The Ilia's Motion Relative to Each Other and to the Sacnlm movements of the ilia have been described and will be reGillet

described

test extensively to

and Liekens.9 These authors have used a

accentuate gait parameters in order to study sacroiliac joint motion. This is graphically in

2-5 and 2-6. Figure 2-6A shows the Gillet and Liekens observed that

right sacroiliac joint in when a

stood and raised the

ilium rotated backward rior

for

bent

the right

x-axis rotation) so that the

iliac spine was palpated to move posteriorly and inferiorly in 2-5 and 2--{iB). This move­

relation to the second sacral tubercle

sacroiliac joint. iliac

and sacral tubercle were still

was asked to raise the left leg, a different motion was perceived at the right sacroiliac joint. When the left ilium reached its end

of motion with the sacrum, further

of the left

the sacrum to move in relation to the as the left knee was raised higher, the left ilium and and

This motion is

caused

ilium. For ex-

relative to the right ilium

the 2-5

extension of the right sacroiliac

and Liekens mention that this latter motion of the sacrum relative to the

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Function

63

Figure 2-3 CT Scan Showing Sacral Rotation About Its Long Axis. Source: Re­ printed from Chiropractic Management of Spine-Related Disorders by M.L Ga tterman, ed., p. 121, with permission of Williams & Wilkins, © 1990.

Figure 2-4 Lateral Flexion Localized to the Lumbar Spine

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64

PELVIC LOCOMOTOR DYSFUNCTION

I�

Figure 2-5

A

\

Test and Palpation of Sacroiliac Joint Motion

Left Ilium

Sacrum Axis

Sacroiliac Join! in Neutral Position

continues Figure 2-6 G ra p hic representation of sacroiliac joint motion. (A) Right sacroiliac knee or flexion of the right joint in neutral position. (8) Motion or of the sacrosacroiliac joint. (C) Motion left iliac

Copyrighted Material

65 Figure 2-6 continued B

Bearing Ilium Side of Thigh Flexion

Sacroiliac Joint Flexion

c

Ilium

Side of Leg Raising

�'-+-!lium

Ilium

on

Sacrum

Axis

Sacrum Exl'fmrjinn on Ilium

Side of Weight­ Leg

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PELVIC LOCOMOTOR DYSFUNCTION

66

weight-bearing ilium does not seem to follow the sacroiliac surface contour and is

due to

et aP6 and Wilder et aP7 being able to

discuss the occur to allow

joint translation.

The extension motion at the sacroiliac joint mentioned previously is found

This is most likely due to the assume

posof

in modem

exercise. Extension of the hip and sacroiliac joints is in the daily activities many

the

especially our patients,

joints once in a day?

person. How

extend the hip and sacroiliac

the

accommodates to more flexat these

ion activities at the describes

motion between the ilium on the

evated thigh, the sacrum in the as a "chain

and the ilium on the side of stance

of movement in which one bone pulls

when the end of articular excursion is reached."18(p150) findings of Gillet and

on the

Sandoz18 states that at the end of movement

test, the sacrum is nutated on the side of the flexed thigh

in the

and countemutated on the side of

He also mentions that

further thigh flexion causes the joint.

stance leg at the

Axes of Rotation

As can be seen from the foregoing discussion, there are many opinions to sacroiliac joint function. The

as to pel-

vic motion is still unsettled. The difficulty in this joint arises from its

and

a""C"�'il

and ability to move in a sym-

metric and asymmetric

comments are

It would sometimes be more

:>",r" .'''c

of resiliency or

of the

micro-movement instead

perceptible movement of the sacroiliac joints, owing to the relative thickness of the articular

of the sacroiliac joints

as th.ick on the sacral side than on the iliac side), movement consists more

of

in some

of the

articular space and distraction in others rather than actual ing of the articular surfaces. The summation of such movement in both sacroiliac can

and in the

result in an

torsion.18(pl09)

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Function

67

It seems that the gliding motions occur more often in and in pelvises of women who are occurs more through the joint Sandoz Various axes

of. have been DHJD()Se'Q by

rotation for the sacroiliac

several researchers. Most authorities describe the around a transverse axis through the S-2 the axis of rotation

Farabeuf19

movement occur-

"A{:rrn,An

as one of rotation.

to the sacroiliac joint facet

surface within the interosseous (axial as described by Kapandji,lO locates the axis between the cranial and caudal

at Bonnaire's

2-7B). Weis14 describes the axis of rotation as 5 to 10 em the sacral

In

he de-

scribes a linear or translatory motion of of the sacroiliac joint

caudal lower

This may be why the

excursions seem smaller than those of the upper joint during

clinical assessment. et a120 applied torque and linear forces to the ilia while the sacrum was fixed. He noted the axis of rotation to be located far anterior to Mitchell et aFl describe

the sacroiliac jOint, nearer the

many axes of rotation, including two horizontal and two oblique or diagonal axes.

two horizontal

also make the distinction

between sacroiliac and iliosacral

on whether motion is

initiated from the trunk or lower limbs et aF2 describe a transverse axis of rotation for nutation through the iliac tuberosity on level with the S-2 tubercle. Pitkin and Pheasant15 through the body of in the

also describe a transverse axis

symphysis with an-

iliac movements. Wilder et a}l7 conclude that rotation cannot occur solely around any one of the previously

axes of rotation due to the considerable varia-

tion they found between

rotation found would include

translation, which would

the supporting ligaments and function

as a shock-absorbing mechanism.

PUBIC SYMPHYSIS The pubic symphysis contributes to the functional stability of the ring, and disruption of its functional

can affect sacroiliac joint function. The the pubic symphysis and the sacroiliac

is discussed by Harris and Murray.23 They mention how abnormal

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P ELVIC LOCOMOTOR DYSFUNCTION

68

2-7 Axes of motion at the sacroiliac joint. (A) Farabeuf's. (B) Bonnaire's. (0 (D) Weisl's.

motion may lead to state that a width at the yet one athlete

at one or both sacroiliac joints. symphysis of 10 mm is the upper limit examined had a IS-mm

with only

instability present. to

could

symphysis

The pubic symphysis is

held together

stout ligaments

to be "spring-loading" under considerable

the anterior thus stabilizing the

Traumatic

of this ten-

sion destabilizes the pelvis so that structural integrity is the pelvic ring

if the pubic symphysis is iliac

instability occurs, and the sacrum subluxates Pauwels25 mentions that the pubic symphysis is under

nantly

rather than

forces. In contrast,

how the pelvic force vectors converge on the

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Function

Sandoz18

how both kinds of forces can act

69

with

tensile forces at the pubic symphysis predominating in the recumbent ture but reduced during standing due to their transmission via the femora. Luschka26 and Schlenzka27 compare the pubic to the intervertebral discs. Under normal physiological has not

minimal movement, the precise nature of

elucidated. Pitkin and Pheasant15 discuss torsional around a transverse axis in the alllal',Vllllt>llL iliac motions (Figure

Schunke28 noted

bone moved forward in a

motion

one-

HIP It is

that the large ball-and-socket fossa of the shoulder joint. In the the femoral head is only partially

rn,.'<>Y<',.,

,

, ,

,

;

, \

"

Figure 2-8 Torsional Motion at the Pubic Symphysis

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sacrifices to the shal-

for stability, owing to its deep-set socket as

PELVIC LOCOMOTOR DYSFUNCTION

70

This is due to the anteversion of both the acetabulum and femoral head (Figure

surface area is

Consequently, the effective

limited to a small area on the

part of the femoral head.

Rotation and translation occur about three axes directed anterovertically, and

from the

Translational mo-

tion is small and limited to joint cross both the hip and knee

movement at the hip joint is

by knee joint position and vice versa. For example, with the knee fully flexed due to relaxation of the flexion flattens the lumbar lordosis and can exceed 140 stopped by soft tissue approximation. The

joint is extended in the standing around the hip affords

As a matter of

person can rest the entire trunk weight on the hip

ligaments

extending the hip and mitigating the need for

ing the pelvis muscular effort.

extension is affected by the amount of knee flexion present due to of the two-joint rectus

muscle. Full flexion of the knee

tightens the rectus femoris and therefore limits full hip extension. However, with the knee limited

(extended),

extension can occur to about 20

the strong

ligament. Hip extension

lumbar lordosis by tilting the pelvic anteriorly. Forceful extension

a torque force

the sacroiliac joint via the

ligament a situation that becomes useful when one is to manipulate the sacroiliac

examination and

maneuvers,

Anterior

Figure 2-9 Transverse section femoroacetabular of both the acetabulum and femoral neck.

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Note anteversion

Function

Because the hip joints are the

of

center

abductor muscles

considerable forces to the up­ stance. The

stabilize the load at the hip minus

71

to the

is approximately

weight of the lower extremities plus the

contraction of the hip abductors. This can amount to a considerable force approaching three times the body weight.29 Dilling the stance the ipsilateral hip abductors contract to prevent the

2-10A).

down on the opposite side

the compressive force exerted across the joint due to hip abductor contraction can add

to the joint reactive force. With

abductor weakness, the

leans toward or even over the involved abductor contraction to

thus obviating the need

The same mechanism occurs with a the

reduces the need reduction in joint

of diminished abductor contraction force lessens the in situations of a painful

or hip abductor

tend to lean toward the

side.

STANDING POSTURE AND GRAVITY Before we consider the effects of gravitational the

we need to

VVv"'VAU'"

The hip

the joints involved

is situated

and lateral to the sacroiliac joint by about 2 in. TIle being borne by the sacrum is transferred across the sacroiliac joints and along the ilia to meet the at the hip joints

reactive forces from the lower extremities The weight of the trunk forces the sacrum to and inferiorly

nutate forward so that the promontory moves

This movement, or

and the sacral apex moves posteriorly and

tendency to move, is countered by the anterior sacroiliac Jjgaments and large, powerful check ligaments: the sacrotuberous and sacrospinous liga­ ments. The center with the being transmitted riorly on the

is behind the axis

the

the pelvis and trunk, and with the from the femoral

the

Consequently, reactive force tends to tip

heads. With the sacrum simultaneously

tated anteriorly due to the weight nutation at the sacroiliac joint occurs.

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nu-

a relative accentuation of the innominates are

72

PELVIC LOCOMOTOR DYSFUNCTION

A

B

n::-lt::"-",,,ustance. (A) Downward­ femoral head. Upward arrow muscle contraction joint reaction force at hip of trunk over painful lessens hip abductor contraction (8) needed to stabilize unilateral stance.

T

------

Figure 2-11

of Sacroiliac and

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Function

73

Figure 2-12 Forces from the Spine and Lower Extremities Converging on the Pel­ vis. Source: Adapted from The Physiologtj of the Joints, Vol. 3, by I.A. Kapandji, p. 57, with permission of Churchill Livingstone, © 1974.

forced into posterior rotation while the interposed sacrum is simulta­ neously forced into anterior rotation (Figure 2-13). In one-legged stance, the weight-bearing femur imparts a cephalad shear force at the pubic symphysis (Figure 2-14). If an instability were to exist at the pubic symphysis, the pubic bone ipsilateral to the side of weight bearing would shift cephalad. Due to the offset relationship between the hip and sacroiliac joints, one can appreciate the torsional forces occurring at the sacroiliac joint during one-legged stance, and consequently the discomfort that a patient with sacroiliac joint dysfunction can experience during such a stance. In fact, clinically patients with sacroiliac joint dysfunction typically have diffi­ culty bearing weight on the affected side.

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74

PELVIC LOCOMOTOR DYSFUNCTION

forces acting that the innominate is tilted posteriorly the sacrum tilts Source: Adapted from The Physiologtj of the with permission of Churchill Livingstone,

a lumbopelvic rhythm is noted in which

forward tnmk of flexion is

60 lordosis while

This is followed by an additional 25 the erector

When full flexion is this

of the lumbar

by

is restrained by the pull of the

the sacrum is noted to sink

of flexion at the muscles relax between the ilia as the iliac

Gitelman33 mentions a test used by Grice to monitor rhythm. with the index or middle apex with the thumb

palpating the

superior iliac

and simultaneously palpating the sacral the same hand, one should observe them to

up to V2 in during forward trunk flexion if the lumbopelvic rhythm is normal (Figure 2-15). During trunk extension from the forward flexed

the above events reverse. A similar test can be

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Function

2-14 Shear Stress at Pubic ""'JTnnln"�""

with the

75

Unilateral Stance

seated. In either case, if a

superior iliac

is

noted to be lower than the other side and is observed to move Piedallu's

trunk flexion, a

and surpass its mate

sign is said to exist. This is indicative of sacroiliac side as the ilium is carried forward with the

restriction on that sacrum and lumbar

spine. MOTIONS DURING GAIT

Pelvic motions during

occur in a rhythmic fashion. In addition to

of the

center

walking, the and rota­

Illi6 believes that the sacroiliac

joints

function to dampen these torsional movements before they are

transferred to the lumbar should remain any

He feels that

the lumbar spine

stable and not

oscillations to

extent. He thinks that when it

prone to scoliotic deformities and tiP',,""""''''T' '' pensation. the swing

of gait, the entire pelvis rotates

horizontal plane on the side of the

limb.34 The

on the weight-bearing side contracts to stabilize the tal

in the horizon­

cineradiographic techniques, IllF showed that at heel ilium moves

tates on that side. pulled

in the leClUllCCto,

the

while the sacrum nuL-5 transverse process is

At midstance, the pelvis sways toward the weight-

bearing limb, and the posterior iliac rotation starts to reverse toward neu­ tral and

to anterior rotation as the limb is carried into extension

for toe-off. The sacral base on that side also reverses from a nutated

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76

PELVIC LOCOMOTOR DYSFUNCTION

down on person

lion at heel strike to one of counternutation moves over the weight-bearing superior) at toe-off as the process is repeated on the opposite side. SACRAL MOTION WITH RESPIRATION

Sacral motion occurring with the respiratory piratory mechanism, ie, the craniosacral workers in the chiropractic and fields.35-3B and Sutherland36 mention how the sacrum inherently nutates and counnutation-counternutation motion rhythm. This ternutates in a occurs as part the craniosacral proposed by Sutherland36 at a of 8 to 12 cycles per second37 and is of the tory cycle. Inhalation is also associated with whereas nutation occurs with exhalation. The point is that these movements may be assistance. facilitated during manual treatment with MENSTRUAL AND PREGNANCY-INDUCED C HANGES

Brooke14 states that sacroiliac joint mobility increases by as much as and Colachis et a139 and Chamberlain40 state that due to relaxed pelvic and lumbar increased is also seen menstruation. Sandozl8 mentions that Maigna141 observed lumbar hypermobility observed that ....rc.crn:>nr'" sodated with relaxation symphysis and 250%

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Function

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77

78

PELVIC

LOCOMOTOR DYSFUNCTION

2-17 Hhythmic Rotational and Lateral Sway Movements of the Pelvis Dur­ ing the Gait Cycle

ments, indicated by a variable "ern,,.,,,,,,,

that the

mester of pregnancy

of interpubic widening. He also rec-

space gradually widened did not

months, and that it took 3 to 6 months the prepregnant state.

Copyrighted Material

to the third trithe last

2

Function

Relaxin, a polypeptide hormone resembling

79

is believed to be

for the softening or relaxation of the pelvic ligaments and uterand di-

It is found early in

ine cervix to facilitate

to relaxin <:P('rpt1n,n

As a

minishes rapidly after

demonstrates amplified physiologic movements. Sandoz makes

the

the following comments: delivery, and especially the

constitute movements

moments since physiological

are greatly amplified and become more accessible to tion. As the functional

of this period of life repre-

sent nothing more than

that have ex-

ceeded the boundaries

the norm, one can, by deduction,

imagine rather well what is bound to happen under physiologi­ because of the

cal conditions and is more difficult to of pelvic movements.18(pl0l)

small

a physiologic instabilit y of pregnancy commonly occurs, what Young42 terms "pelvic arthropathy of two

II

of which he identifies

In one type, hypermobility exists at both the the o ther involves

and sacroiliac common of

the sacroiliac is the

two is the latter. Commonly seen

characteristic waddling

to the physiologic instability of the joints in gait

of the

pelvis. This mechanics.

period are vulnerable times for a and the added tasks of caring for

joints.

On the other hand,

a child put her at risk for sacroiliac

judgment and care are a must when using manual women so as not to intrude on this physiologically intpr<><:h,no- are the cyclic

also mani-

that the

menstruation. I t is very common to find sacroiliac women near and

the time of their menstrual

is the relief when the pelvic

pain in Even more

by women from menstrual discomforts

are treated for

L IFTING MECHANICS

The

objects results in substantial forces

musculature in the hip and low back trunk and lower

the pelvis

by the situated between the

must withstand rrPTT,,c'n

loads during lifting maneuvers. McGill44 demonstrated how the area of the

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80

PELVIC LOCOMOTOR DYSFUNCTION

sacroiliac joint can be subjected to high loads with moderate sagittal-plane lifts.

a 50-1b weight has been shown to exert over 1400 Ib of force at

the sacroiliac joint by erector

This is due to the force

muscles

their attachments to the sacrum and ilium.

Lifting,

the trunk but also exten-

extension not only

The low back muscle mass cannot generate

sion at the to lift

loads. On the other constitute a

the

extensors (gluteus of

muscle mass that is

generating an extensive contraction force. The

is transferring this

force to the lumbar spine without overloading the low back musculature. and its

In an excellent discussion on low back '-'v"'��'"

to lift-

describe the

and

ligaments, and Various theories

to

fascia

th{1,r::l,'"

how the low back functions during lift-

ing, but they are not yet

proven. One involves the role of the abdomito create enough intra-abdominal pressure

nal musdes46 and their to support the trunk

as Bogduk and Twomey45

out, data from studies

do not correlate well with

between intra-abdominal pressure, disc pressure, back

the

and lumbar

loads. and its

involves the use of the posterior

Bogduk

to sustain higher tensile loads than the muscular summarize: The essence of this theory is that the power of the hip extensors. The back muscles do not too small to lift acts

and is kept

power of the hip extensors to be transmitted through its posterior the mo-

approaches the upright

As the

ment exerted by the lifted weight is reduced, and the back muscles are

at

of

the lift.45(p90)

and Twomey45 add that somewhere

the way, the force

for the lift must be transferred from the ligament muscular

They

on to

to the

how the thoracolumbar fascia

functions to add"dynamic" support to the

ligament

tem. (Refer to the discussion on the thoracolumbar fascia in Chapter 1.) Even

this

seems to

the mechanisms involved with a it too needs to

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Function

81

2-18 Force of Muscle Contraction Exerted Near Sacroiliac Joint

LITERATURE REVIEW OF PELVIC

MOTION

Hippocrates believed that the sacroiliac

was immobile, but he sug-

that movement occurred during

In the 17th

Pare47 confirmed sacroiliac joint movement

and de

Diemerbroeck48 demonstrated sacroiliac joint motion

outside of

pregnancy. Walcher8 published a most controversial paper in the late 1800s that created an uproar in the obstetrical profession at that time. and anatomical the pelvic

be

he demonstrated how by changes in

was "born" the Walcher's position: bilateral This was shown to cause anterior innominate rotation and subse­ opening of the

inlet. Ashmore49 was one of the first to quan­ in the distance between

tify sacroiliac joint motion. She observed iliac

the two

as a consequence of

during forward tnmk bending. A while as a cussed below.

in body

during standing than

positioning. She noticed the distance to be

Mennell50 noticed similar

went from the seated to et aP9 failed to confirm

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This is dis-

PELVIC LOCOMOTOR DYSFUNCTION

82

in body in the sacroiliac

noted movement

In 1920,

and p ubic symphysis simultaneously. Using cadaveric specimens, served that both sacroiliac joints could move but that unilateral sacroiliac

ob-

of the pubic movement was associated he noted ipsilat­

with pubic symphysis motion. On forced sacral

eral posterior iliac rotation and upward and forward motion of the ipsilateral pubic ramus at the sumed to occur

joint. These movements were

walking.

also

sacroiliac joint old.

over 50

motion to be markedly reduced in

Brooke14 described sacral movements as

In

the

motion

in cephalad,

,"" ,.n' �U'"

motion

stated that the

He described how the sacral articular surface formed a

for interlock-

lip at the middle segment,

ing mechanism rotation to take

He

sional movements of the ilia Pheasant describe15 (Figure

Brooke was of the opinion that such tor­

sional movements occurred during

He also observed compensa­

tory hypermobility in the lumbosacral joint when the sacroiliac joint was ankylosed. Could this be why we commonly see L-5 joint and disc tems with

is it that a normally disc

and succumbs to In 1930, Siskin52 studied and noted an average rotation of 4 rit>O"r.'.,,,

behveen the sacrum

and ilium. Pitkin and PheasanP5 observed changes in iliac position when ing normal stance with stances involving the

and left foot

on a l.5-in block. Their conclusions were as follows: 1.

all trunk motions

caused

antagonistic iliac movements about a transverse axis passing through the symphysis

fact that we can use to our ad-

when we want to mobilize the 2. Sacral flexion and extension

with the ilium

fixed

into position. 3.

iliac movements were associated with sacral lateral flexion and rotation. Pitkin and Pheasant mention that sacroiliac to hand and eye dominance.

Copyrighted Material

asymmetry

et a147 suggest that this

Function

could mean that the sacroiliac joints are

83

in the overall

vision. This demonstrates the all-important interde-

tion of

A

of the locomotor and nervous

raised

ugl�eE;t1ClO of Bellamy et al is that sacroiliac joint

and

function may be influenced by handedness and eye dominance. In 1938, Strachan et al13 used cadaveric specimens with one ilium immo­ bilized in a concrete block. Steel pins were placed into the sacrum and Qualitative data on sacroiliac

ilium for reference

response to trunk motion were recorded. The authors

motion in the

observations:

1. The sacrum followed the trunk in flexion and extension relative to the immobilized ilium. rotation and side

2. The sacrum followed the lumbars in

there was a coupled contralateral side

of the

sacrum.

4. With lateral flexion, there was minimal coupled rotation of the sacrum and an

as to its direction.

A year later, Strachan et al53 commented that sacral movements were in nature and occurred more easily in flexion, caudal directions.

and

they seemed more difficult in lateral flexion

and rotation. In 1951, HU6.? observed sacroiliac joint motion during a ments. He embedded small lead cubes on either side of the sacroiliac joints for

index

both

of measure. He then fixed iron

of cadaver as in

to substitute for femurs and

Upon X-raying the

into them

he was able to visualize

sacroiliac jOint motion. On direct

he described a

ral motion between the ilia such that the sacral base scribed an zontal

eight as it moved "obliquely up and down and concurrently

anteriorly and posterioriy."6{p13) He believed that the function of the sacro­ iliac

rhythmic torsional movements of the

was to

gait to spare the lumbar In trying to

his

he used cineradiography to observe sacro-

iliac joint and lumbar motion during

on

treadmilL He in fact noticed

lumbar movements in

sacroiliac lumbar scoliosis the side of unilateral spine would develop a exposure to such

dur-

movements.

from excess

subjects walking on a

motion. He noted that a dynamic compenwith the convexity being contralateral to blockage. He surmised that the lumbar scoliotic

as a In addition, he

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to that

PELVIC

84

LOCOMOTOR DYSFUNCTION

led to

sacroiliac which, if of long

stress at the

direct us to

the

in

lumbar spine

possibly

joints

could lead to coxarthrosis. Illi's observations we often ob-

serve lumbar spine joint problems that occur secondary to pelvic joint functions. llli's research also raises the question of the pelvises to of

of as-

future lumbar

that

pelvic function. that the sacrum rotated in the sagittal plane

about a transverse axis situated at the union of the second and third sacral "p{Yrrl pnr"

He studied lateral

of

coordinate roiliac sacral.range of motion. In

1955, Weisl4 used X-rays to measure sacral motion in living

as they assumed various

of

and trunk flexion and extension. the sacrum

He stated that coupled with rotation about an

motion

occurred more frequently than pure

translational or rotational motions. The

motion seemed to have

from the recumbent to the anteroWeriorly

an ;
below the promontory. He axis in the caudal

described a translational motion along an of the

et aP2

Two other studies by

characterized sacral

and Reynolds55 movement as In

1963, Colachis et aP9 used a very innovative way to assess iliac mo-

tion. They embedded Kirschner spines of subjects and measured different

into the posterior superior iliac between them in relation to nine

They found the greatest movement to occur dur­ while standing. They also confirmed Weisl's work. Gillet and Liekens9 described various

of motion through

extensive palpatory observations. Sandoz mentioned that Gillet's work has

considerable clarification on the

tion of sacra-iliac movement, with the

of direc­

that the latter varies

of movement that is performed by a subject, in

other words, according to the direction in which the physical forces act upon the sacrum, the innominates or both.18(plD6) Gillet's assessment of the to document et aP6 used In 1974, 15.5 to 26 rom of movement between the innominates and the sacrum. In

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Function

85

1989, Sturesson et aP2 used similar and asymptom-

physiologic movements in

motion atic subjects.

noted consistent, although minute, motion about a

transverse axis.

also fOlrnd no

in motion

and

between

they assessed motion represent total sacroiliac bones and commented that functions as a shock absorber due to the <>1"I<>r(,,,_

the

associated with the

This

effect may function to protect the lumbar spine and hip joints from unwarranted mechanical stress. In

Oonishi et al56 stated that upon

Ui�'i.Jl,"LI::U

In

as a whole is

ramus moves

backward while the

behavior of eight

1987, Miller et al57 studied the load

sacroiliac joints. They noticed small amounts of sacroiliac However, with

when both ilia were fixed in observed rotational

motion

one ilium

translational movements to be three to five

times greater. Also in 1987, McGill44 studied the load effects of lumbar extensor muscle contraction on the sacroiliac joint plane lift of 50

He found that with a

a force of 1430 lb was

at the attachment sites of

the lumbar extensor muscles near the the force was of the erector

(Figure

by lumbar extensor

Excessive loads

can

muscle contraction, even when lifting roiliac joint

Most of

by the longissimus thoracis and iliocostalis parts the sac-

under an extreme load because of the muscle attach­

ments near the sacroiliac joint. The implication is that lumbar extension movements, even under light and moderate loads, can sacroiliac

muscular insertional strains than joint disorders. count that the sacroiliac joint is a mobile articulation, ittal

into acin the sag-

it is quite conceivable that extreme loads applied via contrac­

tion of regionally attached muscles could cause injury In

affect the

McGill states that this situation is more likely to create

in joint

1991, Vukicevic et al58 studied mobility and deformation patterns of

physiologically loaded pelvic

using

They observed a downward translation and a forward and of the sacrum to occur

a

tilt-

of 2 to 7 mm (1/16 to 1/4 in).

The axis of rotation was found to be consistent with Weisl's 5 to 8 cm (2 to

3 in) below the sacral promontory. Interestingly, removal of the sacrotu­ berous and

had no bearing on

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and sacral

PELVIC LOCOMOTOR DYSFUNCTION

86

when the interosseous

a:>'",,<' n t

was di-

motion. The sacrum be­

was noted in

ilia, demonstrating little movement. The re­ did not support Bowen and Cassidy's59 contention that surface results

is

in

joint function. The

Vukicevic et al indicate that sacroiliac

termined by the sacroiliac interosseous

motion is mainly deThey also noted that

during the broad range of applied loads, the sacroiliac

surfaces were

never discovered to be in Chapter Review Questions • •

What are the different types Why

a

with a

over

the side of •

What is the spatial relationship between the SIJ and hip joint?

•

What are the SlJs' function and motions "physiologic

•

What is meant

•

What occurs at the

symphysis and

REFERENCES 1. Steindler A. Ilia-Psoas.

Snlnnl>hp

2. Gowitzke BA, Milner M.

Ill: Charles C Thomas, Publisher; 1962. Bases of Human Movement. 3rd ed. Baltimore, Md: WiI-

Iiams & Wilkins; 1988. 3. Grieve GP. Lumbopelvic

and mechanical

of the sacroiliac joint.

Physiotherapy. 1981;67:171-173.

4. Weisl H. The movements of the sacroiliac joint. Acta Anal. 1955;23:80-91. 5. Janse J. The clinical biomechanics of the sacroiliac mechanism.

J Am Chiro Assoc.

1978;12:1-8. 6. Illi FW. The Vertebral Column:

Lombard, Ill: National

of Chi-

ropractic; 1951. 7. Illi FW.

Years of Experience and 35 Years

the Study of the Statics and

Geneva: Institute for

of the Human Body; 1971.

8. Walcher G. Die Conjugata eines engen Beckens ist keine konstante Grosse, sondern lass! sich durch die

def

verandern. Centra/blatt fiir

1889;51:892-893. 9. Gillet H, Liekens M. Belgian Chiropractic Research Notes. 7th ed. Brussels: Motion lion Institute; 1968.

Copyrighted Material

Function

87

IA The PhlJSllJ/n('" of the ,oints. Vol 3. The Trunk and the Vertebral Column. New

10.

1974.

11. Mennell JM. Back Pain:

Mass: Little, Brown & Co; 1960.

Technique. Boston,

and Treatment Movements of the sacroiliac

a

1989;14:162-165. 13. Strachan WF, et al. A study of the mechanics of the sacroiliac joint.

I Am Osteopath Assoc.

1938;37:576-578. 14. Brooke R. The sacroiliac joint.

I Anal.

15. Pitkin He Pheasant He.

NA, Stowe RR, Hower

16.

MH,

17.

1924;58:299.

I Bone Joint 1936;18:365-374. ]W. Movement of the sacroiliac joint. Clin

1Or.,,,,,,,,,,,rJW. The functional

RW. Structural and fLmctional

18. Sandoz

of the sacroiliac

jOint.

Ann Swiss Chiro

of the

Assoc. 1981;7: 101-160. 19. Farabeuf LH. Sur I'anatomie et la

pnYSl.OIOgle des articulations

la

'dl:rUJ:Il"'LlU\e�

avant et

Obstet. 1894;41:407-420.

flnT>rn"rh to the functional anatomy of the

20.

joints in vivo. Anat

21. Mitchell FL, Moran PS, Pruzzo NA. An Evaluation and Treatment Manual of vsreUjuar.mc

Procedures. Manchester, Mo: Mitchell, Moran & Pruzzo Associates; 1979.

Muscle

N, et aL Movements in the sacroiliac joints demonstrated with roentgen stereo-

22.

hotogr'am.metry. Acta Radiol

1978;19:833-846.

23. Harris NH, Murray RG. Lesions of the

in athletes. Br Med J. 1974;4:211-214. l'aI'nOlloJi,!CaI ConditiO/Is, 3rd

24. Steindler A. Kin'eSH)lo"�1

ed. Sm'mc'tJplC! III:

>1rtl(ltlPII,'"

25.

Des

Berlin:

des Menschlichen. Berlin: Kooprs; 1858.

26. 27. Schlenzka

W. Die Besonderheiten der

Munich Med Wschr. 1980;122.

28. Schtmke GB. The anatomy and development of the sacroiliac

in man. Anat Rec.

1938;72:313-331.

29. Kessler 1�"1,

Pa:

D. N/ll11a<7nnerlt

& Row; 1983.

Musculoskeletal Disorders.

30, White AA, Panjabi MM. Clinical Biomechanics of the

Philadelphia, Pa: 1B

Co; 1978.

Carlsoo S. The static muscle load in different work positions: an 1961;4:193-211.

32. Farfan HE Function of erectores 33, Gitelman R. A

pelvis. In Haldeman S, ed. Modern

in flexion of the trunk. Lancet. 1951;260:133. to biomechanical disorders of the lumbar spine and in the

and Practice

tic. New York, NY: Appleton-Century-Crofts; 1980: 297-330. 34. Schafer RC. Clmical Biomechanics: Musculoskeletal Actions and Reactions. Baltimore, Md:

Williams & Wilkins; 1983.

35. Dejarnette MB. Sacroccipita/

Nebraska City, Neb:

1979.

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Bertrand Dejarnette;

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PELVIC LOCOMOTOR DYSFUNCTION

36. Sutherland WA. The Cranial Bowl. Mankato, Minn: Free Press Co; 1 939. 37. Upledger IE, Vredevoogd MFA. Craniosacral Therapy. Seattle, Wash: Eastland Press; 1983. 38. Magoun HI. Osteopathy in the Cranial Field. Kirksville, Mo: Journal Printing Co; 1966.

39. Colachis SC, Warden RE, Becthal CO, et al. Movement of the sacroiliac joint in the adult male. A rch Phys Med Rehabi/. 1963;44:490-498. 40. Cha mberlain WE. The symphysis pubis in the roentgen examination of the sacroiliac joint. A m J Roentgenol. 1 930;24:621-625.

4 1 . M a ignal D. An Investigation of Possible Segmental Instability in Pre-Parturating Women. Bou rnemouth, England: AECC; 1973-1974. Thesis. 42. Young J . Relaxation of the pelvic joints in pregnancy: pelvic arthropathy of pregnancy. J Obstet Gynec Br Empire. 1940;47:493-524.

43. Ganong WF. Physiology of reproduction. In PernoU M L, Benson RC eds. Cu rrerlt Obstet­ ric and Gynecologic Dingnosis and Treatment. 6th ed . Norwalk, Conn: Appleton & Lange;

1 987: 1 09-1 26. 44. McGi ll SM. A biomechanical perspective of sacro-iliac pain. c/in Biomech. 1987;2: 1 45-1 5 1 .

45. Bogduk N, Twomey LT. The lumbar muscles and their fascia. in: Bogduk N, Twomey LT, eds. Clin ical A natomy of the Lumbar Spine. New York, NY: Churchi l l Livi ngstone; 1987; 72-9 1 . 46. Bartelink DL. 111e role o f abdominal pressure i n relieving the pressure o n the lumbar i ntervertebral disc. J Bone Joint Surg Br. 1957;39 B:718-725. 47. Bellamy N, Park W, Rooney PJ. What do we k.now about the sacroiliac joint? Semin Arthri­ tis Rheum. 1983;12:282-305.

48. de Diemerbroeck I; Salmon W, trans. The Anatomy of Human Bodies. London: Brewster; 1689. 49. Asrunore E. Osteopathic Mechanics. Kirksvil le, Mo: Journal Printing Co; 1915. 50. Mennell J. The science and art of joint manipulation. In: The Spinal Column. Vol 2. Phila­ delphia, Pa: Blakiston Co; 1952. 5 1 . Halladay HV. Applied Anatomy of the Spine. Kirksv i lle, Mo: JF Janisch; 1920. 52. Siskin D. A critical analysis of the anatomy and the pathological changes of the sacroiliac jOints. J Bone Joint S u rg. 1930;12:891-910.

53. Strachan WF, et at. Applied anatomy of the pelvis and perineum. J A m Osteopath Assoc. 1939;38:359-360. 54. Simkins CS. Anatomy and Significance of the Sacroiliac Joint. Colorado Springs, Colo: American Academy of Osteopathy Yearbook; 1952.

55. Reynolds HM. Three-dimensional kinematics in the pelvic girdle. J A m Osteopatil Assoc. 1980;80:277-280. 56. Oonishi H, Isha H, Hasegawa T. Mechanical analysis of the human pelvis and its applica­ tion to the artificial hip joint by means of the three dimensional finite element method. J Biomech. 1983;16:427-444.

57. M iller JAA, Schultz AB, Anderson GBJ. Load displacement behavior of sacroiliac joints. J Orthop Res. 1987;5 :92-101.

58. Vukicevic S, Marusic A, Stavljenic A, et at. Holographic analysis of the human pelviS. Spine. 1991;16:209-213.

59. Bowen V, Cassidy ]D. M acroscopic and microscopic anatomy of the sacroiliac joint from embryoniC life until the eighth decade. Spine. 1981;6:620-628.

Copyrighted Material

Chapter 3

Clinical Assessment: The History Linda J. Levine and

G. DeFranca

Chapter Objectives to discuss the

a

of the history in relation to lesions from the

to differentiate mechanical versus

to discuss the types of questions to be asked during the to discuss

n"';.T(�l"V

location and character

to discuss referred

and its differentiation from radicular

to discuss clues from the

that would

the

tissue injured to discuss differential teaches that man 'is pre-

"Modern pared to

he is going to see,'

what he

knows and

virtually what he is seeking."1(p235) How can we remain objective and allow new clinical evidence to

to our minds when

notions of how

with

are cluttered each

should be? To

n;>"PTuclinically as new and fresh is

difficult but at least

to strive for. Furthermore, when dealing with functional disturbances of the locomotor

it is best to shift one's focus of assessment from structural pato functional

This does not relieve one of the

to ity of

But in the majormusculoskeletal conditions

dysfunction of the moving

in clinical

and related soft tissues is

fault.

89 Copyrighted Material

'.... Y"rt."A

PELVIC LOCOMOTOR DYSFUNCTION

90

CASE HISTORIES In this

case histories are used to illustrate

the clinical history in iliac joint,

of

with problems in the following areas: sacrohip joint, and coccyx. Pain diagrams

one case, a visual analog scale is a lOO-mm none to excruciating

a

in

accompany the case histories. The visual that represents a pain spectrum

from

Patients are asked to estimate their

level

on the line. The visual analog scale has been

more sensitive in quantifying

intensity than mere verbal

tors.2-4 The pain drawing is simply an outline of the body on which It has been shown to be very

draw in the location of their certain

Sacroiliac Joint Case History 1 A 34-year-old woman, 3 months postpartum, presented with severe "hip" and leg to move a

pain of 3 weeks' duration after she

in order to

sweep behind it She said that in so doing, she had twisted her trunk and fell a "catch" (here she pointed to her sacroiliac joint region). The pain was sharp and localized to the left sacroiliac joint and buttock, with occasional radiation into the proximal posterior thigh. Trunk bending and twisting to the left hurt her. Walking and climbing stairs were difficult, as any weight bearing caused jabs of pain. The act of rising from a chair was most difficult, although able to

at night, but at times she would

itself was not. She was her

upon turning over

in bed. Flexing her left knee upon her chest seemed to alleviate the pain for a short period of time. She felt limited in her ability to do normal housework without pain. In the last few

before clinical presentation, she had noticed that her entire left leg

felt "heavy" and her calf region felt sore. She denied any bowel or bladder prob­ lems, although she admitted to moderate exacerbation of her pain upon performing a bowel movement

3-1).

Questions for Thought •

Where is the pain located?

•

What

•

What about the fact that this woman was recently pregnant?

the pain? (See below.)

of a sac­ roiliac joint

,....,.(""\,,,,,,..,

from sacroiliac lesions can be re-

Copyrighted Material

Clinical A ssessment: The History

91

>( No Pain

Figure 3-1 Case

Intense Pain

1: Pain

VtC'l'.U.ll'

and Visual

Scale

ferred to the buttock or haunch area and posterior ("high is alStoddard6 mentions that sacroiliac joint may ways unilateral and never central, whereas disc and lumbosacral be central or tmilateral. Hackett7 mentions that upper-pole sacroiliac and that lesions refer lesions refer the posterior thigh and calf absolutely. Sacroiliac pain can radiate to the groin, anterior thigh, and even the and foot,s It is experienced as a deep, dull, achy and is described as heavy or tired. joint blocks and provocation injections, Fortin et al9,10 tried to determine sacroiliac joint pain referral patterns in asymptomatic volunteers. They found that the sacroiliac joint referred 3 cm lateral and 10 cm caudal to the PSIS and that a this accurate in was problems. The pain was described as achy, Schwarzer et apt noted that groin was the only sacroreferred that responded to blocks. on the affected side can continued walking may bring as the joint "loosens up." Patients of­ up onto the chest ten state that lying on the back and flexing the Getting in and out of the posture is usually troublesome. '", over in bed at of pain in the joint. often causes HUH .....

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92

PELVIC LOCOMOTOR DYSFUNCTION

3-2 Area of sacroiliac joint pain referral. Most common areas of referred are cross-hatched.

Commonly, a history of falling on the buttocks is related. Forceful tnmk by leor pushing movements can create sacroiliac joint amounts of force to the sacroiliac joint via the lower exoff a curb or into a hole tremities and trunk. monly the hip, sacroiliac joint, and lumbar tends to put women at risk for sacroiliac joint and this should be asked about in the

Pubic Symphysis Case History 2 A 21-year-old hockey

presented with pubic and right proximal adductor

pain when, after attempting to block a puck with his right leg, he

and

in what he described as below his bladder

hyperabducted his thigh,

area. He said it felt as if he had a bladder infection because of his "bladder pain." Several hours

he

an achy

dial thighs. He found it difficult to walk shoe on at a time by

extending into the proximal meand lie on his abdomen. Putting one

his leg in a sign-of-four position hurt him. Lying on his

back and keeping his thighs adducted afforded him relief. Urination was unaffected

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Clinical A ssessment: The History

3-3 Case

93

2

Questions for Thought •

Where is the pain located?

•

How is this case different from the previous one?

•

What do you suppose the mechanism of injury was? would

the

in adduction

this patient

Pubic symphysis dysfunction can occur with sacroiliac joint dysfuncbut activities

and prolonged

hockey and other Sudden forced hip accidental

adduction, ie,

tend more to stress the as in

gymnastic or

" tends to foster pubic symphysis joint problems, as in

the case above. Athletes who suffer

"pulls," especially hur­ should be examined for pubic symHowsel2 states that shear forces are and race walkers. the frame injure the pubic

pain is also experienced

women who

subsides after parturition but can remain as a dull, localized ache over the exacerbates the pain, as does initiating down. Pain from the

Unilateral weight movements while seated or lycan be

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locally or

94

PELV1C LOCOMOTOR DYSFUNCTION

3-4 Pubic ""'TInih,!<:i.:: Pain Referral Pattern

Patients

themselves from

by

their

from abduct-

too much. in mind the functional

exhibited by the

mentioned by Harris and MurrayP rmPt()mlatllc pubic

occur in a small

of

cases when compared to the number of sacroiliac joint problems seen. Most often, treatment directed just at normalizing sacroiliac joint function alleviates the

This is most l ikely because many

manipulations and stretches directed at the sacroiliac

also

affect the pubic symphysis.

Hip Joint Case History 3 A 5 3-year-old housewife

with right groin pain and stiffness after gar-

dening for hours while in a crouched position on her hands and knees. She found it painful to stand erect and walk the next morning. She could flex her

to put on

but it hurt her and she could not fully straighten it when lying flat. The front of her thigh ached and felt tight. Her groin pain was described as deep and achy. Sitting did not bother her, but

did. No back pain was present

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3-5).

Clinical Assessment: The

3-5 Case

95

3

�---.---.---..------ ------

Pain from the femoroacetabular or hip joint is often .:>",,",prlP especially in osteoarthritis and anterior to the knee is not lfficommon, since the knee and the hip share the same 5-l. Pediatric knee complaints warrant atinnervation levels, L-3 for tention directed at the since knee is a common hip problems in children. Offierski and MacNabl4 discuss the hip-spine and mention how osteoarthritises of the hip and lumbar spine can reflect either hip or lumThe clinical occur much bar involvement predominantly or both confusion. Mid and lower lumbar levels and the sacroiliac joint can refer to the hip joint necessitates the examinain addition to the hip area. tion of lumbar on the hip a common "''-<)cD'''''' or older individual suffering onset. Such is the of Acute exacerbations occur after tends to stiffen Upon or attempting some activity the patient notices a tight into soreness that can progress into a dull ache that radiates from the the anterior thigh. the demonstrates his or area by to distal anterior thigh. Unacthe hand from the customed activities, such as long walks at a vacation resort,

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96

PELVIC LOCOMOTOR DYSFUNCTION

9

Figure 3-6 Hip

Joint Pain Referral Pattern

gardening and housework, or sprinting for first base at the annual com­ pany picnic, can easily trigger pain and stiffness in such a hip joint. Walking can be difficult, and stairs may have to be negotiated one at a time. Hip flexor spasm may create a bent-forward gait when the involved hip is bearing weight. The person usually leans or lurches over the in­ volved side during gait to reduce pain, as explained in Chapter

2. A past

history of congenital dislocation, Legg-Calve-Perthes disease, iniection, or serious trauma should be asked about. These conditions can create biome­ chanical problems long after the disorder is healed.

Sacrococcygeal Joint Case History 4 Three months ago, a 42-year-old man slipped on a loose stairway rug and slid down three stairs on his buttocks. He felt pain in his "tailbone" that was severe and prevented him from ariSing. He was taken to the local hospital, where examination findings, including X-rays, were negative for fracture. His pain had subsided slightly since its onset, but he still found it difficult to sit up straight, especially on hard surfaces. His pain was local to his tailbone, but he also said his lower back ached. He said he was aware of a constant tension around his anus, and defecation was painful at times (Figure 3-7).

Copyrighted Material

Clinical Assessment: The

97

4

Figure 3-7 Case

Questions for Thought •

Where is this patient's pain felt?

.. What is the cause for the tension around the anus? to

.. What would be an indication of a more serious tissues,

rlP,pn,'r

the rectum?

.. How reliable are

in this situation? is extremely uncomfortable and can or joint

sacroiliac

in the lumbosacral and the tip, or can

It can be local to the coccyx,

to the buttocks and even the lower back. The coccyx can be which can result in

from a fall or sitting down dysfunction and resultant occurs and can perpetuate the

joint

Reflex spasm

the pelvic floor muscles

Traumatic

can also

occur after direct trauma. very commonly trauma and have a back

present without a history of direct

coccyx. Often

and even sciatica. Lower lumbar

have a prior onset of lower protrusions or lumbosac-

ral or sacroiliac joint disorders can refer pain to the coccyx. Often with lower back problems who do not strate tenderness at the

of coccydynia

of the coccyx on examination.

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98

P ELVIC LOCOMOTOR DYSFUNCTION

tend to lean for-

Patients with coccydynia find it difficult to sit. ward or onto one buttock. Rising from a chair is

and they usually espe­

find comfort in sitting on a pillow. Bowel movements can be

also be associated with

cially if constipation is a feature. coccydynia. The coccyx can be the site of referred

in the

from

floor muscles yet itself be nontender. The levator ani and coccygeus muscles are commonly at fault. Stift painful movements can be found at the sacrococcygeal joint on examination. X-ray evidence of displacement should not be held as evidence of a coccygeal problem, since

anomalies and deviations

are common. Coccydynia is thought to occur mostly in women and to be of For the most

origin. It occurs in men but with less it is not psychogenic. The labeling of chronic is most likely due to inadequate and referred

phenomena. Manual methods

area are

in

in

for more than 1 year tend to be treatment resistant.

THE HISTORY: LISTEN! William Osler once

"Listen, Doctor, your patient is

you the

"Nowhere in the examining process is listening more important than the initial

It is said that God gave us two ears to listen and one with and that we should use them in that proportion. Jde­ should leave the initial consultation saying, "That doctor

listened and wlderstood me!" This instills rapport and confidence relationship. Anyone can listen, but many do not the flow of information from patient to should be used. This entails the provision of an environment that

the patient's thoughts and feelings to

eXlpn�ssea and heard. Active listening draws the person out to allow his or her story. Interjecting phrases or acknowledgments " "I see," "I understand," or "what else?" prompts the Nonverbal cues such as head nodding or with an interested look are powerful communiI am says allows

what else?" Repeating or paradoctor to

his or her under-

and further establishes this in the

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mind.

99

Clinical Assessment: The

Obviously, control of the situation must be exerted vent the patient from rambling on with To foster trust and self-disclosure in

QUESTIONS TO KEEP IN MIND DURING THE HISTORY The clinical assessment of a patient

with the

Strict atten-

tion must be given to its content. Listening with intent, the clinician should consider several important questions. What tissue is involved? More multiple tissues should be thought of because

"'0,("\""'0

joint in isolation without trauma to or reaction supportive soft tissues, ie, muscles, ligaments, nerves. Additionthe

function of the tissues involved should be understood check with problems of the locomotor or "software" (soft tissues). in nature? Is an active inflammation symptoms? Are there signs and symp­ disease? How and when did the condition start? What better or worse? Where is the pain located? Is the pain re­ or articular? How do postures, movements,

rest, and time modulate VV,::>::>lILJlt::

A mental appraisal should be made of the

structures that can cause pain locally as well as structures that are

distant and can refer In addition to

to the

in question. the patient's presenting concern,

should be asked about past medical history, and a systems re-

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100

PELVIC LOCOMOTOR DYSFUNCTION

view should be should prior treatment and its also be asked occupation should be taken into account, as well as recreational activities. Let us now look more at these Mechanical Versus Organic Lesion?

An question to in mind examination is whether the patient's ",«:;;"''''1''U out the this is organic or mechanical. Most of the can be answered alone. Obviously, we must know and be familiar with what by the we are listening for. The case history illustrates the nl'�,,,p'nt,, as a back of an organic disease Case History 5 A 68-year-old man

with coccyx

of 3 months' duration. He admit-

ted that he had fallen 6 months earlier, but stated that it was his hip that had hurt him then. He said his pain was different now. He described his pain as vague in to the tip of his coccyx.

deep, and almost inside his tailbone. He Nothing he did seemed to aggravate or alleviate his

He stated that it felt sore

and achy and was always there. Neither lying down, movements, nor postures could alter his symptom. He denied bowel or bladder problems, prone to anal fissures with rectal bleeding. Reproduction of

said he was could not be ac­

complished during the examination, which included firm pressures directly on the coccyx and around the area the patient was pointing to. "''''"nu,,, It •

for Thought

What What is the "il',iUJl.lL(U

etiology?

location? hurt him but direct

on it

by as to whether a lesion is mechanical or 3-2). Rest allevireacts to rest and movement ates and movement exacerbates mechanical lesions of musculoskeletal orilt is increase to ascertain which movements in Pain that is not relieved by rest or altered by posture or

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Clinical Assessment: The

Exhibit 3-2 Mechanical Versus

101

Lesion

Organic

Meclwnical Rest

Decreased pain

No

Movement

Increased pain

No change

movements is

rI":"".,,

for

or inflammatory etiology, as is the case and poorly localized usually comes

is

in the above

from deeper tissues or is referred from some other structures. As in this case history, if

cannot be achieved on examination, susIt is most likely referred

picion should be raised as to the lesion's pain from a distant structure or pain

from a deeper tissue rather

than being of local

The above

was referred for UHI);-"V;:l'UL

workup to rule out

disease. A

rectal examination was nega-

visualization

tive, but upon lesion was

the rectal mucosa, a

to be cancerous. Another red

the

in

was over 50 years old, an age group in

which cancer and

Onset of Pain? It can be or not be associ-

Pain can be of recent onset or

ated with trauma. Trauma can affect any of the tissues listed in Exhibit 3-3 and can have extrinsic or intrinsic causes. Extrinsic trauma is the more commonly recognized trauma and entails an externally delivered force a person can be­

as

causing injury to the body.

come injured or trigger a dysftmctional response via intrinsic trauma to the locomotor system with an

movement. Often a patient is his or her pain from this

unable to offer a mechanism of type of trauma. This can be

as well as embarrass-

ing because it raises fears of

or hypochon-

viewed as a

driac. The experienced clinician loskeletal structures can become

the ease with which muscuand

Mennell says

can techniques in

mind."16(p167) At times, the intrinsic trauma is

an open not obvious to the

doctor or patient, yet can manifest itself with a thorough history taken with deliberate

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symptoms. can often

102

P ELVIC LOCOMOTOR DYSFUNCTION

Exhibit 3-3 Tissues of Musculoskeletal

and

Trauma

Bone/periosteum cartilage :wr:,!)V ''''

thoiogi,es That Affect Them

Inflammation

capsuJe

Metabolic disease

Muscles/tendons/sheaths Intra-articular menisci Bursae

incriminate an awkward or the

�A<,f>�'�'

movement that is associated with

of his or her pain onset can be statement that ill felt a catch in my back" or "my back The same can be said of a locked up" is suggestive of joint "pop" sound emanating from the vicinity of the sacroiliac during can indicate hypermobility. A pullPersistent stooping or or tearing sensation while an object implies muscle the pain onset is delayed and is not coincident with the related act the pain. This makes it hard to make the association between the mechanism of and usually make the remarks: "This may sound think it could be from.. . ?" or "I don't know if this means anything, but.. .." These followed astute observations by the statements are that may sound erroneous to the uninitiated but make good sense to the rienced clinician used to dealing with the many faces of clinical tions. Insidious onset suggests disease, but joint and muscle dysfunctions can occur without any cause. It is a common frustration of to their pains. Recent to be unable to relate a mechanism of joint The predominr"
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Clinical Assessment: The

103

Night Pain? Night pain is commonly, although not

associated with neo-

and inflammatory conditions. Patients with bone tumors r"r.... rr'''.... state that they sleep best while upright in a

worsens

after they become recumbent. patients with mechanical lesions can be at

upon rolling over or changing

if movement during their sleep hurts them o r wakes them up. Myofascial trigger points in the minimus muscles can become active in the difficult.

affords relief from

forces but induces translational forces that affect the musculoskeletal pain from nocturnal

over-

in tissues that are already biomechanically comor inflamed.

this pain starts bothering

after

have been recumbent for awhile. Patients with inflammatory condifeel stiffer after a period of rest.

tions

Stiffness? typically have a hard time early in and pain. This may take several hours to diminish. At times the ache tha t cially if

cannot wait to get out of bed because of

them. Chronic diarrhea and sacroiliac pain, espeshould alert one to investigate for inflammatory bowel

disease and associated sacroiliitis. Abdominal pain, fever, and weight loss are other associated thritis

bowel disease. Osteoar-

in

with morning stiffness in the lower back or hips,

but unlike

it typically diminishes after a short

while,

once the

is

and about.

Continued Symptoms and Compensatory Reactions? "tOn,,"'cr

to

IS

biomechanical fault is the recurrence treatment. The

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104

PELvIC LOCOMOTOR DYSFUNCTION

reactions when a joint or muscle problem is of is that prior treatment was aimed at the site of itself. Lack of improvement,

pain and not the

continued and astute assessment for remote conditions painful

rotan'a"

demands continued

reactions.

Fever and/or

L oss? of disease should be asked and fatigue. Infectious and sw;pe�ct€�ct and ruled out.

Visceral Disease? ,,,,cir1l'w,,,

directed toward function of the genitourinary or ):,""UVll

tina I

must be

since lower back pain can be caused by dis-

ease

them.

incriminates a hollow viscus. Flank

pain

to the

signifies kidney and ureteral dis-

ease. Frequency of urination

frequency and ineffectual and/or sacral pain i.ndicate

to urinate along with disease. Monthly

in women associated with their menstrual

cycle can be from

or endometriosis.

Occupation? Posture? Inquiry into the individual's

and its related demands should

include questions on sustained

repetitive movements, exertional and stress. Prolonged periods of

activities, and even job

at risk for dysfunction. A painful crisis is

place the pelvic and often precipitated after a

of

posturing, either

standing. As s tated in

that is unable to adapt

cally to changes in

reveal itself with pain and postural abuse. Patients

function. This

of their mattresses.

should also be Patients sleeping with poor mattress and sore back that

typically awaken with a stiff

loosens up after an hour of being up and

about. A mattress that is too firm can be

as bad as one that sags.

Pain Location and Charader? experienced with methods is very aware of the

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using with which the locomotor

Clinical Assessment: The History

105

and mutable ways. Textbook are almost an

rather than the rule. Joint and soft

are not "aware" of the sentation. This is

of a classic pre-

so for patients'

of

with their local and referred patterns. Owing to segmental and the

from dissimilar and of lesion with

one cannot

confidence by virtue of

alone. The situation gains more perplexity when one considers that soft around the pelvis, that

tissue and bony anomalies are common, and

occur, and that dermatomal territories are "''-''Vi''-"'-

entities that

on cord facilita-

tionY Pain production and its course is ou tside the scope be aware of pain and its lesion is not

clinical presentations that are

and theories of how it ought to present

with our

about how

to be, and clinging to the security aid in

in this

but do not help them. Knowing a " but a more

assessment

from either neural or non-neural tissues are peIt is known that pain can be expe-

culiarities of the central nervous rienced in a limb that no

Harman19 showed how saline

in an area that has been lions into paraspinaJ

and

limb

exists

in

caused referred pain to be

amputees as if the phantom limb were still intact. From the above, it can be seen that

does not inhabit the very tissues or locale where it is felt. It is "rrl�n, ... n

The skin,

that is "all in the head,"

cen-

tissues, and viscera are the three main groups

sensitive structures encountered clinically

pain-

Lesions of the

deep tissues and viscera account for most discussed here. The with

vated

soft tissues and the latter

are inner­ for localany

stimulus in order to initiate the nisms effectively.

"1"\'''1'' ''.1''\,.,

increased

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withdrawal mecha-

106

PELVIC LOCOMOTOR DYSFUN CTION

duction velocities

va;.....

.""

in the neurophysiologic

of

the skin. Nociception from

tissues

vival priorities. Where

probably due to different sur-

withdrawal from a painful stimulus is im-

in addition to being impossible, immobilization from input seems to be the

and

muscle

is used. Accu-

rate stimulus localization and are not critical. Hence, a patient is less apt to localize accurately a lesion in the

than a

somatic tissues, notably joints and related soft lesion. This is evidenced by a using the whole hand, in contrast to a from skin and superficial lesions is somatic tissues is dull,

articular

and well local-

and diffuse. The

of osteoarthritis is a

sues include articulations and their related soft Joint capsules and ligaments are richly the former. Extremes in a

with range of motion

will stress these structures and incite

from them

PAIN INPUT

3-8 Three Main Sources of Pain

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and Viscera

Clinical A ssessment: The

H1<:rrH,/

107

et apo and Iggo et aPl have shown if are involved. only slight movements well within the normal that inflamed jOints of motion and minimal pressures to different types of are more loskeletal tissues are injured, a generic tion is seen for a just as of tissues and sites of lesion. For referral site for problems in the lower cervithe deltoid and even cal thoracic the hip area seems to be a similar for referred lumbar spine, sacroiliac joints, hip joint, from the thoracolumbar pointsr and pelvic viscera (Figure 3-9). Referred Pain?

at a disdeep somatic tissues is frequently from the site of tissue irritation is well known but not commonly recognized. Painful sites continue to be massaged, manipu­ lated, stimulated with therapy injected, and heated, even though the pain may be referred from some other site. Conserelieve or be quently, these modalities may either the ineffective in It behooves us to understand and rornA'.Tori

Points -

/�ijil�

Viscera-Hip Joint Piriformis Trigger Point

/

Sacrotuberous Ligament

3-9 Generic Site of Pain Referral to the Hip

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108

P ELV1C LOCOMOTOR DYSFUNCTION

ate the referral of pain from

somatic

since these structures are

very commonly affected by dysfunction and injury, dromes that cause

instance

ill

painful syn-

to seek our help. to

at a site different

from the site of non-neural tissue irritation. Irritation of neural tissue, in particular nerve roots, displays itself in the form of "root" or radicular However, referred pain from non-neural tissues occurs twice as com­ monly as radicular

The confusion comes from not

that pain

can be referred or projected from non-neural and neural tissues that referred pain does not always imply nerve irritation

and

mechanical

deformation by anatomical structures, the so-called drome. On the

evidence now

is more

that abnormal neuro-

to be the

Dermatomes are territories of skin representing nerve segmental levels tissues and bone, and

supply to the mental nerve

the

sclerotomes

3-10). In

IT"'"",'"'''

non-neural

to muscles. Referred

tissues, usually referred to as sclerotomic, is usually described as

dull,

and diffuse and can be accompanied by autonomic C0l1Cc)mlltar nausea, bradycardia, and monly use

IS

descriptive term toothache when

Patients comsuch

Re-

ferred pain from low back, pelvic, and hip structures commonly travels above the knee. More distal ra­

into the lower

diation can occur, but this is more common in nerve root lesions. Distant

referral from non-neural tissue stimulation has been demThis referred pain is a result of irritated or dysfunctional tissues as coming from some other site. In saline solution into muscle tissue and ob-

Feinstein et aF5 tissues and observed segmentally from dermatomes. These nondermatomal territories were termed sclerotomes and in some instances differed distribution

from dermatomal

3-11 and

McCall et aJ27 in

in

commented on the

McCall et aJ27 showed how structures of the upper

1967, and

of these referred pain of both intracapsular and lower lumbar

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demon-

Clinical Assessment: The History

S-1

L-5

L-5

109

8-1

3-10 L-5 and 5-1 Dermatomes

patterns, especially over the iliac crest

strated overlap of the referred and Injection of the lumbar facet

themselves has been shown to cause and other

low back and referred ion that facet

are

of causing referred

low back pain.30-32 The sacroiliac posterior thigh,

are of the in addition to

has been known to refer

and even foot.8-11 Grievel refers to

observation of pain

to the heel after saline

of the sacro-

iliac joint. According to Bourdillion and Day, "It is reasonable to that on confronting a

in severe pain of sciatic

the first

thought should be 'sacroiliac' not' disc,' even if only because of the statisti­ cal probability."34(p230) Dvorak and Dvorak35 cite references lower abdomen and inner symphysis with an irritant.

thighs after referred to the

abdomen can be a feature in lumbar and sacroiliac ganic

referred to the of the pubic

and lower problems, but or-

needs to be ruled out. Baer36 describes a painful abdorni-

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1 10

PELVIC LOCOMOTOR DYSFUNCTION

3-11 L-5 Sclerotome

Q

3-12

S-l Sclerotome

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Clinical Assessment: The History

111

1, associated a t times with sacroiliac joint lesions it is located just lateral to and below the Named after "in the right iliac fossa umbilicus. Bourdillion and describe it as "34(p20) Pain in and around the appendix sacroiliac is not scribes how thoracolumbar joint caused pain in the sacroiliac, and iliac crest areas in 40% of a group of low back pain pa­ tients. Manipulation of the thoracolumbar region alleviated the lower back to palpation of the skin, subcutaor or at neous tissues, or deep tissues, is commonly referred, either in response to lumbar and great locomotor It of As mentioned

around the trunk and into extremities, and can be objectively obpain from viscera. served. They roughly overlap the areas of Visceral pain can be referred to the lower back and (Figure 3-13). to it, although not Viscerogenic referred pain tends to have a its contents under invariably. A hollow viscus that is attempting to creates that quickly rises in 20 to 30 seconds, has a duration in minutes.40 Back and 1 to 2 and recedes only to recur leg of visceral disease. are rarely the only of visceral dysfunction are apparent; however, it is important to keep in mind that visceral disease can as low back and pelvic joint disorders. response to a painful stimulus is complex, As can be seen, the since the nervous system mediates a variety of responses involving multiple tissues. This is manifested by subtle observable in the different tissues innervated the Lewit38 mentions how a stimulus causes reactions in the various tissue served by the rezones, muscle in the form of cutaneous lated spasms, painful points, joint dysfunction, and JJV,'0H/, level of In other the tissues

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112

PELVIC LOCOMOTOR DYSFUNCTION

4 5 2

6

3

(1) Figure 3-13 Visceral pain referral nary bladder, (4) small bowel, (5) ovary, (6) ureter,

(2) large bowel, (3) uri­ pancreas, (8) uterus, rectum,

(10)

(9)

will

neurologic "circuit" as the involved

Dv,r.cn·,Q,)rQ

reflexogenic

effects on some level.

Radicular Pain? Radicular or "root"

is a

root irritation. Radicular

of referred pain

is described as

and even

It is more

localized by the

as

to referred pain from deep somatic tissues. See Exhibit 3-4 for a comparison of radicular and referred times radicular

movement of a vertebral the

from non-neural tissues. At

comes on after a akin to

a hornet's nest and wit-

storm shortly after. It is usually more severe distally

in the limb. Its course typically coincides with the nerve root's distribution,

the sciatic nerve in the

ever, it is not

of the

a continuous line of pain from

shooting, traveling sensation Valsalva maneuver is

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and leg. Howto distal. A and a

Clinical Assessment: The History

Exhibit 3-4

113

Non-Neural Versus Neural Referred Pain

Neural

NOli-Neural Dull, Diffuse

Sharp, Able to locate

Can be No sensory loss No motor loss No reflex loss

Can have reflex loss

No nerve tension

Nerve tension

to engorge-

venous ment and possible

have observed that direct nerve root inflammation is

only when an

Grieve1 references Triano is not invariably

(2) root tressevere; and

somatic nerve

and the same can be said

proven

leads to the mistaken conclusion that nerve root compression is at fault. Actually, most are referred and not radicular in ing over

as was shown by a

involv­

]200 low back pain cases. O'Brien45 states that nerve root com­ accounts for less than 10% of the total problem. In

roiliac

nerve root

is not a viable

the anatomical relationship between the joint and the nerve roots.46 This fact, combined with the non-neural iliac

as

phenomenon of referred

from

to overlook the sacro-

has led orthodox low back and

To further confuse the situation, radicular and referred manifest with

can coexist. Radicular lesions involvement, such as hypesthesia, degree. Nerve tension signs, eg, a commonly ferred pain. leads one to

and help to

neural from non-neural re-

associated with "hard neurological" radicular

the

referred from non-neural tissues.

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114

PELVIC LOCOMOTOR DYSFUNCTION

CLUES IN THE HISTORY TO THE TYPES OF TISSUES INJURED In listening to our patients' certain clues can lead us to although we should bear in mind that it is more type of to ascertain how for therapeutic and assessment tures, movements, rest, and time modulate pain. Mennell16 discusses seven anatomical structures in the muspathologiand cross-matches them with five culoskeletal cal changes that can affect them 3-3). This results in 35 vv"","v,,, diagnoses to consider (7 anatomical structures x 5 pathological rh,:>n,.,."c 35 possible diagnoses). In the 5 pathological do not usuaffect all 7 anatomical structures, and Mennell states that a more realistic this is not an all-includiagnoses is 23. of sive but by the anatomical structures with the possible pathological changes that can affect them, an organized to a can be made. Often, clues in the history arise that incriminate certain tissues more.

Hyaline Cartilage, Menisci, Synovial Membrane Most consult a clinician due to pain. on sponse alone, one can rule out intra-articular and synovial membrane as since are devoid pain fibers. Intra-articular menisci and bursae occur in select parts of the body, and knowledge of the location will aid in them as painful offenders. Intra-articular menisci are not found in the the but are found only in the vic ulnomeniscotriquetral joint at the wrist, occasionally the radiohumeral the knee and the sternoclavicular The pelvic at the is also devoid of structures occurring at the wrists and ankles. Even though hyaline cartilage is incapable of producing in and of itself, the complaint of a noise, known clinically as crepitus, can indicate the of articular wear. A sandpaper sound connotes minimal whereas coarse denotes adfeature in the of a vanced This is usually not a patient with pelvic joint dysfunction, let alone hip problems, but is more commonly seen in advanced coxarthrosis. fluid. It is only a few reacts to injury by The are found pain cells and is devoid of nearby between the synovium and capsule. Synovitis causes a slow swellover a of and the typically comments on noticing

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115

Clinical Assessment: The History

swelling or

the

the next day. On the other hand, hemarthrosis

creates pain and

arterial

in minutes due to the into the

Hence, the time of onset of joint to

swelling and pain can lead the

or

either

hemarthrosis.

Bursae Bursae do occur in and around various pelvic structures. Bursitis is condition and is more commonly a reaction to some other

rarely a

of

problem. It can also be a

disease of the

true bursal involvement causes

vascular

warmth, and possibly discoloration in a known ana­ Most movements are arrested, and direct pres­ sure hurts. The

locale and swellil1g must coincide with the known of

anatomic location of a bursa for the practitioner to entertain a

bursitis. This may seem to be an obvious point, but the bursa is a com­ monly incriminated structure because of the practitioner's willingness to with a

the

So, too, the diagnosis of arthritis, an-

other vague and useless the

Referred

lumborum and

from

in

minimus and lumbar and sacroiliac

commonly masquerade as trochanteric or ischial bursitis to

joint

the uninitiated by virtue of their pain distribution. are the

Common sites for bursitis about the

disorder or gout.

Bone, Periosteum Bone tissue

is insensitive to pain, but the

teum are pain sensitive. The

is

and endossensitive to

injured directly, ie, by direct trauma, is sharp and intense, as anyone who table knows.

A history devoid

of pathology.

his bare

lesion or pressureboring endosteal pain that is

and sometimes throbbing in nature. Night

are ominous symptoms

on

of traumatic etiology should

A

building infection within bone creates a nrl"'la,�p"",\!'P

and is

or sustained

associated with

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and resting

116

PELVIC LOCOMOTOR DYSFUNCTION

2

.)

3

�

rl

3-14

r)

I I

4

�

Sites of bursitis around the hip. (1) Trochanteric bursa, bursa between maximus and vastus (3) (4) ischial bursa. See also Exhibit bursa under the psoas

(2)

More commonly, bony insertion sites are described as sore or as a "bruised"

Patients often describe such sensations occurring at superior iliac

their

a referred tenderness

and bony rim of the iliac crest. This is More points only when points are

patients are aware of these painful

v<:;.uv,,,,,,

are touched. Interestingly, some painful periosteal certain joint or muscle problems. For example,

the fibular

in short, tense hamstrings. The sacroiliac

tu-

and hip adduc-

iliac crest is usually tender with thoracolumbar lumborum and problems are associated with a

muscle trochanter. The

posterior superior iliac spine is often tender in a number of is not specific for any.

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and

117

Clinical Assessment: The

Exhibil3-5 Lesser-Known Bursal Locations

trochanter minimus tendon

•

greater trochanter

extemus tendon and

joint

•

obturator intemus tendon and lesser sciatic notch

•

quadratus femoris tendon and lesser trochanter

Joint Capsules sensitive to pain

if they lie deep to the body

articular discomfort often associated with reThe same can be

for the

ligaments. Pain is elicited by motion stretching the capsule, movements, or specific movements performed to place maximum tenis often

sion in isolated l igaments. Sustained stress applied to associated with a burning discomfort after a latent

of up to

30

sec-

onds. This is usually encountered in hypermobility states and situations of overload.

Muscle Muscle is made up of three types of tissue: fascia. Certain locations in the

to the musculotendinous unit. in and arolmd the

in

and

these are not found

and hip

induced by

saline injections was

ized, whereas

from muscle

spinal

vation

belly,

entail tendon sheaths as an added

as sharply local-

was diffuse and tended to refer

patterns different

the

innerweary ache" is

the skin. Grieve47 mentions that an

usually an attribute of limb and vertebral muscle pains seemingly second­ ary to

Muscle l esions are usually associated with

joint

sudden pulls, sustained

or direct trauma. Patients o r stretching

may state they felt something "tear" or "pul l . "

the muscle with various movements hurts. Postexercise soreness is also a common complaint, usually worse the second day after the Muscles act as loyaL ever-obedient servants of the nervous master that a is

the

their every action. Their response to injury and dysto the nervous

thought to be

directives. Muscle

yet it is commonplace to locate

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118

PELVIC LOCOMOTOR DYSFUNCTION

muscle spasm that is not.

direct trauma, referred tender-

pain, muscle spasm is usually experienced as tightness

ness, or and not as

to joint or

Reflex muscle spasm in in nature, and some

tissue trauma is

somatic it has

little to do with is an important and common cause of discomfort arisTravell and Simons' m\!or,aSC:lal

ing from the musculoskeletal

typically refer pain distally from the involved <>V1C\""" O,v'",rl

dull, and

as

point.

and does not follow a

pain does not invariably follow

segmental pattern.49 The

dermatomal, myotoma!, or sclerotomal distributions. It is referred in specific

to each muscle, For example, the refers

down the lateral or

thigh and

a radicular problem Myofascial pain can occur with rest or motion. Many times, aware only of the referred

and not of the location of the inciting

B

A

Figure 3-15 Gluteus minimus portion of muscle, (B) Anterior

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referral

(A) Posterior

Clinical Assessment: The

pOints regularly refer pain in

The important point is that characteristic for each muscIe a distance from the

119

H",tnt."

that this can

and often is, at

point.

Nerve Root lancinating So-called "root"

associated with nerve involvement.

is

is described as severe,

in nature,

to

follow a nerve root distribution, and usually worse distally in the limb. Tingling and numbness may also indicate a possible nerve involvement. section "Radicular Pain."

See the

Joints or click. Hypermobility of the pelvic and hip

Joints themselves a

will comment on

with clicking, and

is commonly

noise while walking or getting in and out of

chair. The noise

is often painless. A snapping noise about the lateral hip is indicative of a usnapping-hip" syndrome, in which the iliotibial band snaps over the is usually sharp and

trochanter. Joint pain from joint

occurs with movement. Rest alleviates the pain, and swelling is typically not a feature. It is often seen in

after trauma and immobilization.

MelmellJ6 believes that some of the pain of arthritis is due to tion. Unilateral

is characteristic

dysfunction unless

multiple trauma has occurred. Bilateral symptoms,

in both sacroiliac

joints, without a history of trauma, is more indicative of inflammatory dis­ ease, and further questioning as to

fever, and other symptoms of

disease should be asked.

DIFFERENTIAL DIAGNOSIS Pain in and around the

can be caused by a

of con-

ditions that demand clinical differentiation. The clinician should possess a framework of differential

in his or her mind from which to buttock, and thigh

work. When a

whether the condition is a mechanical/locomo-

the clinician must

tor condition or an organic/medical disease. When

to

a

to relate the symptom or

problem, the clinician should to the known

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of

120

PELVIC LOCOMOTOR DYSFUNCTION

and

for

.-ncr:'It)""

the following case

history: Case History 6 A

woman presented with left lower back

old daughter. The

after

her

was located just medial to the posterior superior iliac

and was of a sharp, jabbing nature. She said she heard and felt a pop sound when she

down. The

hard to localize

radiated into the

felt

and was

and

It ached and made her back stiffen with rest for the first 2

days, and moving around at first relieved her. Afterward, rest made it feel better by

and was not

but bending, getting in and out of her car,

and climbing stairs hurt her. She admitted to sleeping well, problems or bowel or bladder

She admitted to no

at the history, the clinician should the case and summarize it. For

for the first night. 3-1

an overall feel for

the complaint summarized above

sowlds mechanical in etiology and nature. It seems to be attributable to a lifting injury, alleviates with rest, and worsens with movement. Next,

the anatomy in the area, the clinician should at-

to

3-16 Case

structures involved that could cause the

6

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Clinical Assessment: The History

121

even if

In addition to the local structures! any

distant, tha t can refer pain into the area i n question needs to be considered. In reference to the above examp le, a number o f structures beside the sacroiliac joint can refer

medi a l to the

Lumbar and

iliac

facet joints, erector

tus l umborum

and

trigger points, and pelvic viscera are j ust a few from the outside inward, one

can menta l l y question a list anatomy at the

p ossible s tr u c tures. The first

of

site includes the skin and subcutaneous structures. I s tha t is pre-eruptive, or a painful

this referred The next

muscles. Is this l igaments, nerves!

citis or a strain? The nex t and articula tions. Is there evidence of

myofasc ial

ligament

muscle

or radicular involvement? Still

is the vertebral or pelvic bone involved. Is the still

elitis, neoplasia, or fracture?

from osteomy-

a re visceral structures, in-

cluding the vasculature. Is there visceral d isease or vascular tha t can account for this pain? As the list of tissues is compiled, the pathologies possibly

them

should be considered. Does the etiology involve trauma! inflammation, neoplasia, metabolic

in this case

or functional loss? For

the p resence of tissue inflammation i s in the first 2

w i th rest patient's

subsided, rest afforded her more relief and move­

ments caused her more of a

a mechanical dysfunc-

tion. Once the anatomical structures affected are compiled and are crossmatched with the

a d ifferential list o f

diagnoses can b e made. The last

i s to use the history a n d physical

examination to rule in or out any of the possibilities

on the diag­

nosis list. Examination of the pa tient in the above case history revealed and she resolved completely w i th manual

sacroiliac joint treatment directed a t that

The clinician confronted with lower back pain should first rule out severe disease. A lthough rare, a n first when dea ling with lower back Patients should b e

medical condition to rule out is the cauda of

this

back pain, bilateral lower extremity

pain and

numbness, a l ong w i th saddle p a resthesia and loss o f sphincter controL If they are

of having this condition, a n immediate

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PELVIC LOCOMOTOR DYSFUNCTION

1 22

decompression should be performed, since per­ loss is imminent. nr,p":<:'n,'p

disease should be ruled out.

of

to

with medical disease n rc";,,:,,,, /-

with symptoms belonging to one

ing groups: 41

fever and / or weight loss at

41 41

morning stiffness

41

acute, localized bone pain from fracture or bone expansion

41

visceral pain need to be assessed mediof etiologies should be foremost in the clinician's

mind when he or she confronts a patient with p a i n in the lower back, pelare only a few

and lower extremities. The following

vic

tha t can be used to

one's thinking process

are adapted from

Borenstein and 41

mechanical

41

rheumatologic

41

infectious

41 41

vascular

•

visceral

•

metabolic/endocrine

•

psychologic

Mechanical Fortunately, mechanical other

However,

of back

are more common than

tend to cause

examination needs to be the various conditions. The more common mechanical disorders will be differentiated. Sacroiliac joint disorders cause

unilaterally that can extend into the

lower ex tremity, but so do lumbar facet a n d disc lesions. whereas getting in and out of a chair bothers a

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with either a sacro-

Clin ical Assessment:

123

The

iliac joint dysfunction or a disc syndrome, the act of sitting itself will and stra ining at the stool

bother a disc patient more.

will exacerbate a lumbar disc condition but not a sacroiliac will exhibit an antalgic posture, with much

Additionally, the disc

forward. The patient with a sacroiliac joint condition

difficulty

will have difficulty bending forward but can usually be coaxed to bend A

more than a disc

can bend

with a lumbar facet

pain with trunk ex-

but

forward without too much tension. Additionally,

from a

jab of

position can cause a

with a facet syndrome. Also, whereas

tends to remain above or facet

pain

from sacroiliac

knee in referred pain

problems, it commonly radiates to below the knee in radicu­

lar pain syndromes of disc of

loss of motor, sensory, and reflex

functions and nerve tension

are not present in sacroiliac or facet joint

On examination, problems, whereas test is

are in disc conditions. The straight-leg-raising

negative or mildly positive in sacroiliac and facet joint disor­

ders, but strongly positive in disc involvement. Thoracolumbar joint

often refers pain to the sacroiliac and

buttock regions.

restricted thoracolumbar

with segmental muscle spasm will be evident in the absence of lower lumbar facet or sacroiliac

signs. Nerve signs will be missing.

problems can cause buttock and restricted

of motion will be localized to the hip and knee.

also radiate into the anterior will cause groin The

as can sacroiliac

joint signs of pain, spasm, and

but with

pain. can

flexion with adduction

mostly with

symphysis will refer

anteriorly to the lower abdomen

and inner thighs. Recent pregnancy or prolonged hip adduction activities are commonly associated with the onset of pain. Tenderness over the pubic

pubic

and adductor insertions is present, and

tension in

is common.

Osteoarthritis

and

older patients with morning

presents in

that only

and around. Stiffness is a

about 30 minutes after

feature on physical ,",,,;.nTll! n

demonstrate evidence of degenerative joint disease. with advanced osteoarthritis and bizarre lower extremone should think of central stenosis. Bilateral and weakness are common. Different parameters function as well as levels of innervation can be affected between the two lower extremities.

claudication can be a feature

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124

PELVIC LOCOMOTOR DYSFUNCTION

scan. of the lateral canal w ill

w i th unilateral symptoms of

buttock, thigh, and even leg and foot pain and w ill look like a evidence of disc narrowing and of a narrowed lateral canal aid in the nosis. lumborum,

of the erector

Myofascial trigger

and piriformis can cause p a i n in and about the lower back, and lower extremities.

their

referral

and are discussed in a l a ter pain

direct trauma or recent preg­

occurs with a history

and local izes the pain to the

nancy. The patient has coccyx. Levator ani

of the l a teral femoral cuta-

is a nerve

neous nerve as it leaves the pelvis under or through the inguinal ligament. The symptoms are pain and be seen in obese or

i n the anterolateral thigh. It can p a tients, in whom the inguina l

Direct trauma to the nerve at its iliac

is

near the anterior su-

can be a factor.

Rheumatologic disorders of importance for our discussion are the seThe characteristic ch lr m," ""

that loosens up after a few hours

of severe one to suspect an

arthropathy. The sacroiliac j o ints are commonly or unilaterally. The absence of the rheumatoid factor and sedimentation rate

are also characteristic.

inflammatory a r thropathies most c o m m o n l y includes ankylosing s p o n d y l it i s, Rei ter's syndrome,

a rthritis, and

enteropathic arthritis. In

spondylitis, also known a s

sacroili itis is usually

involves young

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the

Clinical Assessment: The History

125

with spinal stiffness. Although all the seronegative spondyloarthropathies can have an elevated HLA-B27, this occurs more commonly in ankylosing spondylitis and Reiter's disease. Reiter's disease involves the triad of conjlmctivitis, urethritis, and ar­ thritis of the lower back and lower extremities. The sacroiliitis is usually unila teral and occurs in young males. Psoriatic arthritis entails the characteristic psoriatic skin lesions associ­ ated with axial skeletal and upper extremity joint pains. Psoriasis usually occurs first but can occur simultaneously with or after the onset of arthri­ tis. Onychodystrophy (onycholysis, ridging, pitting) is commonly present. It affects both m a les and females equally. A history of Crohn's disease or ulcerative colitis together with lower extremity arthritis and sacroiliac pain should tip the clinician off to the possibility of enteropa thic arthritis. Diarrhea, either bloody or nonbloody, with abdominal pain and cramping that are associa ted with low back pain, is characteristic. Both sacroiliac joints are usually involved. Rheumatoid arthritis occurs more commonly in females and involves the cervica l spine more commonly than the lower axial skeleton. A sym­ metric upper or lower extremity arthritis is characteristic with joint pain, redness, and swelling. The rheuma toid factor is usually present in

80% of

cases.

Infection Infection is not a common cause of lower back pain but should enter the differential diagnosis. Osteomyelitis, pyogenic sacroiliitis, and herpes zoster are examples. Fever and malaise are present but are general consti­ tutional signs. Localized tenderness over the involved infection is present. A history of intravenous drug use or urinary tract infection should raise the suspicion of spinal infection.50 The ESR is almost always elevated, but the white blood count may not be. X-ray findings show up later in the disease process. Definitive diagnosis is accomplished via cultured tissue aspira tions. In herpes zoster (shingles), a burning pain appearing in a segmental dis­ tribution is characteristic. Approximately 1 week a fter the onset of pain, the typical erythematous papular rash tha t develops into a vesicular rash appears. A prodrome of fever, malaise, and gastrointestinal symptoms oc­ curs before the segmental shooting, burning pain. Difficulty in diagnosis arises when the patient presents in the pre-eruptive phase. However, rec­ ognizing the quick onset of a segmental burning pain that does not cross the midline and waiting a short period for the rash to develop will aid in the diagnosis.

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PELVIC LOCOMOTOR DYSFUNCTION

126

Neoplasia Neoplastic

'-<1"'

... ""

'....

clinical course that displays relieved by rest or

uV:"ll'u.

cious lesion: Case A 39-year-old man presented with

7

and groin pain that had been "m,nr.>",,,;,,,,II,,

getting worse over the last 3 months. No h istory of trauma could be recalled, The patient stated that the pain was constant and kept him up at night. He could not get into a comfortable position, The pain was described as being deep and

Walk­

ing was difficult. He admitted to feeling hot and t i red,

Physical examination o f this individual revealed an ill-appearing son displaying a

of motion was

favoring the affected limb.

painful and limited due to vealed

with an

lucencies

head with extension into the proximal bone cancer. TIle

a rare

say, someone with back

who

history of cancer should be

metastatic

of

the back pain is new

especially

history of cancer

of recent onset. Deyo et apo comment that a has a high

specificity

(.98) and that

patients should be con-

sidered to have cancer until proven otherwise. However, with an

malignant

weight rp<:: n n,nl'1

of more than

1 month duration, and failure to

to conservative therapy.5o Bed rest r n rn rr, () n of the

Eighty nant

have this

that are

in the

are over the age of

50, a

history. An elevated ESR leads one to

disease. Imaging studies

aid in locating various tumors, but

to

50% of bone loss needs to be A bone scan is

before bone destruction can be evidenced

a very sensitive but nonspecific test. CT scans and MRIs aid in the tumor. Definitive

is achieved

biopsy.

myeloma is the most common as

bone tumor. It often

backache and

The classic

lytic lesions are often not found. Multiple tures and ill health followed by the

of Bence Jones protein in the may be necessary.

urine help establish the

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Clinical Assessment: The History

127

Vascular Abdominal aortic aneurysm is a n uncommon source of back pain and occurs in white males between the ages of 60 and occurs due to d ilatation and The back unrelated to

70.51 Lower back structures or

of

is associated with a dull,

epigastric

or meals. On examination, a pulsatile mass m a y be

on level with the

w i th l a teral expansion

Streaks of calcification in the wall of an a r teriosclerotic aorta may be seen on

CT scan or ultrasound examin ation of the abdomen will visual­

ize the aneurysm. Arterial occlusion of the aorta at the bifurca tion can result in Leriche low back pain, buttock or thigh pain of a clau-

Visceral Disease Some visceral organs of the abdomen and pelvis are in close to the

n rr' Y IITI

and pelvic musculoskeletal structures. Visceral

cause low back and pelvic pain due to inflamma tion, expansion, or infection. Direct stimula tion of

can cause lo-

cal pain, or pain of a referred nature can be felt, often a t a

from the

diseased organ. and

Visceral pain is not relieved by rest or aggravated by activity.

of organic disease can usually be found. Pain and tenderness a t the costovertebral angle, groin pain, and urinary changes indicate disease. Severe pain tha t causes the patient constantly to writhe about for relief and tha t starts in the back and radiates to the

and

indicates renal colic and ureteral disease. A Groin pain accompanied by a visible or curred after heavy exertion signifies an inguinal hernia. Gastrointestinal problems may show altered bowel movements or oc­ cult blood with a normal urinalysis. Acute assume the sitting posture with their knees curled intense

and upper lumbar pain. Bladder

lower abdominal and sacral pain, w i th nocturia being the classic Prostatic pain can be referred to the

rectum, and sacral re-

gions. Symptoms of nocturia,

and inef-

fectual urge to urinate indicate obstructive d isease. Rectal examination and serum prostatic acid

assay should be

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nprtn,rrTI

128

PELVIC LOCOMOTOR DYSFUNCTION

The female organs of reproduction can cause lower back associated with other

is

Such pain

organ disease. The

is often sacral as well as lower abdominal.

abnormal uter-

ine bleeding, and infertility indicate t h e necessity f o r a gynecologic workup.

Metabolic/Endocrine with bone changes f ound elsewhere be­ and

sides the axial

may indicate endocrine or metabolic disease. Presence or absence of compression fractures after minor incident, ished bone mass, and

changes of dimin-

backache in an

woman with no Osteomalacia

abnormal blood

for bone biopsy and

may be

is

serum calcium.

associated

with hypercalcemia, female predominance, gastrointestinal tissue removal

renal colic, and a history of to

surgery.

neurologic disease as a

Diabetes mellitus can

Femoral neuropathy is common, with anterior thigh often worse at

uria are present.

Increased thirst and poly-

fasting blood sugar i s

and a

of d iabetes has often been made.

Psychologic Patients who have had organic pathology ruled out, do not care, and display and marked

on

health care provider need

to be evaluated for psychologic overlay of their back rare form of back pain and can be i dentified by distraction tests and and ob j ective information.

between

vation of

Waddell et a152 use five groups of tests to evaluate for signs of disease during the examination: traction tests,

simulation tests,

(1)

disturbances, and

(4)

derness as an indicator of

disease

(3) dis-

overreaction to pain. Tento an excessive

response to mild stimulation over a wide area of tissue and / or tenderness not related to a specific structure. Simulation tests simulate a real test that in fact is not An

cervical axial loading that results in back pain. This response should not occur, of the examiner to a

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basis of

Clinical Assessment: The

Distraction tests include the

c:tr" r t" n o-

129

by

a

with another normally nonpainful maneuver. An the

test after the patient raise. The two should correspond. If the

reports

straighHeg�raising test and if no pain is elic-

with

ited with the si tting s traight-leg-raising test (Bechterew's """rr:o! , n c

then a dis-

to test or principles.

Overreaction pertains to

verbal and expressive

to examination

This includes

rt'>c,,,r>, nc,,"c

limb withdrawal

and painful CONCLUSION The history is is key.

in

a

to the etiology are sought. An overall

the case should be visualized first. The anatomical structures possibly in­ volved in

generation should be considered as well as the different ro(:eS:3es that may be operant. A list of DOSSl iDle the differential is narrowed with the such as

Chapter Review Questions a mechanical versus an organic lesion in the •

What is intrinsic trauma?

•

What is the difference between root or radicular pain and non-neu­ ral referred pain?

•

indicate the various tissues that can be

What clues in the

involved in a musculoskeletal condition? •

Review the mental

a differential

used in

nosis. •

Patients with medical disease '-w.,"".u��

•

their lower back

can be

into what five

Name the

of etiologies the clinician should think of

when confronted with a low back pain •

v\That are the nonorganic

of disease

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to Waddell e t

130

PELVIC LOCOMOTOR DYSFUNCTION

REFERENCES L Grieve GP. Modern Manual Thera�}y of the Vertebral Column. New York, NY: Churchill Livingstone; 1986. 2. Scott J, Huskisson

4. Ohnhaus

Ee.

of pain.

Graphic

Ee. Measu rement o f pain. Lancet.

3 . H us kisson

E E, Adler R. IVleme,aOlOg.lCiU

Pain.

1976;2:1 75-185.

1974;2:1 127-1 131 .

nr.,hlp'm�

son between the verbal rating 5 . Uden A, L a n d i n LA. Pain

( w lr " n, h v

c/in

i n scia tic

1987;216:124-130. 6. Stoddard

A Manual ofOstetrpathic Practice. London: Hutchinson, Long; 1969.

7. Hackett JS.

III: Charles C Thomas, Publisher; 1957.

joint Ligament Relaxation.

specific characteristics o f nonspecific low

8.

10. Fortin JD, April! CN, Ponthieux B , Pier J. Sacroil i ac joint:

referral maps upon

ing a new injecti o n / a rthrography technique. Pa rt II: C l i n ic a l eva luation. 1994; 1 9 : 1 483-1489.

N. The sacroiliac joint in c hronic low back

1 1 . Schwa rzer AC Aprill CN, 1995;20:31-37.

road wa l ker.

12. Howse JJG. Osteitis

R Soc Med. 1964;57:88.

13. Harris !'JH, Murray RO. Lesions of the symphysis in athletes. 1 4 . Offiersk i CM, Mad":ab

C.

15.

1 6 . Mennell JM . 1 7. Kirk

E1,

L

syndrome.

1974;4:21 1 -214.

1983;8:316-32 1 .

Mi fflin Co; 1 95 1 .

Boston, Mass:

Client-Centered

Br Med j.

Joint Pain. Boston, Mass: Little, Brown & Co;

1964.

Denney-Brown D . Functional variation in derma tomes in the macaque monkey dorsal root lesions.

1 8 . Feinstein B. Referred

J

Nrcurol.

1970;139:307-320.

from mll -aVf'rt,pto,'al

AA, Tobis J5, eds.

nV1uro,1Cn,�s to the Validation

I l l : Charles C Thomas,

1 977:139-174. 19. Harman J B . The localization o f 20.

pain.

Br Mcd j.

1948; 1 : 188-192.

VE, Morrison JFB. Mechanosensitive nerve of t h e c a t . J Physiol (Lond). 1 976;259:457. K, Hick

R.

21.

afferent Wl.its in the hypogastric

In: Kruger L,

mechanisms i n arthritic rat

Je, eds. Neural Mechanisms: Advances

V o l 6. New

in Pain Research and

York, N Y : Raven Press; 1984. JH. Observations o n referred pain

22. 23. I n m a n

VT,

from muscle.

Clin Sci. 1 938;3:175-190.

S aunders IB. Referred p a i n from s k e leta l structures.

J Nerv Ment Dis.

1944;99:660-667. 24.

DC, Parsons eM. Referred head

and its concomitants.

1 944;99:546-554.

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J Nerv Ment Dis.

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J N K. Ja meson RM, Schiller F.

25. Feinstein B,

somatic tissues. J

Bone loint

on pain referred from

1954;36A:981-997.

J M, W h i tt y C W M . Patterns of referred pa in in the normal subject

26.

Brain.

1 967;90:481-496. 27. McCal l nv, Part WM, O'Brien J P . Induced pa in referral from oo�;ter'ior l umbar elements i n normal Spine. 1979;4:441--446 . 28. H i rsch 0, Ingelmark B, Miller M. The anatomical basis for low back pain. Acta Scand. 1963;33: 1-17. Robertson J. The facet 1976; 1 15 : 1 49-156. 29. 30. RK. Low back p a i n : w i th reference to the a rticu lar facets. lAMA. 1933;101:1773-1777. LA 31. n"nnv�c'� su b luxation: d is t u rbances in a n d around the intervertebral foralow back pain. J Bone Joint 1936;18:428. .

CE. The articular facets in relation to low back pain a nd sciatic radia tion.

32.

J Bone

1 941;23:481-496. JH.

pain sensibility.

34. Eourd i l lion JF, 1987.

Ltlncet. 1949;1 :943-949.

EA. Spinal

& Lange;

4th ed. Norwalk, Conn:

35. Dvorak J, Dvorak V. Manual Medicine: 1984.

New York, NY: Thieme-Stratton, Inc;

JIf}(mn
36. Baer WS. Sacroiliac strain. Bull Johns

1 9 1 7;28:159-163. Arch Phys Med RehabiJ. 1 980;61:389-

37. 395.

Boston, Mass:

38. Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor B u t terworths; 1985. 39. Head H . O n disturbances of sensa tion w i th ease. Brain. 1 893;16:1-133.

reference to the pain of visceral dis-

and Co.mlJrehem;ive

40. Borenstein DG, Weisel SW. Low Back Pain: Medical Pa: WB Saunders; 1 989. ment.

R . The clinical picture. In: Hirsch e, Zotterman Y, eds.

41.

Press;

Cervical

Oxford:

1 971:5.

,.,�,u .,,��.,u of t h e l um b a r nerve roots in scia t ic a . Acta 42. L i n d a h l O. 1966;37:367-374.

Scand.

43. Sunderland S. Traumatized nerves, roots, and In: Korr I, ed .

ropathological

Therapy, New York, 44. Triano jJ,

Plenum Publishing MW. Nerve irritation: a

model of sci atic neuritis.

1982;7: 1 29-136. 45. O'Brien JB. The role of fusion for low back 46. Pitkin He, Pheasant He

tela l g i a .

C/in North Am. 1983;14:639-647.

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of resistance forces.

1981 . Am I

The Trigger Point Manual, Balti-

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132

PELVIC LOCOMOTOR DYSFUNCTION

50. Deyo RA, Rainville

Kent KL. What can the

and

examination tell us

about low back pain? JAMA. 1992;268:760-765. 51. Gore t Hirst AE Jr. Arteriosclerotic aneurysms of the abdominal aorta: a review, Prag Cardiovasc Dis. 1 973; 1 6: 1 1 3-150, 52. Waddell G, McCullogh JA, Kummel E, Venner RM. back

1980;5:1 17-125.

Copyrighted Material

N""-fl,ro-;on

in low

Chapter 4

Clinical Assessment: General Considerations

Chapter Objectives To discuss the following topics: .. the vertebral subluxation .. physical

of pathologic versus functional disease

.. the "Five Nevers" of musculoskeletal .. whether a lesion is pelvic or lumbar in .. "joint irritability" and its .. the examination of

of motion and joint

..

during the examination

joint .. tissue tension testing •

the use of palpation

•

the soft tissue and skin

the examination

The purpose of this chapter is to discuss in related to examination of the functional musculoskeletal disturbances. examining process more specifically. \Nhere the

raises

as to the etiology (or

problem, the examination sets out to confirm them. The factors

in

the history should decide the extent of the examination. One

pay

strict attention to the

of the patient while at the same

133

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134

PELVIC LOCOMOTOR DYSFUNCTION

time searching for related problems. The examination should be tailored to assess the anatomical and functional integrities of the musculoskeletal system that are suspected to be involved. This is, of course, assuming that visceral and other forms of pathology are ruled out. Joint signs of pain, stiffness, and spasm are looked for and related to where they occur in the available range of motion. The locomotor system is a complex entity to assess. Osseous structures articulate via kinematically linked joints, and both of these are enveloped by inert and contractile tissues. Meanwhile, the nervous system is care­ fully "listening," biasing information, and directing function by the milli­ second. Joints function to move; muscles contract and generate tension; ligaments restrain. These basic functions should be assessed to ascertain the tissue involved and the dysfunction present. Findings on physical ex­ amination can be organized into different categories to aid in making a diagnosis and treatment plan. For example, a patient can be examined to determine which of the five components of the vertebral subluxation com­ plex are involved.

VERTEBRAL SUBLUXATION COMPLEX1 Although the terminology is not quite accurate, the concept of the verte­ bral subluxation complex (VSC) provides a practical model to work with. Unfortunately, terminology can be confusing, with connotations attached to words that do not cross over to other professional disciplines. The word subluxation is not used here in its literal sense of a bone out of place. The

VSC is a complex, multifaceted clinical entity made up of five basic com­ ponents that may be singularly, but are usually multiply, operant in a patient's presenting problem, all contributing to the clinical picture:

1.

Neuropathophysiology2-4 involves changes, both subjective and objec­

tive, that indicate nerve involvement, facilitation, inhibition, or atro­ phy. 2. Kinesiopathology5-7 involves changes concerned with joint biome­

chanics, ie, abnormal mobility (hypo- or hypermobility), joint play loss, compensatory reactions, "pathomechanics."

3.

Myopathology&-lO concerns reactions of muscle to injury and dysfunc­

tion, ie, spasm, weakness, myofascial trigger points, shortening, and inactivation.

4.

Histopathologyll,12 involves the cellular, vascular, and tissue response to inflammation, ie, edema, lymphedema,

5. Biochemical response13,14 involves the chemical response in the local

area of inflammation and the general response (Selye's general

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135

Clinical Assessment: General Considerations

proinflammatory and

of the body to stress,

adaptive

anti-inflammatory hormones. one can are active in the

that have more than one

condition. Most

component involved. Aberrant joint mechanics (kinesiopathology) can stimulate arthrokinetic reflexes (neuropathophysiology) t hat facilitate skeletal muscle

spasm to edema and pain

pathology). (histopathology and biochemical)

A

most likely be

posed general adaptive syndrome due to abundant stress factors will af­ fect

the

entire

process

through

the

hormones. These

increased

circulation

are

of

stressed and ex-

that inflame tend to recur. Knowing which components are involved aids in mechanical joint

For

the local inflammatory

"",cnr.:nc",

(cryotherapy,

anti-inflammatory

muscle spasm, trigger points, or shortened myofascial therapy, postisometric relaxation, stretches. Finally, individuals can be counseled such methods of stress reduction as

and nv,,,rr,co

and biofeedback.

PATHOLOGY can lead one

chapter, certain historical

As stated in the

to suspect pathology. Similarly, the examination will lend several will be discussed. The patient

will

but not

ill.

will not seem to alleviate the

may have a

time

and the examiner

the

espe-

cially if the pathology is visceral and not affected by movements. The tem­ should be taken, along with other vital and inflammation can raise the body chanical should

of the musculoskeletal

whereas medo not. The examiner

in mind the "irritability" of the

area

below). Mi-

nor movements that trigger immediate muscle spasm, especially if intense and widespread, should warn of possible and masses should be gional addition, functional

Obviously,

along with areas of warmth and redness. finding of serious disease. In joint dysfunction and myofascial

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PELVIC LOCOMOTOR DYSFUNCTION

points, and referred pain from non-neural tissues are not associated with "hard" neurologic signs, ie, myoparesis, hypesthesia, and hyporeflexia. Nerve tension signs are similarly absent. Question for Thought

Does restoring joint mobility with manipulation that alleviates a patient's pain nullify the presence of a pathologic process? THE "FIVE NEVERS"

Zohn and MennelP5 mention the "Five Nevers" when discussing generalities of the physical examination:

1. Fluid can never be palpated in a normal synovial joint. 2. The normal joint capsule is never palpable. 3. Normal ligaments are never painful on palpation. 4. Osteoporosis senilis never affects the skull. S. Osteoporosis senilis never affects the lamina dura around the teeth.

The third "never" is important to bear in mind when palpating the liga­ ments arOlmd the sacroiliac joint and pubic symphysis. MennelPo men­ tions that ligaments are never painful unless traumatized or unless the joint they support is dysfunctional. As joint mobility and inflammation are corrected with treatment, joint ligament tenderness usually abates. This can serve as a general indicator of progress for both clinician and patient. LUMBAR VERSUS PELVIS

When suspecting pelvic joint dysfunction, it is well to rule out lumbar spine involvement first (Figure 4-1). Look for joint signs (pain and stiff­ ness, local muscle guarding, segmental dysfunction) localizing to the lum­ bar spine. Lumbar joint dysfunction is associated with a painfully re­ stricted lumbar motion segment. Hard neurologic signs (myoparesis, hypore£1exia, hypesthesia, nerve tension signs) localizing to lmnbar levels raise the suspicion of a radicular problem. Keep in mind that thoracolum­ bar joint dysfunction can create pain in the sacroiliac region17 (Figure 4-2). JOINT IRRITABILITY

Regarding joint irritability, the response to examination maneuvers can yield important therapeutic information. A sense of a condition's irritabil-

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Clinical Assessment: General Considerations

4-1 Lumbar

�v'-.uu,�.u

4-2 Thoracolumbar

Pain Referral

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137

138

PELVIC LOCOMOTOR DYSFUNCTION

can also be derived from the history. The of joint to pain, the amount of movement and (3) the time it takes and amount of for the to "settle down" to its undisturbed state. Acutely inflamed joints and tissues tend to exacerbate easily and should be handled with extreme care. Attention must be paid to sudden to joint movements. The more irritable the brisk the muscle guarding. These joints demand care and r"'<:n.,,�r if their are not heeded. A revolt with and examination will in painful retribution and further needless sufferover a few days than to It is better to assess such a situation a full-scale examination all in one visit. In addition, most pro­ vocative tests will be positive in such a highly irritable state, and the cliniChronic conditions seem less cal will able to tolerate more vigorous examination maneuvers.

RANGE OF MOTION

range of motion are addressed. Active movement is in that all it tells us is the of the to no,.t,-",."" ment and the general area of involvement. Passive movements include physiologic and accessory or joint play movements. Passive physiologic movements are the same as active movements; an examiner peror joint movements are involforms them for the patient. movements also performed the examiner and are intrinsic to normal joint function. Taking a joint through a passive range of motion of the motion and soft tissue information as to the restraints (see the section "Selective Tissue Tension" later in this gross testing can be normal in spite of of motion tal movement abnormalities. For the overall shared by several joints in a kinematic chain can be normal, loss of joint joints at compensating at one level can be hidden movement assessment ac(:eS:SOI'V movement or joint play techstates: "There ment and palpation as voke or reproduce

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Clinical Assessment: General Considerations

4-3

139

of Motion

of motion can Resisted muscle be included in r;l,�O',>-()r-f1n, muscular, musculotendinous, and tt>rl()rU'rIAc::t",,,, tion "Selective Tissue Tension" later in traction and the quality of movement are range of motion When range at which pain commences is structures set of without any resistance from the or of the paactive inflamm ation or implies severe pain the range Pain tient to allow the movement to be inflamed of motion (through-range indicates an joint and one that is constantly painful. Pain onset that is commensurate with resistance at or near the end of a joint's range of motion indisoft tissues (inert, cates of the loligamentous), which is more indicative of a chronic problem.

JOINT PLAYIJOINT DYSFUNCTION assesses the involuntary accessory movement play motion is the small (1/8- to 1/4characteristic of all synovial joints. Joint

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140

PELVIC LOCOMOTOR DYSFUNCTION

inch)

range of motion that is

for all

function smoothly during active

to involun-

movements.

tary, joint play cannot be evaluated by active range-oF-motion tests but movement characteris-

palpating the

must be assessed

tics of the joint. Likewise, joint

which

is an active utilized on joints that lack joint

The loss of joint play is termed joint painful

and is characterized by and

Mennell states: which are too often

"This leads to reiteration of the basic in practice, that:

(1) when a joint is not free to move, the

muscles that move it cannot be free to move it,

muscles cannot

be restored to normal if the joints which they move are not free to move,

on normal joint

normal muscle function is

movement, and

(4)

muscle function

and

may cause deterioration in abnormal What causes

Usually trauma, both intrinsic and exand

but also Hans or disease. Joint viscerosomatic reflex pf()CeSSE�S "">r'M",,.,

is

inflamma-

can even

of

a

heart-shoulder). Menne1l6 believes that

most common cause of osteoarthritic

MennelP6 outlines the

rules for joint

assessment:

1. Both the patient and examiner must be relaxed.

2, One and one movement are examined at one time, 3, One facet of the joint examined is moved upon the

stabi-

lized facet.

4. Movement is compared to that of the joint on the opposite side. 5, No forceful or abnormal movements should be used. movements must be 6. The at the onset of pain. movements should not be done in the

T

inflammation or disease.

JOINT SIGNS When one is comparable joint

a patient with a in the

joint should be sought.

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of joint

Clinical Assessment: General Considerations

141

joint involvement are pain, and spasm. Jomt subjective account. 'The approare those that correlate with the joint should exhibit these For example, a joint with an acute left sacroiliac problem may exhibit localized testing of the left sacroiliac joint with passive pain and stiffness movements or provocative tests. These are comparable joint signs exhibited by the joint. additional may incidentally reveal a right Patrick-Fabere test, hip problem. Further testing may uncover restricted physiologic movements and that the patient was not even aware of before the examination. This is not to say that the has to do with joint but that it does not correof this patient's the overall late with the Another would be stiffness of the opposite knee joint in the above-described hypothetical This is not an appropriate joint sign reflective of the patient's sacroiliac joint COMPRESSION WITH PASSIVE TESTING

Often in our search for comparable joint the patient's In this sory movements using joint physiologic or accessory movements can be in eliciting and symptoms Maitland21 considers joint an to add to passive movement testing. He it can reveal subtle, early in the friction-free movement of due to a joint surface disorder. Joint surface here means the structures interbetween the subchondral portions of each bone participating in the articulation. Included is the synovial fluid. Normal hyaline and movement. Changes in synfor fluid are traumatic and rheumatoid ovial fluid, as seen in its OflCHE!CrlVe may have a role in 'Dlese changes, as well as can increase the coefficient situation that may be by testing passive movements with simulta,,,,-'.U","\;; in its early comments: ... ",pr\.rrm' ....

is familiar with the feel of moving a or nearly all, its hyaline cartilage. have a that some of these others. We therefore, be

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PELVIC LOCOMOTOR DYSFUNCTION

must exist when this comes

in the f'h",n'")"AC

' fW'_"'AO

in friction first be-

examination. It is the movement which ... can be assessed

by passive movement, and ... this assessment can be earlier if ment.21(plll)

is utilized during the test move-

the articular

is

may be from sensitive subchondral bone. compression should be used in three instances: cannot be reproduced with regular

response is

disorder should be sus3. when

4-4

is present but no

Distraction and

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are evident

Clinical Assessment: General Considerations

143

SELECTIVE TISSUE TENSION

Cyriax23 developed a system of assessment aimed at incriminating the type of tissue responsible for a patient's pain. Essentially, it is based on whether the tissue is contractile and how it responds to active, passive, and resisted range-oF-motion testing. In addition to muscle, the contractile tissues include those structures affected by the contraction of muscle, ie, tendon and tendon insertions. The noncontractile or inert tissues include the passive elements of the musculoskeletal system, ie, joint capsule, liga­ ments, bursa, fascia, dura mater, and nerve roots. Passive motion is tested first while observing for pain response and type of end-feel exhibited. Cyriax23 mentions six end-feels to differentiate among (Exhibit

4-1).

An active motion stresses both contractile and inert tissues and is only a

general guide. However, passive motion that is painful and active motion that is painful in the opposite direction incriminate a contractile tissue, since it is stressed during both contraction and stretch­ ing (Figure 4-5). When passive and active motions are painful in the same direction, inert or passive elements are incriminated (Figure 4-6).

A resisted muscle test with the joint held at midrange theoretically stresses mostly the contractile elements and helps to rule out the inert structures. However, one must bear in mind that muscle contraction also creates joint reaction forces. These forces create joint compression and some amount of articular stress. Holding the joint in its neutral range

Exhibil4-1 End-Feels23 Bone on Bone

A hard, abrupt cessation of movement, as experienced in passive extension of the normal knee

Soft Tissue

The sensation experienced in passive flexion of the normal knee and hip

Spasm

Twanglike cessation of movement due to muscle spasm guarding a fracture, inflammation, or neoplaSia. Always abnormal

Capsular

Hard cessation of movement, as when a leather strap is stretched. Normally felt at the extreme of hip rotation. Abnormal if felt sooner or firmer than usual

Springy Block

A rubbery end to motion, as when a door hits a hard rubber ball stuck between the door and its jamb. Indicates internal derange­ ment, as in a torn knee meniscus

Empty Feeling

More movement seems possible but is quickly arrested by the patient's experience of pain. There is no sense of articular or soft tissue resistance. Always abnormal; usually seen in abscess, neo­ plasia, bursitis

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144

PELVIC LOCOMOTOR DYSFUNCTION

o

Figure

4-5

When Contractile Tissue Is Involved

o

Figure 4-6 Involved

Pain

When Passive or Inert Tissues Are

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Clinical Assessment: General Considerations

145

and painless contraca should limit this to some extent. and painful contraca normal contractile element. A tion tion indicates a minor lesion, whereas a weak painful contraction means a more serious lesion, a breach or tear in the structures contracted. A weak and painless contraction denotes neurologic compro­ mise. It is difficult truly to isolate tissues on exarninaand therefore selective tissue tension tests should be weighed ciously. PALPATION

Grieve states that: of the in assessing where or manipulating the vertebral column, should perto work in haps rest on what is found by palpation, active, and tests of movement."18(p196) is more an art than a It seems that yet it forms an important cornerstone in the evaluation process of the dysfunctional locoand expemotor It is a psychomotor skill that as do Heart and lung auscultation rience to ophthalmoscopic and oto'SCCIO on the part of the examiner. Palpation is strate both error and the hands to touch and feel our the process of mation about tissue texture, temperature, tool to assist in the It is also a size, and bonding process. a palpatory method for a""·"",,o,u Gillet and Liekenss iliac joint motion. A few studies investigating the dure demonstrated mixed with reliability was associated to good. Evaluation of the sacroiliac joint's upper with better results. Intraexaminer scores seemed better than those between examiners. that joint Gillet's procedure can be in the clinical assessment of motion because intraexaminer reliability is more important: in most clini­ cal situations, only one examiner is involved in the assessment of the patient. Others contend that is too subjective and able A to be considered is that the examination tests experimental confusion and skewed results assessment maintains a central role in the examination of locomotor dysfunctions. as in other areas of clinical conclusive data are not available; palpation continues to be a

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P ELVIC LOCOMOTOR DYSFUNCTION

for either or emotional reasons. More studies used apand better methods will appear to improve our proach. Palpation attempts to localize areas of pain and movement restriction that we as clinicians understand their and demonstrate to a functional assessment often exlet never even touched alone touched the painful area. From the standpoint, it is critical that the examiner touch the painful area or at least demonstrate to the pa­ hurts. It is also important to tient that he or she knows where the have the say, "That's it! That's my pain! You've found it!" to palpation and provocative we should in cases of repatient's exact symptoms. Sometimes we cannot, Many times our are all that we have to go ferred a the motion of joints, Movement joint's accessory motion or joint Actual motion in the sacroiliac joint is difficult to a sense of seems to be a more accurate description. Since the sacroiliac joint is not moved directly by any particular muscle group, its motion is to or tnmk motions while it seemingly "floats" in a play. In a similar situation, the talus independently any direct muscle control, since it receives no to movements of tendinous attachments. Its movements are the sacrum has several and muscles. In the to it that indirectly affect its motion. trunk and hip muscles it seems that the sacrum is dependent on sacroiliac joint play function painlessly between the ilia. In motion palpation, it is not so much the motion as the that is can be Fortunately, the body has two sides whose compared, and this should be taken advantage of in the examination. It has been said that the more lightly one touches, the more one feels. This cannot be overstated.

SOFT TISSUE AND SKIN CHANGES The skin can

clues to locomotor disturbances through funcSigns of overactive tions27 can be observed. include changes in skin sweatcan manifest with ing, and electrical resistance. Recent of the soft tissues (ligaments, muscles, smooth subof more chronic conditions whereas tissue

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Clinical Assessment: General Considerations

147

feel hard and stringy.28 The skin can become thickened and tender and take on a "puckered" appearance when it is lifted and squeezed between the fingers-the so-called "peau d'orange" effect.29 Rolling the skin off the underlying muscle layer will meet with a resistance and tenderness over joint and muscle lesions6•16,28,30 and can be used as a confirmatory sign of their existence. In slender individuals, if the skin over a problematic sacro­ iliac joint is rolled, it will be tender, taut, and possibly slightly thickened. To perform skin rolling, one pinches the skin between the thumb and fingers on each hand. One holds both thumbs down on the skin tip to tip, and advances them by rolling a fold of skin up over them with the fore­ and middle fingers (Figure 4-7). LENGTH-STRENGTH AND MOVEMENT PATTERNS In conjunction with range-of-motion testing is the "length-strength" testing of muscles and the observation of key movement patterns. The ner­ vous system directs movements in terms of whole motions and not indi­ vidual muscle activations.2 Normal activation sequences have been ob-

Figure 4-7 Skin Rolling

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148

PELVIC LOCOMOTOR DYSFUNCTION

served for various movements.31 and

with resultant inhibition of

movement as

Certain muscles have a predilection to become shortened and

observed by Janda31 (Exhibit 4-2). He noted that the important postural muscles demonstrate the to

Janda10 states

motor

muscles inhibit their an-

inhibition, tight

tagonist muscle

especially in

propensity to

to poor posture and and cause a

known in the field

It is

neurophysiology that facilitation of an

muscle group is associated with reflex nist

For

inhibition of its

a contraction

extend the knee joint

the

phenomenon is "hard-wired" into the same phenomenon is and

will

if the hamstrings are inhibited from resistand is reflex based.

to occur

(facilitated). The innocent

reflex command of inhibition and lengthening the shortened and tight strengthening response in the is because the muscle

nrcn,,,,,,

was

quence of neurophysiologic processes, via the nervous

and not loss of neuromuscular controL The

cess does not entail a true

in the usual sense, and thus the term

pseudoparesis is used.

On the other hand, a tight and shortened muscle will not It needs a force external to itself to

it. In quoting by the

Ralston, Kendall and

Exhibit 4--2 Common Imbalance of Pelvic Muscles Weakened/Inhibited Quadratus lumborum

Gluteus maximus Gluteus medius

Erector spinae

Gluteus minimus

Psoas

Vasti

Rectus femoris

Rectus abdominis

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Clinical Assessment: General Considerations

Inhibition

Facilitation

Antagonist

Agonist

149

Figure 4-8 Reciprocal Inhibition

pull of antagonistic muscles, gravity, or some other process outside the control of the muscle in question. The lengthening of a shortened muscle is passive, not active. Therefore, shortened muscles tend to remain short un­ less some extrinsic factor lengthens them. Shortened, tight muscles can overpower any weaker antagonists, either by force or by neurologic inhi­ bition, and create a postural imbalance. If this situation is prolonged, the weaker antagonists can suffer from what Kendall and McCreary call "stretch-weakness."32 Unfortunately, if the tight, hypertonic muscle state persists, inhibiting antagonist muscles, aberrant movement patterns result that can be habituated by the neuromuscular system. The cerebellum "memorizes" these inappropriate movement patterns, and they become

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150

PELVIC LOCOMOTOR DYSFUNCTION

The tight muscles adapt and

the weak

Reeducation of normal move-

weaken more and

by remedial exercises and proper proprioceptive input from

ment

the periphery can help correct the habituation. Thus, the

of one

of muscles

a

can create postural imbalances altering

stretch-weakness of its

locomotor function. These imbalances occur in

as

The issue of which of the two above problems is pri-

described mary, the adaptive

or the

of which came

the

is tantamount to

the chicken or the

Three maneuvers for the lower back ment

quality

can be used to assess moveIn the prone position, hip

below and Chapter

extension is performed, and the proper contraction sequence of the hamstring, low).

muscles is looked for

maximus, and erector second movement

lying

tested is

be-

abduction in the side-

and the simultaneous contraction of the tensor fascia lata

and gluteus medius is looked for. The third movement pattern tested is a trunk

feet are cradled to detect lifting off. Lift-

while the

ing up of the

inappropriate a few

In the One is

flexor recruitment. seem to predominate.

of

pelvic crossed syndrome: tight and shortened erector

and psoas muscles crossed with weak and inhibited abdominal and gluteus maximus muscles33 muscles inhibit their

and

4-9). The erector

maximus

An anterior

situation

5, the section

the abdominals and tilt is short-

A second common pattern seen about the pelvis includes ened tensor fascia lata and

lumborum muscles and weak, inhib-

ited glutei minimus and

muscles. The iliotibial band is usually taut

as well. An abnormal movement nous firing of the glutei

in this situation entails and tensor fascia lata during

abduction. Although they usually all contract

hip abduc­

tion, the above imbalance usually results in the tensor fascia lata firing flexion. Iliopsoas external

rotation.31

also becomes adductor muscles and weak

ductors often coexist! in which case the patient has a difficult time raising the uppermost

in the side posture. Just by

muscles to their normal abduct the The layer

the patient is

and

the adductor able to

and is another

observed and can be visualized

posteriorly on postural examination (Figure 4-10; see also Chapter

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In

Clinical Assessment: General Considerations

Tight Erector Spinae

151

Tight Psoas

Weak Gluteus Maximus

Figure 4-9

Pelvic Crossed Syndrome

of weak, inhibited muscles alternate with this areas or layers of shortened, muscles. For example, from the posterior one can weak commonly observe tight lumbar erector muscles. It appears that the muscles with a postural importance show more of a tento shorten. muscles that show a dency for weakness are termed phasic.JO These muscle imbalances are affect that can thought to create abnormal movement the locomotor system. An example can be found in the abovementioned movement pattern of extension. Polyelectromyography has shown that the movers in order of are the mus, and erector In a situation of disturbed muscle maximus is weak, and its contraction is

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PELVIC LOCOMOTOR DYSfUNCTION

Weak/Inhibited

ShortenedlTight

Upper Trapezius Cervicals

Thoracolumbar Erector Spinae

{

l

4-10 Layer those on the

Gluteus Ma)(lmus

Muscles listed on the left are often weak and inhibited.

or even absent, sate to carry out

Lumbosacral Erector

the

and 5hort-

and erector contractions compen-

extension. The tight and shortened muscles

and erector

seem to activate

competing for action at the expense of the inhibited

maximus

muscles. states that "there is now enough evidence that of muscles occurs in close

with

lions which is considered to be the most common cause of tions such as low back dysfunctional

condi­

"35(p199) Impaired afferent proprioception from

is thought to cause

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muscular re-

153

Clinical Assessment: General Considerations

Janda10 stresses the importance of a properly controlled and coordinated neuromuscular system to the osteoarticular

and health of the

Abnormal tensions

muscular imbalances may hasten

and foster joint muscle's

Radin38 relates how a

dysfunctions.lO

in the joint and

failure to lengthen contributes to is important for

a sense of balance of

stretching the pelvis during

due to

across

nAn",,,,,,,',,

muscles about the

examination can yield information about muscle disten-

sibility and any adaptive

Muscles of interest about the

include the erector spinae, hamstrings, rectus can be formulated for these. In addition,

ing and

proprioceptive input provided by the clinician or special exercises can reto use more appropriate movement

educate the nervous

Bullock-Saxton et aP9 showed that use of wobble boards or balance shoes enhanced or "reactivated"

maximus muscle

and de­

creased its time to 75% maximum contraction.

LEG-LENGTH INEQUALITY There is a vic obliquity

seen on

studied with low back pain, 13% to

LLl in low back pain.40 Of 22% demonstrated an LLl

(1 em)

4% to

much debate still exists as to the role of to about 7%

of % in

of

adults.

Giles40 states that LLI of 1 em or more seems to be more prevalent in with lower back pain than in the asymptomatic population. There is tremendous debate as to what constih.ttes a clinically <:10'''''''-'''''''

LLl

Rush and Steine!,"1 found an

LLl

of 3/16 in

cm) or more

to the backache of 1000 soldiers studied. Travell and Simons41

Y2 in (1.3

as a

even in asymptomatic people as a studied back

LLl

in over 1100

amount of LLl to correct for, measure.

359 of whom were controls.

and unilateral chronic

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were common in

154

PELVIC LOCOMOTOR DYSFUNCTION

Table 4-1 Leg-Length Discrepancies Found To Be Significant

Rush, Steiner1

3/16 in (0.5 em) 3/16 in (0.5 em)

Giles'"' Travell, Simons<2

3/8 in (LO em) 1/2 in (1.3 em)

the study group. Her study demonstrated a

incidence of LLI on the

to the left (39%), The

right side (53%)

of the short leg

was idiopathic in 92% of the cases, in contrast to known

trau-

factors. An LLI of 5 mm or more was found

or growth

to be significant in 75% of the patients, as

to 435% of the con­

trols. Further, she found a sixfold increased incidence of having an LLI of

15 mm (0.58

in a

of subjects with low back pain when

to those without.

and sciatica were more com-

IArlO'_It>CT

syndrome,"

side. In writing about the

FribergM

hip

and sciatica to occur on the same

which happened to be the long-leg side, 91% of the time. The average LLI with hip-spine symptoms was 12.8 mm (1/2 in) versus

in those

5.2 mm

in) in the control group. Friberg found that lift

com-

monly resolved her patients' symptoms, even chronic low back and pain. Measurement The most commonly used clinical method for the distance between the ASIS and the inferior ipsilateral medial malleolus, A more functional method is to observe the the relative heights of the ante-

and

patient in the standing

iliac spines and iliac crests. If a leg-length dis-

rior and crepancy exists

manifests itself by

amount of lift material is

obliquity, the needed

under the

appe,ars level via visual

short

until the

or with the aid of a leveling de-

This method is more functional in that it tests the paposition. The patient can also and the examiner can observe the initial

the

of distortions

(pelvic obliquity, spinal curvature, trunk contours) self-correct. Travell and Simons42 feel that this clinical trial method of determining LLI is more accurate than measuring LLI via tape measure while the patient is supine.

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155

Clinical Assessment: General Considerations

A

2 - 2

3 Ngure 4-11 (A) Short right tural correction after clinical scoliosis; (2) leveling of pelvis;

(1) (3)

lumbar scoliosis; (2) oliquity. (8) Posof lift placement: (1) red uction of functional of lift material.

clinical methods for the assessment of LLI are inaccurate for several reasons.

accurate

landmarks is difficult at tients, thus affecting the within the pelvis

location of subcutaneous in muscular and obese pa-

of measuring

LLI. Second,

due to either a small

of the innominates at the sacroiliac joints, causes a the

or counterrotation between

creating error in measuring. These clinical meth­

ods are also inadequate because they do not

information about the

position of the sacral base upon which the spine rests or about how the reacts to the

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PELVIC LOCOMOTOR DYSFUNCTION

the clinical methods for as their limitations are in LLI can be used as simple methods. Triano45 investigated the erector spinae EMG response to LLI and a under the heel while standing and under the ischium while sit­ whether the lifts balanced any asymmetric EMG the EMG results with After he concluded that EMG was a more accurate determinant .,r".rn,.,n� than conventional methods used to assess pelvic and sacral

ex� amination allows visualization of how the and pelvis biomechanireact to an LLL It is that in response to a short leg, the pelvis drops on side and the lumbar spine exhibits a scoliosis side. Janse47 mentions a basic distortion to the with the n;,l-tpr'n of the associated with an in which the ilium on the short-leg side rotates posteriorly, the sacral base on the same side rotates anteriorly and inferiorly, and L�5 counterrotates on the sacrum, with its transverse process going posteriorly on the side of the posterior innominate. and Beckwith48 studied the Results showed that nate and sacral base were lower in 88% and 72% of the cases lumbar scoliosis convexity was ipsilateral only 45% of the cases, with 32% contralateral and 23')10 deviation. Radiographs are also needed to visualize any sacral base obliquity. Sacral base unleveling is unusual in low back pain in the absence of the sacral base an LLI.49 Giles40 mentions the importance of asymmetries and anomalies obliquity in relation to the LLI. Due to to the LLI. For within the pelvis, sacral base obliquity may not the sacral base may be level in the presence of an LLI without a may then unlevel resultant lumbar scoliosis. Applying a lift to this the sacral base and cause possible lumbar compensations. Travell and to lumbar biomechanics Simons46 mention that an LLI is insofar as there exists a sacral base combinations of sacral base obliquity and LLL Asymmetric joint loading is thought to occur as a result of deviations imposed by LLI. Giles40 has found structural in lumbar joints associated with a 1- to 1.5-cm LLI and has studied between low back and LLI. The consisted of

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Clinical Assessment: General Considerations

at both the lum-

and subchondral bone

articular

bosacral level and the

157

and

of the scoliosis.

lumbar vertebral wedging were also found.50 Giles's histological and clini­ cal studies have led him to conclude that patients with an LLI of

1 cm

or

with shoe lifts to 40

more and a postural scoliosis should be lessen the compensatory burden on the lumbar

LLI carries with it potent biomechanical consequences and can be considered a

risk factor for arthritic

in the hip and

LLI is associated with osteoarthritic knees, joints.

these

For

in the

were noted more

the longer-leg side. 'The hip on the

on

side is in a relative position of

adduction, which subsequently reduces the weight-bearing area of the joint. As a

tive changes OCCUr.53,54 In

joint surface forces are generated, and Morscher54 noted a marked asymmetry

in the EMG response in the low back and

muscles with an ILl of 3/8 a

in. The hip abductors on the

side were

higher joint reactive force,

with the smaller available area of

acetabular

contributed to more joint stress on the long-leg

side. Vink and

noted an increased EMG activity in the

muscles contralateral to the LLI. 'Ibis response was noted in with an LLI as little as

1.5 mm.

Mahar et al56 demonstrated that the

weight shifted to the longto the

side and that there was an increased postural sway amount of LLI.

stated that their findings support the viewpoint that

minor differences in

may be distribution.

of LU on lateral

side when the LU than 6 rom) side. Lawrence was righting reflexes and

Bandy and Sinning58 used heel lifts to correct

to 3/8-in LUs and

noticed that sagittal-plane kinetic patterns were improved in the and ankle while the

due to

medius activation to level the knee,

were observed walking and

on a

treadmill. stance phase was increased on the side received more weight normalized after heel lift

In an creased

DeLacerda and Wikoff60 demonstrated an in­ a constant workload in subjects with LLL

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158

PELVIC LOCOMOTOR DYSfUNCTION

Travell and Simons42A6 mention how LU is the most common ing factor in lumborum points, the most overlooked source of low back pain. also cite Gross's work61 that failed to show any help from lifts used to correct 3/15-in LUs in marathon that because both feet do not simultaneously touch runners. It is with a does not the lumbar the ground during scoliotic curve.46 Bandy and did demonstrate implacement. in runners after provement in From the above, it can be seen that LU can create and therefore should be screened for and, if to the locomotor deemed corrected. joint and muscle should be attended to first and the clinical situation reassessed implementing lift therapy. should first be assessed for An individual with a and postural dysfunctions in the locomotor The are addressed first in addition to appropriate exercise on tight muscles and strengthening weak with recurrent problems, the LLI is ones. If the patient continues to the while he investigated more by clinically or she is and then observing for any resulting The equally distribis on the lift material with the patient to kinesthetically uted over both feet for 3 minutes. This accommodate to the "corrected" The lift material is then removed side. Patients invariably notice a kinesthetic dif­ from under the The height ference and comment how the corrected position feels to demonstrate sacral and the pelvis is of the lift material is base obliquity and changes in the spine. X-rays can be taken in the uncorrected and corrected to determine how the to the lift evidence of sacral with the thoracolumbar placed over the sacrum indicates a favorable response. The patient can then be referred to a orthotist for lift ·k��., w

.. What are some physical ..

Review

of pathology?

differentiate a typical lumbar

.. What important information does yield?

one of

joint's level of "irritability"

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159

Clinical Assessment: General Considerations

range of motion

.. What important factors

examination?

should be considered during a .. Discuss joint play and its relation to nonnal .. What is meant by

motion.

"selective tissue tensions"? are seen in acute versus chronic condi-

.. What soft tissue tions?

have a

.. Which muscles around the

to shorten and

become tight? .. What is the

of

in lower back

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of the Spine.

[urltiI1lgt(Jn Beach, Calif: Motion

Insti-

tute; 1981. of disease processes: some

2. Karr 1M. The spinal cord as

perspec-

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cord as

of sympa1979;4:57-62.

thetie innervation as a common

4.

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5. Gillet H, Liekens M.

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Institute; 1984. 6. Mennell

JM.

Back Pain:

un'VfI,,,,,>

Boston,

Mass: Little, Brown & Co; 1960. 7. Jirout]. Studies on the dynamics of the spine. Acta Radiol. 1956;46:55-60. 8. Travel! jG, Rinzler SH. The rrn.r"t"�r,,,, 9. Korr 1M. PT()nr·,nc·pnto 10. Janda

V. Muscles, central nervous

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Ne,lIfobioloilic Mechanisms in Manipulative

New York, NY: Plenum Publishing

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11. Cotran RS, Kumar V, Robbins SL

Pnlh,,/,wlr

Pa:WB

Saunders; 1989. 12. Salter RB, Simmonds DF, Malcolm BW, et at. The UIL"V),'L'" effect of continuous passive

in

motion on healing of full-thickness defects in the rabbit. J Bone Joint 13. Selye H. The Stress

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17. Maigne R. Low back pain of thoracolumbar origin. Arch Phys Med Rehabil. 1980;61:389395.

18. Greive GP. Common Vertebral/oint Problems. New York, NY: Churchill Livingstone; 1981. 19. Mennell JM. Joint Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston,

Mass: Little, Brown & Co; 1964. 20. Maitland GO. Peripheral Manipulatiol1. 2nd ed. Boston, Mass: Butterworths; 1977. 21. Maitland GO. The importance of adding compression when examining and treating syn­ ovial joints. In: Glasgow EF, Twomey LT, Scull ER, Kleynhans AM, eds. Aspects of Ma­ nipulative Therapy. 2nd ed. New York, NY: Churchill Livingstone; 1985. 22. Broderick P A, Corvese N, Pierik MG, Pike RF, Mariorenzi AL. Exfoliative cytology inter­ pretation of synovial fluid in joint disease./ Bone Joint Surg. 1976;58A:396-- 399. · 23. Cyriax J. Textbook of Orthopaedic Medicine. Vall. Diagnosis of Soft Tissue Lesions. London: Balliere Tindall; 1978. 24. Wiles MR. Reproducibility and inter-examiner correlation of motion palpation findings of the sacroiliac joints./ Can Chiro Assoc. 1980;24:59-68. 25. Carmichael JP. Inter- and intra-examiner reliability of palpation of sacroiliac joint dys­ function./ Manipulative Physiol Ther. 1987;10:164--171. 26. Herzog W, Read LJ, Conway PJW, Shaw LO, McEwen Me. Reliability of motion palpa­ tion procedures to detect sacroiliac joint fixations./ Manipulative Physiol Ther. 1989;12:86-92. 27. Glover JR. Characterization of localized back pain. In: Buerger AA, Tobis JS, eds. Ap­ proaches to the Validation of Manipulation Therapy. Springfield, III: Charles C Thomas, Pub­ lisher; 1977:175-186. 28. Maitland GO. Vertebral Manipulation. 5th ed. Boston, Mass: Butterworths; 1986. 29. Stoddard A. Manual of Osteopathic Practice. London: Hutchinson, Long; 1969. 30. Bourdillion JF, Day EA. Spinal Manipulation. 4th ed. Norwalk, Conn: Appleton

& Lange;

1987. 31. Janda

V. Muscle Function Testing. Boston, Mass: Butterworths; 1983.

32. Kendall FP, McCreary EK. Muscles: Testing and Function. Baltimore, Md: Williams & Wilkins; 1983. 33. Jull GA, Janda

V. Muscles and motor control in low back pain: assessment and manage­

ment. In: Twomey LT, Taylor JR, eds. PhySical Tlrerapy of the Luw Back. New York, NY: Churchill Livingstone; 1987:253-277. 34. Lewit K. Manipulative Therapy in Rehabilitation of the Locolllotor System. Boston, Mass: Buttelworths; 1985. 35. Janda

V. Muscle weakness and inhibition (pseudoparesis) in back pain syndromes. In:

Grieve GP, ed. Modem Manual Therapy of the Vertebral Column. New York, NY: Churchill Livingstone; 1986:197-201. 36. Wy . 37. Siosberg M. Effects of altered afferent articular input on sensation, proprioception,

muscle tone and sympathetic reflex responses./ Manipulative Physiol Ther. 1988;11:4004 08. 38. Radin EL. Aetiology of osteoarthrosis. Ciin Rheum Dis. 1 97 6;2:5 09-522. 39. Bullock-Saxton JE, Janda

V, Bullock MI. Reflex activation of gluteal muscles in walking.

Spine. 1993;18:704--708.

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Clinical Assessment: General Considerations

4 0 , G i les L G F . Allatoll/ielll Basis

161

Back Pain, Baltimore, M d : W i U iams & Wil kins; 1 989.

4 1 . Rush WA , Steiner H A . A

Am

o f lower extremity

J

Rad

Ther, 1 946;56:616-623, Pain and

Travell jG, Simons DC.

Point Manual. Vol 1.

Ba l t imore, M d : W i l l iams & W i l kins; 1983, 43.

O. C l inical symptoms a n d b i omechanics of lumbar

0, H i p-spine

44,

and spine and hip joint

1983;3:643-65 1 .

length ineq u a lity.

cl inical biomechanics,

and conservative treat-

ment. lv1anual Med, 1 988;3:144-147. 45, Triano Jj . Objective

e v idence for use and effects of l i ft therapy,

J Ma-

nipulative Physio/ Ther, 1 983;6:1 3-16. Point 1'v1anual. Vol 2.

Pain and Dysfu nction: The

46. Travell J G , Simons DC,

Baltimore, M d: W il l i a ms & Wilkins; 1 992. Lombard, Ill: National

47, Janse J, tic; 1976, 48.

H, Beckwith D, Short

49.

on 288 consecutive chronic LBP

50. G i les LGF, Taylor JR. Lumbar spine structural changes associated with leg-length in­ Spine. 1982;7: 159-162, 51 , Gofton J P, Trueman GE. Studies i n osteoarthritis of the hip: Part II. Osteoarthritis o f the d isparity, Can Med Assac f. 1971;1 04:791-799.

and

52, Krakovits G, Uber die

elner Beinverkurzung a uf d ie Statikund Oynamik

Z Orthop, 1 967; 1 02:4 1 8-423,

des 53, Dixon AS],

S,

54, Morscher E. 1 972;1 :9-19, HAC.

55. Vink

pelvic t i l t and lumbar back muscle

activity 56. Mahar RK, K irby RL, MacLeod DA. Simu lated leg-length d iscrepancy: its effect on mean position and postural sway, A rch Phys Med Rehabil, 1 985;66 :822-824. 57. Lawrence OJ, Latera l ization of nary report. !

J

Ther. 1 986;7:173-179. O i no w i tz H D, P o l c h a n i n o f f M. Limb length analysis, ! Am Podintr Med

60, DeLacerda FG, W i koff 00, Effect of lower gait. ! 61.

a prel i mi -

WE. K i nematic effects o f heel l ift use to correct lower

58, Bandy WD, d ifferences,

in the presence of structural Ther. 1984;7:1 05-108.

a n elec-

1 985;75:639, asymmetry on the kinematics o f

Phys Ther, 1 982;3 : 1 05-1 07. discrepancy i n marathon runners. A m

Copyrighted Material

J Sports Med, 1 983; 1 1 : 1 2 1-

ChapterS

Examination

Objectives

The essential features of the manual functional examination are postural and gait f.''''CJ.uu"",,,u

joint

of motion, including

play assess-

provocative maneuvers; observation for

locomotor

muscle length and strength testing; and observation re-

This is in addition to assessing motor, of the

flex, and vascular

that pa-

concerned.

thology has been ruled out, the main goal of the functional examination is to rule in functional aberrations of the locomotor system. As stated before, presen-

serious

accounts for only a small percentage of

tations.

the possibility of its presence must be borne in mind.

For our

pathology has been ruled out,

is still

the

in pain and in need of a functional assessment. Whereas in the part of the examination we are all ears, communicated to us eyes and

the

attentive to information

in the

feeling, and

for dysfunction in the vari-

ous tissues of the locomotor system that may be involved. During the

short and

muscles are noted

their weak, inhibited antagonists. Joint restriction and points are searched for. These joint and muscle dysfunctions are

'�'-,U"H��

in order to consider an appropriate treatment plan to tests will will not. It is

the patient's

whereas others

that the examiner

muscle pains for three reasons:

(1)

to let

162 Copyrighted Material

the patient's

and

know that the exam-

Examination

iner knows where the

(3) to

163

to understand the condition better, and

the examiner

clues as to how to treat the condition.

do locomotor disturbances occur in isolation. A clinical case may clues that will alert the clinician to search for associated or linked The gait

maximus because of atrophy or

examination

link decreased hip extension on that side. Poor psoas

ex-

may be observed further on in the exami-

tension and abduction nation.

examination may indicate a weak

the

For and inhibited

erector

muscles may be associated with the

above and may be found together with

lumbar

motion on full­

trunk flexion. Provocative and function testing may be positive for joint gluteal

dysfunction in the hip and sacroiliac joints, with trigger

found. When the examination is over, the clinician

knows that in addition to

joint

he or she needs

to address trigger points; short, overactive muscles; weak, inhibited and com-

and poor movement patterns. The web of in so many cases, especially

that is

ones, must be

that the locomotor system is function-

with the

interdependence, dysfunctions are of-

interdependent. Because of

in chains, almost predictably so.

10 discusses sitting,

we examine the

attention to cer-

lateral decubitus, and prone positions,

tain salient features that pertain to our discussion of pelvic joint and mus­ cular

This discussion is not meant to represent a compreone, for that matter.

hensive examination-nor a

an attempt has been made to mention the many tests used in examining this area. This is not intended to formed at one time. Some tests

that all of them should be

each other; however, this can

afford further confirmation of

No one examination

has shown enough sensitivity or

to be

by itself. How-

ever, the more physical examination findings that incriminate a particular structure,

the sacroiliac

the

the chance of

et all state that the

of a

when it is established on a combination STANDING Gait

In the initial aspect of the

a

should be made to ascertain any deviations

Copyrighted Material

and

assessment

the normal. It is well to

164

PELVIC LOCOMOTOR DYSFUNCTION

is the rule in the human body and that

consider that

be­ to some

cause something is not the way it is "supposed to be"

norm does not automatically mean that it is the cause of the Hn,,.,,,u,,.r

clinical inferences can be made and

LA'.nv.LLu.

gait, one should note a fluid, rhytlunic movement in the while observing from the

and lateral np'r<:r,pr'rn"p<: phases, with 60% of the 40% in the latter. The stance

is conveniently divided up into stance and spent in the former and into heel strike,

and

phase is subdivided into tion

5-2). During the

midswing, and deceleralike a

phase, one limb

lum toward heel strike while the other

unilateral support At the

instant of heel

is still in contact with the

ground,

or double-stance there is no double-support

phase.2

and the body is

literally in flight between ankle

The

oriented to allow forward motion in multiple directions, the allow movement only in flexion-extension. The movement plane

by a thrust in the

is

and gluteus maximus muscles. As the swings through its step, i t is functionally shortened

ened and

sacroiliac and

conditions

joints, short-

and the elderly.

hamstring and hip flexor

aware of the motions the

The astute beach observer is exhibits during

can be

Short stride

act to retard the motion of the seen in painful

hip and knee flex-

ground clearance. The

ion and ankle dorsiflexion to allow

While we walk, the

dal oscillating motion in the sagittal

as well as deviating

as

it shifts over the weight-bearing extremity. The center of gravity is disat unilateral

about 2 in as it goes from its during midstance to its lowest and trunk counterrotate in the

"'U'V""'JL

The

during plane with

The pelvis rotates anteriorly about 40 degrees ("pelvic the advancing limb by hip

around the

via contraction of the internal hip rotators

are unable to rotate around a

and stiff hip

demonstrate a diminished pelvic step.2 teus medius on the of the

the swing

the glu-

side contracts to afford horizontal

Hip abductor weakness is

Copyrighted Material

by a slight

of the

Examination


iIi

-0

�

15 C\= (5

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Ci5 (fi
......

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ch :0

:::J 0 0

'iil c.J

"-< 0
,..c:

P-, Q) u

�

...... U1 ....

..h III ....

::J

o.c

ii::

Copyrighted Material

165

166

PEL\lC LOCOMOTOR DYSFUNCTION

c o

�Ol Qi

(.) Ol o

c 0

.�Ol Qi

8

«

I

.....

.n; l:J --

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Copyrighted Material

Examination

167

pelvis on the swing-leg side. a gluteus medius lurch be evident (see below). about 1 in each as the The pelvis is also noted to deviate weight is transferred with each step due to the lateral thrust of gait. This movement occurs principally due to the subtalar and The main muscles ..pcnr.,,_ and determines the width of the this action are the retromalleolars and gluteus the leg is adducted relative to the

"Pelvic Step"

Figure

5-3

Pelvic Motion in the Transverse Plane During Gait

Copyrighted Material

168

P ELVIC LOCOMOTOR DYSFUNCTION

pelvis, and the swing leg is abducted. Disruption of the symmetric lateral sway to each side of the midline may be a sign of sacroiliac and/or hip joint dysfunctions. Interestingly, some studies relate temporal and kinetic gait variables, as measured by a force platform, to have improved after sacroiliac joint manipulation.H The movements the pelvis makes as a re­ sul t o f the well-o rchestrated activity of many muscles and joints help dampen the vertical motion and shock forces generated in gait. In painful limps, the patient remains on the symptomatic side as little as possible. In addition, the patient will diminish the load applied to the painful limb by trying to "jump" over it using a propulsive force supplied by the good limb and quick upward movements of the upper limbs. The observer gains a sense that the patient tries to walk with a lightness versus a heaviness when weight bearing with the painful side. The trunk is also inclined laterally away from the painful side. Auditory cues alone can be­ tray an abnormal gait, as any good horse trader knows. Painful hip problems create a limp such that the pa tient leans over the affected side. As mentioned in Chapter

2, placing the body's center of

gravi ty over the painful hip joint eliminates the need for the usual hip ab­ ductor contraction required to stabilize the pelvis in the coronal plane. This tends to lessen the joint reaction force from muscle contraction and therefore diminishes pain.? This leaning or lurching is often manifested in hip osteoarthritis and can be a very subtle movement. This lurching to one or both sides is not to be confused with the lurch of a weak gluteus medius. It is similar but occurs for antalgic reasons as opposed to a neuromuscular deficit. That is not to say that a gluteus medius weakness cannot coexist. An inhibi ted or "pseudoparetic" gluteus medius m uscle is often compen­ sated for by an overactive quadratus l umborum muscle. This is evidenced by hip elevation or "hip hiking" seen during gait. Question for Thought How would you differentiate a gl uteus medius lurch from a painful hip joint gait? Painful hip conditions, especially chronic ones, are commonly associ­ ated with shortened, tight hip flexors that tend to pull the affected hip joint into flexion and the lumbar spine into more lordosis. Consequently, the patient is forced to stoop over into flexion when bearing weight on that leg (Figure

5-4).

If both hips are involved, the patient walks with a stooped

hip-contracture gait. Weakness of the gluteus maxinms results in an exten­ sor gait in which the trunk is extended back when bearing weight on the

Copyrighted Material

Examination

169

Flexion

Increased Lordosis ---

Hip Flexion from Short Hip Flexors

Figure 5-4 Gait

affected side

with Shortened

Flexors

Painful stiffness or stiffness alone in the hip joint

will result in a lack of lateral sway of the

during the stance phase in

gait] Commonly seen in hip

osteoarthritis, is a toe-

ing-out gait. Weakness in the

in the psoas muscle, or hip

joint dysfunction with or without

shortening can all

contribute to decreased hip extension. As a

the lumbar spine

compensates and extends the hip via erector places strain on the lumbar

and can be

l::>Lldl1L.C:U

contraction. This during gait obser-

vation as hyperlordosis and muscle contraction.

hip flexors will

cause a diminished toe-off, and a

lumborum will

hike up the iliac crest on that side.

Copyrighted Material

170

PELVIC LOCOMOTOR DYSFUNCTION

Posterior Weight Bearing

Weak Gluteus Maximus

Figure 5-5

Gluteus Maximus Gait

Observation of the direction in which the patellae point during gait can yield clues as to femoral version. The angle of version or torsion is the angle the femoral neck makes with the frontal plane as the femur is "twisted" on itself during development. This is evidenced by the fact that a femur bone resting on a level surface with the condyles lying flat will have the femoral head and neck angled off the surface slightly. Normally, the femoral neck is anteverted 12 degrees anterior to the transverse axis of the femoral condyles. Confusion often results when describing knee or patellar facing in relation to anteversion or retroversion. A better under­ standing can be gained if one holds constant the neutral orientation of the femoral neck and acetabulum. One then takes note of the effect that femo­ ral version changes have on the orientation of the femoral condyles and patella (Figure 5-6). For instance, in femoral anteversion, the angle of ver­ sion is increased as the femur is "twisted" more on itself. This causes more of the femoral head to be uncovered in the acetabulum; therefore, to have

Copyrighted Material

Examination

171

A

B

c

6

Figure 5-6 Knee and patellar orientation with anteversion and retroversion. (Al of (2) transverse axis of femoral condyles, (3) Normal: (1) femoral neck and head. (B) Anteversion: (5) increased femoral version, (4) axis o f version (0 Retroversion: (6) decreased

at the the femur needs to be optimal rotated Consequently, the individual stands or walks with the posA genu patella facing more medially, exhibiting a toe-in seen with anteversion, ture is rothe femoral the angle of version is In tate externally, and the patient walks with a toe-out gait.2 In retroverted hip joints, the added external rotation seen during gait can create musclewho in the external rotators, especially in

Copyrighted Material

172

PELVIC LOCOMOTOR DYSFur-;CTlON

unaccustomed walking.

in prolonged Genu varus is often associated with a Overall hip

hip joint.

of motion is normal in both anteversion and retroverand external rotation

but internal rotation is increased in the

is increased in the latter. This may create an imbalance of muscle about the

and

and lower

ral version provides us with a good example of the locomotor functional

in which biomechanical

one area will cause

elsewhere. For

occurring at femoral anteversion

is associated with an increased Q-angle at the knee This is further associated with a

defor-

iliotibial

pronated

Additionally, sacroiliac joint dysfunction and a shortened Achilles' heel cord are commonly seen with a

iliotibial band.9

Tight, shortened iliotibial bands are also commonly found in older and manifest chronic hip and sacroiliac

adults who tend to be

iliotibial bands

to identify

problems. It is

on because these structures become relatively resistant to treatment if they shortened. In

are allowed to become sion, one can educate

femoral ver-

on dysfunctional

iliotibial bands and the abovementioned

shortened associated with

and teach them specific exercises to

Granted, not much awareness of

can be done for the actual femoral version abnormality, and attention to the clinical

that may arise is

Posture

An individual's posture should be assessed to ascertain clues that to his or her

information is

as stated

common in the human musculoskeletal

tprpn,rp" drawn

postural distortions,

and

those of a subtle

nature, should be made with caution. This is meant not to downplay the """","'-">''1'-'0

of the poshlral attitude but to

the clinical mind with

discernment. Posture should be assessed from all sides to visualize how the patient is in relation to all

oriented to

A plumb line can be used for

reference. As one views from the posterior, the plumb line should ideally bisect the

halves, and the head,

be level

The

should be

of the iliac crests and

outward. The

n..

(PSISs) can be ascertained by palpating each unlevel

is

and

a

Copyrighted Material

"t,,'ri.\r

should

Examination

173

A

mrlpntpti

alignment. (8) Postural deviations seen with legwaist, (2) lumbar (3) shallow curve at

(5) lower tive

of the

fold on side of short

This is not an accurate assessment by any means but clinical benchmark. For

and

fibular head or tibial

lateral malleolus can be assessed to determine where the

U<::J,''-1'<::1

serves as a

pelvic torsion at the sacroiliac

Copyrighted Material

lies.

174

PELVIC LOCOMOTOR DYSFUNctJON

where one ilium is counterrotated in relation to the 10

in iliac crest heights without a femoral neck

is not uncommon and can create

trochanter

uneven

The waist can appear indented more and the with

side of a

on the

will appear to hang further away from the

side.

in comparison to the arm on the

Any lumbar scoliosis due to an oblique

may be associated with in­

creased skinfolds at the waist on the side The contour of the

the scoliotic

should be observed

curves and distortions.

The fullness of the erector spinae bulge can be

for tone or

spasm. The horizontal gluteal folds marking the inferior teus maximus muscles should be level and

the glu-

bilaterally atonic

The fold will be lower on the side of a short maxim us, commonly found in chronic sacroiliac AUTt:"'Ar

and hip le-

if the gluteus maximus is smaller from atrophy, the fold since the

level with the opposite side, or even muscle

does not sag as much due to

and outer quadrant of the

In

the upper

maxim us will appear flat if decreased

tone is Shortening and

from observa-

of the adductors are

tion of the medial contour of the thigh

5-8B).

A faint letter "5"

short adductors

can be seen because the third

bulkier in the

joint problems. The area at the

often seen in pubic symphysis and junction of the

and short adductors appears

distally, a small hollow

and further

can be observed above the medial

of the knee.

As mentioned in observed

4,

the layer syndrome13•14 can commonly be

behind as one notices with

of hypertonic muscle

of weak muscle groups. For n;'lIffl"TriTHT

muscles are

tight, alter-

nating with weak, atrophied gluteus maximus and lumbosacral erector spinae muscles. Next, the thoracolumbar erector and tight,

with

are found to be and weak

fixator muscles. The upper

and lower

scapulae, and cervical erector the Viewed from the atus,

a plumb line should transect the

thorax, lumbar

levator

are then seen to be tight at the

and

Copyrighted Material

of

Examination

A

175

B

Look for the

"8"

--/--- 2

5-8 (A) Observations o n postural examination. Symmetry be noted between the (1) thoracolumbar erector spinae and (2) lumbosacral erector (3) flattened area, (4) level of gluteus maximus, (5) shortened maximus. (B) Hip adductor fold, (6) level of sagging, atonic of long adductors. observations: (1) bulge due to short adductors, (2)

the hip joint axis and slightly anterior to the knee malleolus

axis and the lateral

Posture as viewed from the lateral will

infor­

mation as to anterior or posterior pelvic observe an anterior the

tilt from two

H_<.1lll.<.L'-"

maximus and short-

crossed

ened, tight tight low

weak abdominals and shortened and extensors. If the imbalance i nvolves

bar

only

the former, to the lum-

the lumbar lordosis will be increased and short, Slight flexion at the hip may be

If

it involves primarily the latter, the lordosis will be more with the thoracic kyphosis starting forCing a forward head and neck position

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up in the

5-108).

thoracic,

176

PELVIC LOCOMOTOR DYSFUNCTION

2 ---f--

3

4 --t ---/

5 --+-

6 ---+f ..

Figure 5-9 Normal a l i gnment in lateral postural examination: (1) atus, (2) shoulder (3) lumbar (4) s lightly to hip (5) slightly anterior to knee axis, (6) anterior to malleolus.

meaxis,

and shortened hamstrings are often associated with a flat lordosis and the knees are commonly

and posterior tilt of the tended

5-10C). If they are

the muscle belly will

in reaction to a weak Flatness of the

contour denotes weakness. The tensor fascia lata often cre-

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A

c

8

}4 5

6

u

t"1'"J � ::::.

3"i-·

� S· ""

S· ;:: 5-10 Postural observations from the lateral (A) Short lordosis. (8) (1) Shallow hamstrings, (3) atrophied hamstrings, (4) (C) (1) Shallow lordosis, (2) (5) iliotibial band groove, (6) knee hu,n<"·,,yh'm

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Irmir"',,,

(2)

......

::j

178

PELVIC LOCOMOTOR DYSFUNCTION

ates a flattened contour in the to

anterolateral contour of the

Its

due

the iliotibial band creates a

aspect of the thigh.13

groove in

Seen from the anterior, the abdominals should appear symmetric when and the two sides. Weak

the upper and lower muscles commonly pregnancies.

especially after multiple with a

obliques manifest

is visible just lateral to the rectus abdominus muscle iliac

relative

of the anterior

and

to the crest and PSIS

groove that

5-11).

The

(ASISs) can be assessed earlier. If all three should be sus-

leg-length pected. Trunk

of Motion

Gross tnmk

is not accurate in

but it can be used as a Hons made

'V�_ClU'LU

tool. Certain

general

()n'�pl"\!;:'l-

the various movements may yield valuable informa-

tion.

-+-- 2

3

Figure

5-11 Anterior view of abdomen: (1) (2) tensor fascia lata groove, (3)

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lateral to rectus abdominis band groove.

Examination

179

Flexion Forward flexion should be performed smoothly, with the lumbar lordo­ sis seen to reverse or at least flatten. Short and tight erector spinae muscles or lumbar joint dysfunction can create a persistence of the lordosis. In full flexion, the erector spinae muscles should fully relax, except for the ilio­ costalis thoracis, allowing the spine to rest on its ligamentous support,15 In sacroiliac joint dysfunction, a pulling sensation is usually experienced and is localized to the lower back and affected sacroiliac joint. With some coax­ ing, the patient is able to flex further. However, in disc lesions, flexion is very difficult, and leg pain can become a predominant feature, usually in­ creasing with progressive flexion. During the forward-flexion maneuver, both PSISs can be palpated and observed for Piedallu's sign (Figure 5-12). If in full-trunk flexion one of the PSISs travels further than the other, a positive Piedallu's sign is present. Often while the patient is in the standing position, one PSIS is observed to be lower, yet during flexion it moves cephalad to emerge higher than the other PSIS. This is called the overtake phenomenon. That one of the PSISs travels further than the other is thought to be due to sacroiliac joint restric­ tion. As the spine bends forward, the sacrum follows. If restriction in one of the sacroiliac joints is present, the ilium, and thus the PSIS, will follow and travel further cephalad than its fellow PSIS. This is not an exact test but serves as a quick screen. Often after manipulative reduction of a sacro­ iliac joint restriction, this test is seen to normalize. 'VVhile the patient is in the forward-bent position, the examiner can per­ cuss the PSISs and spinous processes with the ulnar aspect of his or her fist to jolt the articular structures (Figure 5-13). The patient with joint dysfunc­ tion will experience a sharp pain that is short lasting. Pathology should be suspected when the pain elicited from percussion lingers, is severe, and causes the patient to cringe. The return to the upright position can yield very important clinical clues. It should be done smoothly, starting with hip extension and fol­ lowed by erector spinae contraction and spinal extension to neutral. At full flexion, a relaxation response in the erector spinae muscles should oc­ cur, causing the spine to hang by its ligaments. With joint dysfunction of the posterior facet joints, segmental reflex muscle guarding blocks this re­ laxation response. Upon the patient's arising from full-trunk flexion when the erector spinae should still be relaxed, the facilitated erector spinae muscles immediately contract and extend the facet lesion prema­ turely.16 This causes a jab of pain and is called the reversal sign. Most back conditions can cause a tentative recovery to the neutral position, but a

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180

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 5-12 Piedallu's sign. (A) Note that right posterior iliac spine is lower. (B) Note that right pos terior iliac spine "overtakes" left side with trunk flexion.

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Examination

Figure 5-13

181

Percussion

slow, tortuous return should lead one to suspect pathology and not joint dysfunctionY

Extension Trunk extension may be uncomfortable in sacroiliac joint lesions but is usually more so in lumbar facet joint dysfunction. Localizing combined extension, lateral flexion, and rotation (quadrant testing) to individual lumbar facet levels will help localize lumbar joint signs. This is similar to testing the whole lumbar spine with Kemp's test, but the combined move­ ments are localized to the individual l u mbar segments with the examiner's thumb.

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182

P ELVIC LOCOMOTOR DYSFUNCTION

Lateral Flexion is seen to arc in a smooth

During lateral flexion of the trunk, the muscles on

curve with the erector centrically

5-14A and

the side of lateral

convex side

The

should sway

and the PSISs should remain leveL18,19

tion of these events can be seen in hip and sacroiliac joint dysfunction, with the contralateral pelvic sway

A

alto-

minimally or

lumborum muscle can limit lumbar side This is evidenced

the lumbar

at the

thoracolumbar junction as the whole lumbar spine is "fixed" in

by

the hypertonic quadratus lumborum (Figures 5-14B and 5-15A). The PSIS opposite to the side of bending can

be seen to rise up in

relation to the other when of the erector

contraction

group on the hip

disharmony of muscle function. Spasm or adaptive

abductors and/ or adductors can also prevent normal pelvic motion in the frontal

and

assessments of these muscles are indiis observed,

lateral

B

A

\

-3

3

,.,,,�. u'n

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muscle, (2) posterior iliac (1) contraction of muscles in occurring at thoracolumbar reof posterior iliac

A

B

lr1 � :;:, ;:!

�. 5"

;::: Figure 5-15 (A) Note angulation at thoracolumbar spine and rising up of right posterior superior iliac spine under examiner's right thumb. The left erector spinae muscle group is contracting. (8) Normal right lateral bending.

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>-'

�

184

PELVIC LOCOMOTOR DYSFUNCTION

Sacroiliac Palpation: Gillet's Test

The following are to accentuate normal parameters to assess sacroiliac joint function. The is asked to raise the knee as high as possible, and movement of following landmarks is inferior iliac spines (PlISs), monitored with palpation: the sacral tubercle, and sacral apex (Figure Because of its morto it that seem to phology, the sacroiliac joint has and lower adGillet and Liekens20 and As a function both parts by monitoring motion at the PSIS (upper asvocate pect) and PIlS (lower aspect) in relation to the sacral tubercle and apex four areas are assessed: the upper and lower asj oint on both the left and sides. The following is of the examination of the sacroiliac The examiner sits behind the standing patient and his or her thumb on the right PSIS and left thumb on the sacral tubercle to assess movement at the A firm skin conof the sacroiliac tact is necessary so that examiner is not fooled by skin movement. The patient is asked to raise his or her knee as high as he or she can, and the examiner monitors the movement of the right PSIS in relation to the sacral tubercle 5-17A). The patient's knee is usually raised bent.

•

.......---. ------4,.---- 3

0

III 0

--

4 -.------t""

(

5

J

Figure 5-16 Sacroiliac joint palpation (4) iliac

(1) S-2 tubercle, (2) sacral inferior iliac (5) sacroiliac

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A

B

lT1 £i � �. l::l ..,..

o· ;:::

Figure 5-17 Pa lpation of upper aspect of right sacroiliac joint. (A) F lexion. Note that examiner's right thumb travels inferior. (B) Extension. Note that examiner's left thumb travels inferior.

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>-' (7:) Ul

186

PELVIC LOCOMOTOR DYSFUNCTION

mention that physiologically blocks or restricts the joint. is more movement to occur in the to make more evident joint restriction in that sacroiliac joint. the right PSIS should be palpated to As the right knee is raised move inferior in relation to the sacral tubercle as the ilium goes through a nAch",.",,. rotation through the sacroiliac joint. refers to this moveat the level of ment as sacroiliac joint flexion, and since we are upper the PSIS, it is termedflexion The movement is perceived as a slight shifting or gliding motion the PSIS relative to the sacral tubercle. Technically, the PSIS should move posteri­ orly and its inferior movement is more definite and can be as much as 1h in. No movement relative to the sacral tubercle denotes joint fixation or restriction. this maneuver, the entire pelvis en masse moves slightly the contralateral the illusion that the PSIS is moving. However, PSIS movement should be as­ sessed relative to the sacral tubercle so as to monitor sacroiliac joint func­ tion. may manifest itself with a noise and increased the can also be coming motion during this maneuver. from the femoroacetabular joint or iliotibial band, as in the "snapping-hip syndrome"23. This can usually be felt with the small of the around the hip. hand as it wraps nt::l1nllnO" the same anatomical contacts as above, the examiner then the sacral tubercle is asks the patient to raise the left leg. In this now monitored in relation to the PSIS on the weight-bearing and it should be observed to move in a posterior and inferior direction (Figure of the right sacThis movement is called extension at the upper in a lungeroiliac joint. This maneuver is mechanically similar to forward position with the right leg extended backward (Figure for the sake of convenience, the patient is asked to raise the left instead, while relative sacroiliac joint extension is palpated for on the side. To monitor flexion motion of the lower the examiner's thumb is moved to the to the sacral apex or lower than the PSIS contact. The left thumb is the subcutaneous aspect of the sacrum just medial to the right thumb, thus the patient of the right sacroiliac joint. straddling the lower and the right thumb contact is monitored in is asked to raise the relation to that of the (Figure 5-19A). What should be observed is a the PHS. An caudal and slightly lateral deviation of the thumb

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A

B

t"T1

£i

::!

;::i' � o· ;::

Figure 5-18 (A) This position is similar mechanically to that in Figures 5-18B and 5-17B. (B) Raising the left leg actually puts the right hip into relative extension.

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>-' (Y) '-1

188

PELVlC LOCOMOTOR DYSFUNCTION

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Examil1ation

the ischial

alternative contact would be to

189

with the

thumb while maintaining the sacral apex contact. To assess extension of the sacroiliac joint's lower aspect, the examiner's but the

palpatory contacts remain the same as above for the "lower" is asked to raise the left

(Figure

The sacral contact is

now monitored in relation to the iliac contact. The sacral apex should be in relation to the PIlS contact.

observed to move

In all the above maneuvers, the move in-

osseous structures,

roiliac joint while dependently if motion is

1£ no movement is detected or if both

as a

joint fixation can be suspected. Basically,

thumbs move

flexion and extension movements should be

for at each

following four locations: the upper and lower

of each sacroiliac

joint. If all four locations are not

the

joint problems are

missed. Sacroiliac joint fixations often occur in multiples and restriction of the upper

a diagonal fashion. For iliac joint is

associated with fixation in the lower aspect

site side joint.

finding joint restriction in the upper

alert one to assess the lower poles as well. If one assesses restrictions will be missed in the lower

important Similarly, if

extension

flexion fixations are checked for, an

fixation will be missed if test, patients will often make

During the

movements in reaction to restricted sacroiliac or will bend

raise a leg, the extend at the hip to they will stick the (Figure

out laterally to aid in

Chronically stiffened sacroiliac joints can demonstrate a

In such

lack of motion at all ruled out with radiographs

must be

manipulation is undertaken.

In general, flexion movements are monitored with iliac contacts or ischial

and extension movements are monitored with or apex). When the patient lifts the knee, the

sacral contacts

examiner's ipSilateral thumb should move with the appropriate contact. leg is

For example, as the should move with the then the

the examiner's

contact. If the examiner is PSIS or PIIS should be or lower

is

thumb the to

of the sacroiliac

For an extension restriction, if the

left knee is raised while the examiner still monitors the the examiner's left thumb on the sacrum should move.

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190

PELVIC LOCOMOTOR DYSFUNCTION

A

B

2_"

Figure 5-20 '-VlHIJ'" for stiff hip and sacroiliac (A) (1) Lumbar hip extension; (2) knee flexion.

in knee-raising test. sticks buttock out

laterally.

movement indicates joint fixation. The type of fixation found determines as is discussed in Chapter 7. the manipulative technique SITTING Small Hemipelvis

(SHP) such that the An often-overlooked anomaly is a small on one side is smaller than other. About 20% to 30% height of the of examined demonstrated an SHP.24 Inglemark and Lindstrom25 noted a significant association between leg length inequality and hemipelvis size. Commonly, an SHP is associated with an ipsilateral length short upper and smaller face.26 finding one on examination may lead to the observation of the others. A small will tend to manifest itself symptomatically

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Examination

to

191

inequality,

and attitude should be torsion between the ilia at the sacthe

Travell and Simons12 proper a

used to assess a small hemipelvis. A clinical trial lift" under the lower side can be done to level the

ascertain any corrective effects occurring in the spine and trunk above.

In an examination for an SHP, the face, and

feet should be raised

the plinth and the patient's distal

must be seated on a firm surenough to fit two fingers between (Figure

sessments are then made of the anterior and and iliac crests. An SHP

Relative superior iliac

exists if all landmarks

one side. Lumbar scoliotic deviation and shoulder height be observed in the sitting position with leg-length lift"l2 is used to level the

with SHP, as

may

are in the standing

To correct this asymmetry, a "butt the patient is in the

position

This can be an important asymmetry to correct in someone

Figure 5-21

Right Small

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192

PEl.vlC LOCOMOTOR DYSFUNCTION

/

"Bull Lift"

1/1

II /

Figure 5-22 Correction of Small

with a "Butt Lift"

PSIS Measurement PSISs can be measured to compare

The distance between the

5-23).

with the measurement taken prone will suffice. One should make sure to of each PSIS.

A cloth

to Mennell,9,17 this distance should increase

by If.! to % in when the patient of

from the sitting to the prone position. sacroiliac joint disease and can be an

He says that its absence

spondylitis. In addition, this movement is often or in those who sit for

time and exhibit restricted sacroiliac joint motion in most points

measure

a measurement from the same

the

periods of the four

test.

Lumbosacral Joint Versus Sacroiliac Joint Sitting trunk rotation can

important information

lumbar facet from sacroiliac joint dysfunctions.9 As the patient sits upright with hands interlocked behind the head, the examiner the trunk by

pulling on the

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arm and

rotates C011-

Examination

193

Figure 5-23 Sitting Measurement of Posterior Superior Iliac Spine Distance

tralateral scapula (Figure 5-24). A painful response can be elicited by the torsional stress placed on the ipsilateral (side to which the patient is ro­ tated) lumbosacral and sacroiliac joints. To differentiate lumbosacral from sacroiliac joint involvement, the pa­ tient is asked to slump backward onto the examiner (Figure 5-25). Pain in this position commonly is due to lumbosacral dysfunction, since this posi­ tion stresses the lumbosacral region. If this maneuver is not painful, the patient is then rotated to the left while in this slumped position until the right ischial tuberosity (not the buttock itself) leaves the table (Figure

5-26). By twisting the sacrum between the ilia, this maneuver places a back-

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194

PELVIC LOCOMOTOR DYSFUNCTION

Figure 5--24 TrW1k Rotation ward torsion in the left sacroiliac joint and an anterior torsional stress in the right sacroiliac joint. Pain provoked on the left side indicates backward torsion dyshmction of the left sacroiliac joint. If the examiner now places his or her hand on the right ASIS and presses downward toward the table while maintaining the trunk in the torqued position, the backward tor­ sional strain in the left joint will be relieved, and any elicited pain will be lessened.9,17 The procedure is then repeated on the other side (Figure 5-27). On the other hand, when the trunk is rotated to the left while the patient is in this slwnped position, the patient can experience pain on the right side as the right sacroiliac joint is stressed in anterior torsion. As the right ASIS is pressed toward the table, the torsional stress is relieved, and any provoked pain due to a right anterior torsion dysfunction is diminished.

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Examination

Figure 5--25

Backward-Lying or Slump

195

Test

As an aside, this testing of sacroiliac torsional stress has been found to be useful as a therapeutic maneuver, especially in pregnant women exhib­ iting sacroiliac joint disorders. It is used mostly as a strong stretching mo­ bilization. Also, this test does not differentiate involvement in the upper versus lower poles of the sacroiliac joint. Piriformis Strength

When the hips are flexed to 90 degrees, the piriformis acts as a horizon­ tal hip abductor. Therefore, one can test the strength of this muscle in the seated position by resisting the separation of the patient's knees (see Chapter 9, Figure 9-10). Weakness and pain are common with piriformis

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196

PELVIC

LOCOMOTOR DYSFUNCTION

Figure 5-26 Backward torsion applied to left sacroiliac joint. Note pressure on the right anterior superior iliac spine to relieve torsional stress. trigger points. Piriformis trigger points are often seen in association with sacroiliac and hip joint disorders. SUPINE Trunk Curl-Up The patient is supine with knees bent, feet flat on the table, and arms across the chest or ou tstretched. The clinician monitors hip flexor recruit­ ment by cradling the patient's heels and feeling if they lift during the test (Figure 5-28). The patient is instructed to do a posterior pelvic tilt and curl up until the scapulae come off the table. Ten repetitions are performed,

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Examination

197

Figure 5-27 Back ward Torsion Applied to Right Sacroiliac Joint

and the last one is held for 30 seconds. Any lifting of the feet, signifying hip flexor recruitment, extreme trunk shaking, or inability to maintain a poste­ rior pelvic tilt indicates a positive test for weak abdominal musclesY A positive test for weakness or inhibition is usually due to tight erector spinae and/or psoas muscles that are reciprocally inhibiting the abdomi­ nal muscles. These would need to be assessed along with lumbar spinal joint mobility. Pubic Symphysis

Pubic symphysis joint problems are not a common occurrence when compared to sacroiliac joint problems, but when they do exist, attention

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P ELVIC LOCOMOTOR DYSFUNCTION

198

Figure 5-28 Trunk

curl-up test. Note that patient is resting heels on clinician's

hands.

should be given to them. The diagnosis of pubic symphysis joint dysfunc­ tion is generally presumptive and is based on three clinical criteria (Figure 5-29): 1. asymmetry of pubic tubercle relationship 2. tension in inguinal ligament/short hip adductors

3. tenderness at pubic tubercles and at inguinal ligament and hip adductor origins Sagittal-plane rotation at the sacroiliac joint (positive- or negative-theta x­ axis rotation of the ilia) appears limited in the presence of PS fixation,2o.28 and the standing knee-bending test then shows restriction of motion. Tenderness and tautness are palpated for along the course of the inguinal ligament, especially at its origin and insertion. Typically, it will be tender to palpation in sacroiliac joint and pubic symphysis joint dysfw1Ctions. Palpa­ tion of the symphysis pubis is accomplished by moving caudally from the midline lower abdomen until the joint is reached. The heel of the hand is

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Examination

199

2

of pubic SV1TIOiflVSIS joint problem: (1) pubic tubercle origin and of inguinal ligament, (3) tension in of adductor (5) tension in adductor (4) painful muscle.

used, with the fingers pointing cephalad. The examiner is with the pelvis and

cephalad. The examiner should exercise

when palpating this area. If it is deemed the

hand and

:>",,,,.(',,..,.,..,

under

examiner's

using the index fingers, the

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200

PELVIC LOCOMOTOR DYSFUNCTION

examiner compares the relative position and tenderness of each pubic tu­ bercle. Pain and tension are present if this joint is in dysfunction. Sacroiliac joint problems often coexist with pubic symphysis problems.29.31J Indirect joint provocation tests can be used. This entails flexing one thigh on the chest while extending the other thigh off the table. This places an extreme physiologic countertorque on the PS. A similar maneuver, inci­ dentally, is performed to mobilize this joint, as discussed in Chapter 6. While the patient is supine, the pelvis can be observed for asymmetry in the anteroposterior dimension. The pelvis may seem to be slanting toward one side, as there may be a small hemipelvis. These patients may have a history of lower back, pelvic, or hip discomfort while lying supine due to their asymmetry. An appropriately placed piJJow can be an effective rem­ edy for them. Sacroiliac Joint Distraction, Iliopsoas Palpation

The ASISs can be gently pressed apart Simultaneously to gap the ante­ rior aspect of the sacroiliac joints (Figure 5-30). The iliacus can be palpated just medial and deep to the ASIS (Figure 5-31). Tenderness here is com-

Figure

5-30

Anterior Distraction

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Examination

201

Figure 5-31 Iliacus Palpation (Marker Is on ASrS)

mon in hip and sacroiliac joint problems. Trigger points in the iliopsoas will also cause pain here. To palpate the psoas muscle directly, refer to Chapter l. A short, tight psoas will palpate as taut and tender. Care must be used in this maneuver so as not to injure nearby viscera. Straight-leg-Raising Test

A straight-leg raise (SLR) should be performed to assess nerve tension and hamstring length (Figure 5-32). The knee should be held in extension, with neutral ankle position and neutral hip position with respect to rota­ tion, abduction, and adduction. Hamstring tightness is noted in addition to any elicited pain. The SLR test is often touted as pathognomonic for nerve irritation when positive. However, just as "no man is an island," certai.nly no individual tissue is isolated from the rest of the musculoskel­ etal system. Tests designed to provoke a specific structure invariably af­ fect adjacent structures. Muscles are connected to tendons, which are con­ nected to bone, which when moved affect joints and their associated restraining tissues, including nerves and blood vessels.

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202

PELVIC LOCOMOTOR DYSFUNCTION

2

Figure 5-32 Structures moved or stressed during straight-leg-raising test: (1) lum­ bar facet joint, (2) sacroiliac joint, (3) hip joint, (4) ha mstring muscles, (5) sciatic nerve.

Besides sciatic nerve tension, the SLR also affects the following struc­ tures: hamstring muscles, sacroiliac joint, hip joint, and even lumbar facet joints. Nerve irritation can be suspected if the SLR test is strongly posi­ tive31-33 or if the well-leg-raising test is positive.34 A sacroiliac joint prob­ lem can yield a positive SLR test but is usually seen at higher angles of elevation, usually above

45 degrees. The patient will experience pain in

the joint, buttock, and/ or proximal thigh as the ipsilateral sacroiliac joint is stressed in posterior rotation. The opposite leg should rise to normal range without difficulty, and the double-leg-raising test, which stresses the lum­ bosacral region by tilting both ilia simultaneously, should be negative. Shortened, tight hamstrings are commonly found in chronic sacroiliac conditions. They also aid in perpetuating joint dysfunction in the hip and

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203

Examination

Some

pelvic

strings. Of more clinical Flexor

hip flexion in each hip joint while

The examiner should assess

observing for tissue contracture in the contralateral is best achieved by

the

knee held against the chest.

examination table, with one should

This

one leg other

off the table so that the thigh is horizontal and the The lumbar lordosis should be lost, and

u v ,/u,-U.

to increase

flexion onto the trunk. This is

the clinician's pushing his or her thorax

patient's foot on the side of the flexed knee with

Chapter 9,

Short hip flexors on the side or even marked flexion of the thigh

with the leg off the table cause

above the horizontal. If the rectus femoris is short and tight, the knee joint hangs vertically but more di­

will extend so that the lower leg no

A tight iliotibial band and tensor fascia lata manifest as a

in the lateral tella.35 In

of the thigh and lateral

the

may abduct

of the sartorius

A

cause flexion at the knee joint and slight external rotation of the thigh. Tight adductors are indicated by slight adduction of the thigh. will manifest as

ful and / or restricted osteoarthritic

joint, the

joint

flexion. In a

pain on the side of

will be seen not to

flex directly onto the chest but to deviate shoulder. Tight hip flexors are often associated with

the line of the inhibited glu-

teus maximus muscles. This should be assessed with the prone

exten­

sion movement Gaenslen's Test

Gaenslen's test is a classic test parts a

sacroiliac joint

extension force

since it im-

the sacroiliac joint as well as the hip

joint

5-34). When performed in the side it is termed the Gaenslen-Lewin test and can be used to differentiate lumbosacral from sac-

roiliac joint

as described by MennellY on the supine

A Gaenslen's test can be

sacroiliac joint by extending one thigh extended

the chest. A

off the table and

stretch is also

which may be uncomfortable to the

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on the

204

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 5-33 Hip flexor length test. (A) Normal finding. Note that thigh is resting flat on table and leg is hanging vertically off table. (B) Abnormal test. Note that thigh is off table, leg is slightly extended at knee.

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Examination

205

Figure 5-34 Gaenslen's Test

three provoca tive tests that can help localize a problematic sacroiliac joint. The other two are the Patrick-Fabere and Yeoman's tests. Patrick-Fabere The classic test for hip problems is the Patrick-Fabere test, in which the hip is flexed, abducted, externally rotated, and extended (Figure 5-35). Yet this test also effec tively stresses the sacroiliac joint and is often positive in sacroiliac joint lesions. However, i t is very common to find sacroiliac joint and hip joint problems existing concurrently.

A Patrick-Fabere test is performed by placing the ankle on the contralat­ eral knee and forming a "sign-of-four" with the ipsilateral thigh and leg. Downward pressure is applied on the knee to stress the hip and sacroiliac joints while the contralateral ASIS is stabilized on the table. Pain in the groin can come from both hip and sacroiliac joint problems. Localized sac­ roiliac joint pain felt posteriorly incriminates that joint more. Hip Adductor Length By placing the sole of the patient's foot against the medial side of the opposite knee, and pressing the knee toward the table, one can assess the

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206

PELVIC LOCOMOTOR DYSFUNCT10N

Figure 5-35 Patrick-Fabere Test

tension in the small adductors (Figure

5-36) .26 Another way of testing ad­

ductor length is to abduct the straight leg until tension is met and compare it with the other side (Figure by flexing the knee (Figure

5-37) . Then, if the long adductors are relaxed 5-38), and if further abduction is possible, the

long abductors are short and tight. If hip abduction in the plane of the table is limited when the knee is held in both the straight and slightly bent posi­ tions, the short adductors are tight.35 Hip Rotation/Posterior ShearfHip Flexion-Adduction With the hip joint held in

90 degrees of flexion, medial and lateral rota­

tion can be examined by leveraging movement through the flexed lower extremity (Figure

5-39). Sacroiliac joint pain is often reproduced with ex­

ternal hip rotation in this position. Attention is paid to the end-feel and range of motion at the hip joint. Normally, a painless, leathery stop should be experienced. A more functional assessment of hip rotation is made in the prone position. A posterior shear accessory movement can be applied to both the hip and the sacroiliac joints by pressing the femur into the table with the hip at

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Examination

Figure 5-36

Length testing of short adductors. Note that foot is placed medial to

knee.

Figure 5-37

207

Length Testing of Long Adductors

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208

PELVIC LOCOMOTOR DYSFUNCTION

Figure 5-38 Knee Flexion Used To Relax Long Adductors

90 degrees of flexion (Figure 5-40). The examiner's other hand can simul­ taneously palpate the greater trochanter or sacroiliac joint sulcus to assess motion. Slight adduction will tend to gap the sacroiliac joint posteriorly. Small shifting movements can be felt, and pain provocation is looked for. Maximal adduction while at 90 degrees of hip flexion stresses several structures and is not a good localizing test (Figure 5-41A). Lewip6 states that this mostly stresses the iliolumbar ligament, as the posterior aspect of the ilium is abducted from the sacrum and spine. By standing opposite the side to be examined, the examiner grasps the flexed knee and pulls the thigh into adduction, thus gapping the ilium from the sacrum and L-5. Pressure is then applied along the long axis of the femur. This is similar to the above posterior shear test except that much more adduction is used. Restriction of hip adduction and pain provocation are noted. To influence the sacroiliac ligaments, the thigh is flexed more onto the trunk and adducted (Figure 5-41B) . Pressure is also directed along the axis of the femur. With the hip flexed to 90 degrees and strongly adducted, pain experienced in the groin may be referred from the iliolumbar liga­ ment or hip joint. Pain experienced in the buttock, posterior thigh, or lat­ eral thigh with the hip flexed more than 90 degrees is usually from the

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Examination

A

B

Figure

5-39

Hip rotation.

(A)

Externa l .

(B)

Interna l .

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209

10

Figure

PELVIC LOCOMOTOR DYSFUNCTION

5--40 Anteroposterior shear of hip and sacroiliac joints. Note slight hlp ad­

d uction.

sacroiliac ligaments.36 Groin pain more often limits adduction in these tests and is more commonly due to hip join t problems. Hip Joint Accessory Movements If hip joint dysfunction is suspected, accessory or joint play movements should be explored in the supine position for posterior and lateral glides as well as long-axis extension with the hip in neutral, and inferior glide with the hip at

90 degrees flexion (Figures 5-42A through 5-42F).

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Examination

211

A

B

Figure 5-41 Hip flexion / adduction provocative test. (A) Note strong adduction at 9 0 degrees of flexion. (B) Note adduction with maximal flexion.

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212

PELVIC LOCOMOTOR DYSFUNCTION

A

6

continues Figure 5-4 2 Hip joint accessory movements. (A) Posterior g lide. (6) Lateral g lide. (C) and (D) Long-axjs extension. (E) Inferior g l ide at 90 de g rees flexion. (F) Same as (E) but with le g over shoulder.

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Examination

213

Figure H2 continued C

D

contin ues

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214

PELVIC LOCOMOTOR DYSFUNCTION

Figure 5-42 continued E

F

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Examination

215

Double-Leg Raise and Lumbosacral Tilt

Two tests in the supine position can be used to incriminate lumbosacral versus sacroiliac j oint dysfunction. A double-leg-raising test is performed to tilt the pelvis as a whole on the lumbar spine, thus stressing the lum­ bosacral jOint (Figure

5-43) . If lumbosacral joint dysfunction exists, the

angle of leg raise will be less than that occurring in the single-leg-raising test with sacroiliac jOint dysfunction. Another maneuver stressing the lumbosacral joint in lateral flexion is performed next.9,17 To perform this test, the supine patient's hips and knees are flexed to 90 degrees simultaneously while the examiner cradles

both lower legs (Figure

5-44), With cradling of the lower legs, the pelvis is

Figure 5-43 Double-Le g-Raise Test

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216

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 5-44 Lumbosacral tilt test. (A) To the left comp resses left lumbosacral facet joint, d istracts right joint. (B) To the right.

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Examination

217

tilted t o both the left and the right t o gap and compress the lumbosacral joints alternately. Lumbosacral joint dysfunction is manifested by pain and restricted motion. SIDE·LYING Hip Abduction Movement Pattern

the

In the leg in the coronal

is instructed to abduct the straight

Simultaneous contraction of the tensor fascia lata

and gluteus medius is looked for. Palpation of these muscles should be done

and even so, very

i f visual observation is

tion must tions. If the

palpa-

unwanted contrac-

used to reduce the chance of

medius is inhibited and contracts poorly, the to recruit

to roll the pelvis posteriorly in an

will have a

tensor fascia lata contraction. Flexion at the hip will be observed. External rotation

and

contrac-

tion of the quadratus lumborum. The duction without

5

in ab-

and the

is

seconds. Lin1b

to hold the

for

and the pelvic movements

scribed above are looked for and denote a positive finding for a poor hip abduction movement If this test demonstrates poor hip abduction should be looked for and treated: weak and overactive hip adductors, overactive tensor fascia tus lumborum, and overactive

overactive quadra-

Sacroiliac, hip, thoracolumbar, should be looked for, as

and/ or upper lumbar joint ten accompany this

the following gluteus

of-

movemen t

Quadratus Lumborum Trigger Point

One of the firs t

to test for i n the

is the most

overlooked muscle involved in myofascial pain

I t can mimic lum-

lumborum muscle

back: the

of the lower

bosacral, sacroiliac, and hip problems.37 The patient lies on his or her side with the involved side up and the onto the

of the table; a

and the upper

under the

to rest on the table behind the l ower leg. Stand-

ing behind the erector

arm raised over the head and cushion is

the examiner presses just lateral and

to the

group, probing the length of the quadratus lumborum

muscle

the inferior

muscle

a

of the 12th rib toward the iliac crest. A will

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at its

218

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 5-45 (A, B) Quadratus lumborum muscle trigger point examination. Twelfth rib is marked.

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219

Examination

marked tenderness. Referred pain from the

points in the quadratus

sacroiliac joint, in the

tocks, and even groin.

butlumborum are com-

with sacroiliac and thoracolumbar joint dys-

monly found in

functions and should be looked for routinely.37 Tensor Fascia

and Piriformis

Points

position, other muscles just as im-

While the patient is in the

as the quadratus lumborum to examine are the tensor fascia lata, and the quadratus

are

associ-

however, gluteus minimus involveTo find these

the triangular iliac crest is systo the

referral

2 --j----->.

(TPs): (1) anterior iliac i s tensor facia lata anterior set of solid are set of solid circles are medius TPs; X's are

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220

PELVIC LOCOMOTOR DYSFUNCTION

characteristic for each of these muscles. With the patient's in front of lowermost flexed at the and knee and gluteus maximus is relaxed so that the examiner can palpate trochanter muscles. A line drawn from the PIrS to the of the roughly outlines the of this muscle will be

minimus, since it lies palpation is necessary for the to the gluteus medius and gluteus maximus in Individual bands of but muscle are difficult to elicited. 26 The tenderness is more accessible anterior fibers are palpated anterior and posterior to the tensor fascia lata muscle.26 The minimus points refer pain down the posterior or lateral of the thigh also mima radicular problem. The are commonly located just below the medius border of the iliac crest. Pain from gluteus medius centers on the lumbosacral and sacroiliac and buttock, mimicking sacroiliac joint, and hip Tensor fascia lata inferior and lateral to are the ASIS. This muscle to refer pain to the hip of the thigh as far as the knee.26 and down the anterolateral in which one abductor length can be tested in the same tests the quadratus lumborum muscle. The is that the examiner lowers the u ppermost leg off the back of the seen as a lack of Restricted table indicates shortened hip abductors or hip function. position by havabductor ctr,,, n ,:y t h �d fu�� � Adductor the examiner to the lateral off the the can be assessed by gravity while the examiner uppermost and thigh. The examiner then exerts 1/«:","", "0 to the lower distal medial thigh toward the table, and the Iliotibial Band

of the iliotibial band, an Ober's test can be To test the formed by holding the ankle of the while the is in a extendthe knee to approxim ately 90

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Examination

221

Figure 5-47 Hip Abductor Muscle-Length Test

ing the hip slightly, and allowing the knee to dangle from the iliotibial band toward the table (Figure 5--48). A shortened and tight band will not allow the knee to descend. Skin rolling over tight iliotibial bands is resis­ tant and painful. The iliotibial bands feel coarse to the examiner and "bruised" to the patient. Tight iliotibial bands are commonly seen in chronic hip and sacroiliac joint problems. Horizontal-Plane Gapping and Provocation of the Sacroiliac Joint

While the patient is still in the side-lying position, provocative or joint­ stressing tests can be performed in the horizontal plane at the sacroiliac

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222

PELVIC LOCOMOTOR DYSFUNCTION

Figure 5-48 Ober's Test

joints. If the examiner places the fleshy part of his or her forearm over the anterior half of the iliac crest and presses toward the table, slightly anteri­ orly and slightly cephalad, a gapping of the sacroiliac joint can be im­ parted while the opposite hand palpates for it (Figure

5-49). Next, the ex­

aminer can compress the joint by placing the forearm on the posterior half of the iliac crest while pressing toward the table. The goal of these two procedures is to sense resiliency of the pelvic ring and to provoke the patient's presenting symptoms. Sagittal-plane shearing of the sacroiliac joint can be accomplished by the examiner's standing behind the patient, facing slightly cephalad (Figure

5-50). The hand closest to the patient reaches anteriorly to cup the ASIS comfortably, while the other hand palpates the sacroiliac sulcus posteri­ orly. By leaning well over the patient so that the examiner's sternum comes in close proximity to the patient's uppermost hip, the examiner is in a strong position to impart an anterior-to-posterior shear on the ASIS of the iliac crest. The examiner's palpa ting hand can then d iscern shifting movements of the sacroiliac joint, as well as provoke any pain response from the patient. Obviously, the abovementioned procedures are then re­ peated on the opposite side.

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Examination

Figure

5-49 Horizontal-Plane Gapping of Sacroiliac Joint

Figure 5--50 Sagittal-Plane Shearing of Sacroiliac Joint

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223

224

PELVIC LOCOMOTOR DYSfUNCTION

Sacroiliac Joint Play in Torsion the examiner stands behind the the cephalad hand in front

in

With the

the innominate the caudad hand on

p atient and of the ASIS and

ischi a l tuberosity

as the ischial

5-S1A). The ASIS i s

is p ushed in order to

torsion. Restriction and pain provo-

joint-play the innominate in c a tion a re looked for.

hand contacts the PSIS play in anterior torsion, the To while the c a u d a d hand cups the pelvis anterior to the acetab u l um. To while the acetabulum torgue the innominate anteriorly, the PSIS is (Figure

is PRONE

Me asurement of PSlS Distance """''' ''T ' H lS prone, measurement of the distance between the two

and d uring

with tha t measured

examination. One should observe an increase in the dis-

tance

about V4 to V2 in. Absence o f this increase

chronic

or

d ysfunction.

Hip Extension Movement Pattern To test the the

is asked to raise

extension movement into hip extension

activation sequence to

l ook for is hamstring and gluteus maximus first, contr a l a teral erector spinae

and

erector

last.

should

be done o n l y if muscle contraction visualization is d i fficult, b u t it should be

ligh t so a s not to facilitate unwanted muscle contractions with tac­

til e stimula tion. The c l inician should l ook for the following: reduced j oint mob i l i ty; weak, inhib i te d gluteus

overactive erector or

hamstring muscles; or a shortened psoas muscle. Sacroiliac and thora­ columbar joint dysfunctions should also b e searched for. Wha t is comseen is an overactive erector fore

maximus contraction.

the thoracolumbar area. It

contraction

first, beup into w ith hip

Heel-to-Buttock Test can be assessed while muscle of the The to the b u t tock (Figure the knee and trying to touch the

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Examination

225

A

B

Figure

sion.

5-51 Joint

play

of sacroiuac joint. (A) Posterior torsion. (B) Anterior tor­

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226

PELVIC LOCOMOTOR DYSFUNCTION

Figure 5-52 Prone Measurement of Posterior Superior Iliac Spine Distance

Figure 5-53 Hip Extension Movement Pattern

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Examination

Figure

5--54

227

Heel-to-Buttock Test

maneuver additionally imparts an anterior torsion to the sacroiliac joint by virtue of the rectus femoris muscle attacrunents to the anterior aspect of the pelvis. Pain may be provoked in a symptomatic sacroiliac joint as a consequence. However, this test also extends the lumbar facet joints slightly, stresses the knee in flexion, and stretches the femoral nerve. Therefore, this test is not too localizing, and the findings should be inter­ preted in light of other findings uncovered during the examination. Lack of conditioning, long-standing hip and sacroiliac joint dysfunction, and knee problems are associated with rectus femoris muscle shortening that can limit this test. As mentioned earlier, some patients are "naturally" tight and, in this case, will never be able to touch their heel to their buttock. Yet they should display synunetry between the sides. Limitation of this test due to muscle shortening indicates the need to stretch the anterior thigh muscles. Tightness of these muscles can tether pelvic and hip joint function and needs to be assessed. Hip Ro tation/Piriformis Length

Internal and external hip rotation can be better assessed in the prone position by flexing the knee to 90 degrees and pushing the lower leg later­ ally and medially to cause internal and external hip rotation respectively (Figure 5-55). In femoral anteversion, the gross range of motion will be

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228

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 5-55 Hip rotation .

(A)

Interna l.

(B) Externa l .

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Examination

229

normal, but the percentage of internal rota tion will be more than that of external rotation. The reverse is true in retroversion. The examiner as­ sesses the range of motion of which the hip joint is capable and checks for end-feel. Sacroiliac joint pain can be provoked especially when the lower leg is pressed laterally. Subtle sacroiliac joint gapping can be perceived by using a long-lever gapping teclmique, as shown in Figure

5-56. The examiner kneels next to

the patient and uses his or her chest to stabilize the pelvis. The fingers of one hand palpate the sacroiliac sulcus nearest the examiner while the other hand presses the opposite leg laterally. Small shifting movements are palpated for. Localized reproduction of pain in the sacroiliac joint is found in dysfunction. This test can also be used to mob ilize the joint. The piriformis muscle is an important pelvic and hip joint structure of­ ten involved when sacroiliac or hip joint dysfunction is presen t. The length of the piriformis muscle is assessed by pressing the lower leg later­ ally, thus imparting a stretch to it. Care must be taken to be gentle. An overzealous application of this stretch can send the piriformis into spasm and create leg pain. By having the patient resist the examiner's lateral pressure on the lower leg, the strength of the piriformis can be checked.

Figure 5-56 Long-Lever Sacroiliac Joint Gapping

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230

PEL VlC LOCOMOTOR DYSFUNCTiON

Yeoman's/Gluteus Maximus Muscle Test/Hip J oint Play Another classic provocative test for the sacroiliac joint is Yeoman's test, in which one imparts hip extension while stabilizing the pelvis to the table (Figure

5-57). This not only imparts an extension torque through the sac­

roiliac join t but also affects the hip joint and its anterior soft tissues, along with the lower lwnbar facet joints (Figure

5-58).

As mentioned earlier, three provocative tests that reliably localize pain on testing to the problema tic sacroiliac joint are the Patrick-Fabere, Gaenslen's, and Yeoman's. Mierau et aP8 found that two out of three of these tests were positive and localized pain to the affected sacroiliac joint in over 90% of the time. In very heavy or muscular patients, it is difficult to palpate the delicate movements of joint play. Thus, more information is gained by indirectly moving the joints through long-lever provocative testing, as above. For the average patient, especially if the problem is acute, the provocative tests will lateralize the problem to one joint or the other, and specific palpatory pro­ cedures can help further delineate the dysfunction. One can test the gluteus maximus muscle in this position by pressing down on the distal posterior thigh while the knee is maintained in flexion

Figure 5-57

Yeoman's Test

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Examination

2

5-58

231

3

Structures moved or stressed d uring Yeoman's test: (1) femoral nerve, (3) psoas muscle, tendon, and bursa, (4) sacroiliac (5) lumbar

is first The ability of the patient to hold the test maximus muscle is ascertained. In hip and sacroiliac problems, the in the often weak and atonic. This becomes very evident to the above test. To test hip joint extension Yeoman's test above while the can also be chanter to assess joint play (Figure table and the tested in the prone position, with the trochanter pressed toward the The examiner for restricted motion and

Sacrotuberous Ligament The examiner should the sacrotuberous undue tenof the buttock between the ischial sion and pain by pressing into the tuberosity and sacral apex as a firm, painless structure. overcome by palpating between the fotmd sacral apex and ischial tuberosity. With practice, it becomes easier to locate the tough ligamen­ be appreciated when tous structure. A difference in tension can

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232

PELVIC LOCOMOTOR DYSFUNCTION

Figure 5-59 Gluteus Maximus Muscle Test

comparing sides. Deep pressure into the ligament may elicit a pain famil­ iar to the patient that may otherwise elude conventional examination pro­ cedures. This ligament is commonly involved in traumatic falls to the but­ tock with attending sacroiliac and hip jo int problems. If shortened and painful, this liga ment can create pelvic joint problems or allow them to persist. Tightness and tenderness are indications for stretching and direct pressure treatment, as described in Chap ter

9. Pain from

this structure can

be referred to the bu ttock region and down the posterior thigh (Figure

5-62) .

Resultant pelvic pain and pelvic organ dysfunction have been

known to occur due to somatovisceral reflex phenomena ac ting through the 5-2 to 5-4 segments.39 Sacral Accessory Movements/Sacral Apex/Cranial Shear Accurately directed pressures along the sacrum and sacroiliac regions can yield important information concerning movement and pain provoca­ tion. While the patient is lying prone, the pelvis is supported by the two ASI5s and the pubic symphysis, forming a tripod. Applying pressure to the sacral apex while at the same time palpa ting the sacroiliac sulci enables

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Examination

A

B

Figure 5--60 Hip joint play. (A)

In extension.

(B) In anterior glide.

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233

234

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 5-61 Sacrotuberus ligament palpation. (A) Ligament palpa tion. tion o f sacral apex and ischial tuberosity to locate extent o f ligament.

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(B)

Palpa­

Examination

+-1.---- Localized

235

Pain

:::T"''i+-- Referred Pain

Figure

5-62

Sacrotuberous Ligament Pain Referral

one to feel a sense of

and movement

localizes to one of the sacroiliac joints upon occurs often in acute sacroiliac

sacrum in this

ever, effects can also be felt at the lumbosacral

In

test to

sacroiliac joint

the apex of the sacrum in a cranial direction40

Pain

cation is looked for. A modification of this test would be to press concurrently in a sacral may aid in

cranially on the

direction on the PSIS while a shear movement at the the pain to one side or

Additionally, the examiner's thumb

(Figure

5-63C). This

other.

can be placed on the medial

aspect of the PSIS and directed laterally to

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a localized

at

236

PELVIC LOCOMOTOR DYSFUNCTION

A

B

continues

Figure 5-63 (A) Sacral apex pressure. (B) Cranial shear. (C) Craniocaudal shear.

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Examination

237

Figure 5-63 continued c

the joint (Figures 5-64A and 5-64B). The other hand can be placed over the thumb to reinforce the con tact. Alternately, a double-thumb contact can be used against the medial aspect of the PSIS (Figure 5-64C). Although move­ ment is very slight, pain provocation may be elicited. This maneuver may also elicit pain with an irritated iliolumbar ligament. In all these ma­ neuvers, restriction and pain provocation are looked for. This information is then used to aid in mobilization and manipulation of the joint. Sacro-Ilio Cross Another provocative, as well as mobilization, technique is to contact si­ multaneously the PSIS and apex of the sacrum while imparting pressures in opposite directions (Figure 5-65). For instance, while facing perpen­ dicular to the pelvis, the examiner places his or her cephalad hand on the sacral apex in the midline, using a pisiform contact. Crossing over with the caudal hand, the examiner places the other pisiform on the contralateral PSIS. Gentle oscillatory pressures are applied in opposite direction s to sense resiliency and provoke pain. Findings are compared to those of the opposite side.

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238

PELVIC LOCOMOTOR DYSFUNCTION

A

B

continues

Figure 5-64 Direct lateral gapping. (A) With thumb contact. (B) With reinforced contact. (C) With double-thumb contact.

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Examination

Figure 5-64 continued C

Figure 5-65 Sacra-Ilia Cross

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239

240

PELVIC LOCOMOTOR DYSFUNCTION

Trunk Extension Differential Test

The trunk extension differential test can be used to take advantage of the fact that the erector spinae muscles generate substantial tension in and around the sacroiliac joints when they contract. The pa tient is asked to place the hands behind the back and raise the trunk off the table for a few seconds (Figure 5-66) . Any change in the pain response in the sacroiliac region is noted. If there is pain on extending the trunk actively, the examiner has the patient repeat the procedure, but this time he or she stabilizes the painful side joint with firm pressure. If, upon active trunk extension, the pain re­ sponse is diminished or absent with stabilization and the patient can ac­ complish the maneuver more easily, the pain is probably coming from the joint. However, if there is no change in the pain response with stabilization, yet active trunk extension is still more painful than lying prone, the erector spinae muscles are incriminated. If there is no change in the pain, whether the patient is prone, actively extended, or actively extended with stabiliza­ tion, then inflammation or bone pathology should be suspected. Static Palpation

Ligaments are never tender unless they are trauma�ized or unless the joint they support is dysfunctional. 17 Hence, the ligaments about the pelvic joints can be painful due to injury, dysfunction, or pain referral from some other site. The only area where the sacroiliac joint can be palpated directly is in its inferior aspect near the PIIS. The overlying tissues are often tender to palpation and can appear thickened in sacroiliac joint problems. The skin over each sacroiliac joint can be rolled while pain and tension are looked for. Chroni c j oin t problem s can yield sore, "bruised"-feeling liga­ ments for months and even years without the patient's being aware of the pain until i t is palpated. As joint mobility and function are restored with treatment and exercise, this point tenderness abates. In this author's personal experience, palpation of this area at one time revealed a pea-sized soft tissue abnormality, presumably in the ligamen­ tous tissue, that created a very painful radiating sensation into the poste­ rior buttock, thigh, and leg with tingling of the foot. Upon ischemic com­ pression (sustained pressure) of the painful point and subsequent sacroiliac joint manipulation, the pea-sized s tructure was no longer pal­ pable, and the radiating pain could no longer be elicited. Coccyx

The coccyx is often painful in response to sacroiliac joint dysfunction, especially at the undersurface of its tip.36 Tension and trigger points in the

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Examination

241

A

B

Figure 5-66 Trunk extension differential test. (A) Tnmk extension without joint stabilization, (B) With joint stabilization.

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242

PELVIC LOCOMOTOR DYSFUNCTION

levator ani and coccygeus muscles can also create coccydynia (coccyx of these structures is

bu t thorough under-

of the anatomy is an essential discopathy of the

In women, vaginal trigger

dysfunction and

can also cause a painful coccyx.

L-5

and

can result from tension and and levator ani muscles. Travel! and

in the

Simons26 offer a n excellent reference to the

point examination of

this area. The sacrococcygeal joint can be gently joint-played in various directions in a n attempt to

the

An

intrarectal examination to the coccyx with

rior to anterior and transverse pressures can be the

Refer to

6 for the discussion on mobilization of this

joint. Pelvic Floor The levator ani,

The pelvic floor can be a great source of pelvic with its two main

is the most com-

mon source of referred perineal its

to the sacrum, coccyx, rectum, and

can be

Thiele42 states

it can refer

and Pace43 includes the

to the

ani as a commonly overlooked source of low back pain. The coc-

muscle is also known to refer

to the

low back The above h-vo muscles make it

coccyx, hip, or to sit i f

harbor

In addition, defecation may be

trigger

aid in

rectal examination can

points in the levator ani muscle.26 The external anal should also be assessed for tone and

the examiner's

Once

finger can sweep across the expanse of the levator ani on either side midline. The coccygeus muscle can be identified joint and moving

the

finding the

just anterior to the

Tender and taut bands of muscle are searched

that reproduce

Thiele42 discusses the various

of this ex-

amination. RADIOGRAPHS In addition to the standard lumbar radiographic series, consideration should be a

to routinely

the

tube tilt

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view with to Yochum and

Examination

this is the best view for the collimation

the sacroiliac joints.

243

open-

the hip joints can be seen bilaterally. The view or standing and the tube tilted

is taken with the patient either

30

The central ray is centered in the midline just below the level of the ASISs. ERYTHROCYTE SEDIMENTATION RATE With regard to laboratory most useful test in

to

medical from mechanical low

back

is the measurement of the erythrocyte sedimentation rate reflects the (ESR) ."45(p63) The ES R

tion to tissue destruction. Systemically, the body

to tissue injury

with an increased level of plasma proteins made in the liver. Due to the

POSitioning

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244

PELVIC LOCOMOTOR DYSFUNCTION

Table 5-1 Upper Limits for Erythrocyte Sedimentation Rales32

Under 50 years old Over 50 years old

Men

Women

1 5 mm/h 20 mm/h

25 m m/h 30 mrnlh

increased level of these plasma proteins, the red blood cells tend to aggre­ gate more, causing an increased rate of sedimenta tion in an upright tube. This rate of sedimentation is measured in 1 hour. Generally, the ESR is elevated in conditions of inflammation. These would include rheumatic disease, acute infections, tissue necrosis, malignant disease, and abdomi­ nal disease. As such, the ESR is a most practical and valuable screening test for the detection of medical pathology. Normal values vary depend­ ing on gender and age (see Table

5-1).

Extremely high values

(l00 mm/hr

and higher) most likely indicate malignancy.46 Chapter Review Questions •

What are the essential features of a manual ftmctional examina­ tion?

•

What effects do changes in femoral version have on gait appear­ ance?

•

Discuss the various postural findings that indicate joint and muscle dysfunctions common to the pelvic and hip areas.

•

Relate palpation findings in Gillet's leg-raising test to manipula­ tive technique setup.

•

What three movement patterns should be examined for in the pel­ vic and hip areas?

•

What are the clinical criteria for diagnosing pubic symphysis joint

•

What provocative tests aid in diagnosing sacroiliac joint lesions?

•

Explain the trunk extension differential test.

dysftmction?

REFERENCES 1. Griner PF, Mayewsky R}, Mushlin AL, et aJ . Selection and interpretation of diagnostic tests and proced ures: principles and application. Ann Intern Med. 1981 ;94:553-563. 2. Hoppenfield S. Physical Examination of the Extremities. New York, NY: Appleton-Century­ Crofts; 1976.

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4. Robinson RO,

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IVlUnWlllW'WP Physio/ Ther. 1987;10:1 721 76. BM, Read

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to

PJW, et a l . Reliability of motion palpation

detect sacroiHac joint fixations.

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7. Ramamurti CPo 8. Kessler RM,

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Musculoskeletal Disorders. Philadelphia,

Pa: Harper & Row; 1983. 9. Mennel l J M . Back Pain:

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10. Bourd i l l ion JF, 1987.

of posture and its importance: III short leg. J Am

1 1 . Hoskins ER. The

U�I'W""HfI

Assoc. 1 934;34:1 25--126. Pain and IJU.Sn1:"r/,mn: The

1 2 . Travell IG, Simons DG.

Point Manual. Vol 1 .

Baltimore, M d : W i lliams & Wilkins; 1983. 1 3. J u l l GA, Janda V . Muscles and motor control in l o w back pain: assessment and management. In:

J R, eds. Physiclll The:rIlP1f of the Low Blick. New York, NY:

LT,

Churchill

1987:253-277. of the 4 th

1 4 . Janda V, Schmid H. Muscles as a pathogenic factor in back pain. conference IFOMT. 1 , 1 980; Christchurch, New Zealand. TF. The adjustive

anatomy, biomechanics, assessmen t, a nd Peterson DH, Lawrence DL eds. Chiropractic Tech­

New

V'"1""'L1I1", 1 993;1 97-521 .

] 6. Triano jJ, Schultz A B . Correlation lion with low-back d isabiHty

r.h.",,,,,,,,,

measure of trunk motion and muscle func­

Spine. 1 987;12:561 .

17. Mennell J M . The Musculoskeletal

Symptoms and

Md: Aspen 18. Faye lJ. Motion Palpation of the

Huntington Beach, Calif: Motion Palpation Insti-

tute; 1981. to biomechanical disorders o f the lumbar spine and

19. G i telman R . A

In: Haldeman S, ed. Modern De1)elopments i n the Principles and Practice tic. New York, NY: Appleton-Century-Crofts; 1980:297-330. 20. Gillet H, Liekens M .

Ch lrmJral:l1c Research Notes. Huntington Beach, Calif: Motion

Institute; 1984. 2! .

LJ. Motion

Palpa tion and Clin ical Considerations of tlu? Lumbar Spine and Pelvis. HunInstitute; 1986.

tington Beach, Calif.: Motion

22. Schafer RC, Faye LJ. Motion Pilipation ami Chiropractic Tech nic: Beach, Calif: Motion 23. DeFranca GG, The

Chiro-

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Chiro

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PELVIC LOCOMOTOR DYSFUNCTION

stress. Physiother Rev. 1941;21:

in relation to

24. Lowman CL The 30-33.

o f the lower extremities and pelvis a n d their

BE, Lindstrom J .

25.

to lumbar scoliosis. Acta Morphol Neerl Scand. 1 963;5:221-234. 26. Travel! JG, Simons DG. Myofascial Pain and

Point Manual. Vol 2.

The

Baltimore, Md: Williams & Wilkins; 1992. 27. Lewit K.

2nd ed. London:

Therapy in Rehabilitation of the Locomotor

B utterworths; 1 9 9 1 . 2 8 . Nichols PGR. Short-leg syndrome. B y Med j. 1960; 1 : 1 863-1865. 29. Harris NH, M u rray RO. Lesions of the symphysis in athletes. By Med J. 1974;4:21 1-214. associated with pubic

30. Laban MM, Meerschaert JR. L umbosacral anterior A rch

Med Rehabil.

31. K i r ka i dy-Willis W H , H i l l RJ. 1 979;4:102-109. 32. Jonsson B,

test and the severity of symptoms in

B . The

lumbar disc herniation. Spine. 1 995;20:27. tension

33.

and l umbar d isc herniation. Spine. test. New Eng/ J Med. 1977;297: 1 1 27.

WR. The crossed

34.

35. Janda V. Muscle FlInction 36. Lewit K .

iYlU'fllL'UnHi

Boston, Mass:

Therapy in Rehabilitation of the Locomotor

B u t terworths; 1985. lumborum and low back pain.

37. DeFranca GG, Levine LJ. The

J Manipulative

Ther. 1991;14:142-149. 38. Mireau D,

K, Wilkinson A, Sibley J, Von Baeyer C. presentation. In:

C. Dorman T,

on Low Back Pain and Its

Fr()Ceedinllls o f t h e First Relation to the

analysis of

A, Mooney V,

Joint; November 5-6, 1992; San

39. Midttwl A, l5olserHVlolller F. The sacrotuberous

CA. pain syndrome. In : Grieve GP,

of the Vertebral Column. New York, NY: Churchill

ed . Modern Manual 1986:815-818.

40. Laslett M, Williams W. The reliability of selected pain provocation tests for sacroiliac joint pathology.

1994;19:1 243-1249.

4 1 . U H u s HG, Voltonen EJ. The levator ani spasm syndrome:

11

clinical

of 3 1 cases.

A n n ChiT Gynaecol. 1 973;62:93-97. cause and treatment. Dis Colon Rectum. 1963;6:422-436.

42. Thiele GH. 43. Pace J B .

overlooked pain

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Med. 1 975;58: 1 07-113.

44. Yochum TR, Rowe LJ.

and normal anatomy. In: Pine JW, ed. Williams & Wilkins; 1987: 1-93.

Essentials of Skeletal Kl1i11O,IOKI/. 45. Borenstein DC, Wiesel SW. Low Back Pain: Medical ment.

and COirnvrehensive

Pa: WE Saunders; 1989.

RA.

of extreme elevation of

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sedimentation

Chapter 6

Mobilization

Chapter Objectives general considerations concerning mobilization mobilization theory facilitation or muscle on.n .."·,,

GENERAL CONSIDERATIONS by joint architecJoints function to move. That movement is ture, soft tissue restraint, muscular contraction, and neurologic control. The absence of that movement, found on examination, forms the basis for the of to restore motion. concept restores a bone that is out of The should be abandoned. Manipulation and mobilization are rected forces that should be aimed at motion in already restricted In this with passive accessory movements. Passive physiologic movephysiologic ments are those same movements can that the perform actively, eg, hip flexion, abduction. accessory movements are those involuntary movements that occur when an operator motion to the joint. For cannot voluntarily nprt"rTYl rm.J_"V1C extension of the hip Neither can anterior glide or shear movements at the hip and sacroiliac joints be under a person's volitional control. Although small and involthese accessory movements, also called play movements, are for movements to occur.

247 Copyrighted Material

PELVIC LOCOMOTOR DYSFUNCTION

248

What

in the use of manual

ence of "joint These joint that needs to be

nDr�r.r,,"'D"

The use of manual methods to treat musculoskeletal ailments is an anThe main

is to

movement to painful,

and muscles to enhance mobility and relieve any

can be

are actually considered specific types

movement therapy. The of

distinction between the two

and

to remain in control of the

speed of movement, and the discusses

movement. This

As in

Manipulation and mobilization

and the following

discusses

MOBILIZATION THEORY Mobilization is a form of

movement therapy that involves oscil-

latory movements of various

executed in certain parts of a

joint's range of motion. The movement

is still under the control

should he or she decide to halt it. Mobilization also includes

of the

sustained stretches of variable vigor at the end range. The different tudes of mobilization are divided into four for ease of assessment and

Maitlandl

QUIJll'.Q

is reserved to denote a manipulative thrust. The four tion are as follows:

Grade I: a small-amplitude movement executed at the

V"J,,-lll",U

range

of the

Grade II: a larger-amplitude movement to the limit or

but not

or

spasm

Grade Ill: a spasm by

movement that

"",o;a);",;:!

stiffness or

to the limit of range

Grade IV: a

movement at the limit of range that

stiffness or spasm has been performed,

V to

IV

the joint's capsuloligamentous struc-

Although it is not part of Maitland's descriptions of mo-

l refer to this technique

as a

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VI mobilization.

Mobilization

249

Figure 6-1 Mobilization Grades

Grades

and II, Ill, and IV can be applied either more or less (-) III-, etc.) respec-

denoted with a plus (+) or minus

of oscillations is two to three

The usual

per second

more slowly and gently for painful joints and more

for about 20

quickly and abruptly for chronically stiff joints. The choice of the mobilization

used depends upon the type of the examination of joint motion.

hArAt,'WA

whether the resistance to

it is

joint motion is from pain or articular tissues. For

and whether it is from articular or muscle spasm exhibits a "twanglike" end-

feel, and the muscle contraction may be visible. When reflex spasm is en­ countered

mobilization

the treatment movement

should be a sustained stretch just at the point of onset of pain or The pain and spasm should subside in about 20

at which time the

joint can be challenged slightly more. Similarly, joints, oscillations must be

feature in acute demand by the

oscillations are used mostly to reduce

The

and painful and amplitudes of

pain response. Grade through

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I and II

250

PELVIC LOCOMOTOR DYSFUNCTION

stimulation. Gentle, slow oscillations can allow enough improvement to occur so that movements of is

can follow. A painful

to "lull" the

into

cence and allow the patient to relax with the movements. Just as a painful point can be "deactivated"

sustained

chemic compression), a painful joint motion can be continued

..ot,,,,,..,,,,,,

movements. It is amazing how a series of calm down a

II mobilizations can osteoarthritic hlp joint. and

The

of the oscillations should be

the changing

on-pressure to

should be al-

so that they that are not as painful, the

h""rnrlt"nn

However, if sure, then it should be the rebound mobilization.

oscilla­

for instance, a

tion on the lower pole of the sacroiliac joint that elicits pain upon its re­ is made slower than

lease. To mobilize better in this case, the the to

in order to cause a rebounding mobilization from anterior This is a very useful

in cases off-pressures

by quick, almost

Slow, gentle on-pressures

will at first elicit a painful response. However, after 30 to 60 seconds of oscillations are performed, the pain usually subsides.

these

tissues are characteristic of chronic con­ ditions in which stiffness is more of a feature than pain. These joints can be handled more

near the end range of

without reprisal,

motion. Grade III and IV mobilizations are best used in this situation. These aid in

shortened or scarred

structures. Maitland1 describes a staccatolike oscillation combined with sustained

small

IV

III

oscillation near the end range with

of interposed

works well. The larger amplitudes tend to abate any pain caused by the smaller

oscillations. spasm occurs is also

Where in the range the

Grades I and II are used mostly to reduce the

if its onset occurs early in

whereas grades III and IV are used to stretch stii£ened tissues

felt later in the range.1 Mobilization techniques can often be used as nr"n�lr"tr."" maneuvers to a grade V tions. This creates

relaxation

as the patient.

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in

condi-

soft tissues as well

Mobilization

251

FACILITATION TECHNIQUES Facilitation

also termed muscle energy or muscle relaxation tech-

niques, proprioceptive neuromuscularfacilitation (PNF), and postisometric relax­ ation (PR), are also used as a means of mobilizing joints by releasing tension

in shortened or hypertonic muscles. These are covered in more detail in Chapter 9. in brief, and neuromuscular reflexes associated with in the neighboring joints. the tight muscle is contracted isometrically for a few seconds in the direction opposite the of the muscle is restriction or Upon relaxation, or "barrier." For example, to increase formed to it to a new hip extension the psoas muscle can be a muscle energy stretched. The patient lies supine with the thigh and leg on the involved side off the table. The clinician then applies a gentle floorward stretch to the distal is then instructed to contract or thigh until a resistance is met. The press the thigh up the clinician's resistance for 8 to 10 seconds maximum contraction if minimally for PR after which he or she is instructed to relax ("let go"). The thigh is then allowed to drop further floorward, thus increasing hip extension. The pro­ again at the new muscle length achieved. The isometric cess is contraction is associated with a reflex-mediated inhibition that occurs after and the contraction and lasts for several seconds. This is the muscle is passively stretched for that To utilize the reciprocal inhibitory effects of antagonistic muscle group the patient can be asked to press the thigh floorward after his or her 8- to 10-second contraction, rather than having clinician can be recruited to enhance facilitation and press it. breath and holds it for a few seconds inhales a inhibition. The to enhance overall muscle facilitation during the muscle contraction. Upon exhaling, he or she is instructed to relax. In exhalation is associthe relaxation neuromuscular inhibition, ated with of the muscle. MOBILIZATION TECHNIQUES The following section deals with various mobilization Lt::L'UlJl"l hip, and symphysis pubis joints. The t13("'hn,li1' the to the patient's posture and their setup and actual performance. Contraindications to niques are discussed in Chapter 7.

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for

252

PELVIC LOCOMOTOR DYSFUNCTION

Sacroiliac Joint Prone Sacro-Ilio Cross. With the patient prone, the clinician stands perpen­ dicular to the patient's pelvic region. The clinician's cephalad hand makes a pisiform contact in the midline on the sacral apex. The caudal hand is then crossed over the cephalad hand by making a pisiform contact on the opposite-side PSIS. The clinician positions himself or herself such that his or her sternum is over his or her contacts. By pressing downward in the direction of each forearm, he or she imparts a sagittal-plane shearing force to the sacroiliac joint by oscillating the sacrum in relation to the ilium (Fig­ ure 6-2). The mobilizing force actually comes from movement at the hips and trunk being transferred through the shoulders and arms. To lessen the strain on his or her back, the clinician can take a wide stance to lower the center of gravity. Repeated oscillations into a restricted joint create mobil­ ity that is perceived as increasing springiness or pliability at the joint. This also serves as an excellent premanipulative maneuver for the sacroiliac joint.

Figure 6-2 Sacro-Hio

ross

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Mobilization

253

Direct Gapping. The clinician again positions himself or herself perpen­ dicular to the patient's pelvis. He or she then places the thumb pad just medial to the opposite PSIS (Figure 6 3A). The clinician's other hand cov­ ers his or her thumb with a pisiform contact (Figure 6-3B). A mobilizing force directed laterally against the medial aspect of the PSIS will impart a slight gapping movement in the horizontal plane at the sacroiliac joint on the side opposite to where the clinician is standing. The movements should not be so firm that the pelvis and trunk move unless a more vigor­ ous mobilization is warranted. However, a gentle rocking motion can be imparted to the immediate pelvic vicinity. On smaller and slender indi­ viduals, the cephalad hand can maintain a stabilizing contact on the near­ side PSIS and sacrum, with the fingers pointing caudad. Meanwhile, the caudad hand can impart gentle oscillations with the thumb against the medial aspect of the PSIS on the opposite side. A double-thumb contact can be used on larger patients (Figure 6-3C). -

Prone Gapping, Long-Lever. A prone gapping technique of the sacro­ iliac joint can be performed with the clinician kneeling perpendicular to

A

continues Figure 6-3 Direct gapping technique. (A) Thumb contact. (B) Pisiform covering contact. (C) Double-thumb contact.

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254

PELVIC LOCOMOTOR DYSFUNCTION

Figure 6-3 continued

B

c

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Mobilization

255

the patient's pelvis and stabilizing the ipsilateral ilium (right side) with the chest.2 The patient's left knee is flexed to

90 degrees, and the clinician's

caudad hand grasps the ankle and pushes it laterally to cause internal rota­ tion of the left hip (Figure 6--4). Maximal internal rotation of the left hip, via a chain-reaction mechanism, will cause a gapping of both sacroiliac joints (Figure 6-5). This subtle movement can be monitored with the clinician's cephalad hand palpating the sacroiliac sulcus on the right or left side. Extension Mobilization. This maneuver is similar to Yeoman's orthope­ dic test of hip extension (Figure 6-6). The clinician stands facing the pa­ tient just caudal to the level of the pelvis. The clinician extends the patient's contralateral thigh with his or her caudad hand by lifting it just proximal to the bent knee. To affect the upper aspect of the sacroiliac joint, the patient's PSIS is contacted with the clinician's cephalad pisiform or thenar eminence. Oscillations are performed as indicated. A variation of the above technique involves contacting the sacral apex instead of the PSIS (Figure 6-7). This affects the lower aspect of the sacroiliac joint. Varied Sacral Pressures. With the patient prone, various directed pres­ sures (accessory movements) are applied to the sacrum to cause joint mo-

Figure 6-4 Long-Lever Gapping

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256

PELVIC LOCOMOTOR DYSFUNCTION

Joint Gapping

l

Figure 6-5 Mechanics of Long-Lever Gapping Technique

Figure 6-6 Extension mobilization for the upper aspect of the sacroiliac joint. Note posterior superior iliac spine contact.

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Mobilization

257

Figure 6-7 Extension mobilization for the lower aspect of the sacroiliac joint. Note sacral ap ex contact.

bilization movements that may possibly match the patient's signs and symptoms (Figure

6-SA). These pressures are applied in a posterior-to­

anterior direction both centrally and to each side of the midline on both the upper and lower aspects of the sacrum. The sacrum can also be pressed in a cephalad direction from below while the iliac crest is pressed caudally (Figures 6-S8 and 6-SC).

Side-Lying Anterior Torsion. The patient lies on his or her right side with the left leg flexed slightly at the hip and knee so that the knee rests on the table in front of the right leg (Figure 6-9). The clinician can impart an anterior tor­ sional mobilization to the left sacroiliac joint by standing behind the pa­ tient and contacting the patient's left PSIS with his or her right pisiform and the area over the left acetabular region with his or her left hand. The PSIS contact is pressed anteriorly while the acetabular contact is pulled posteriorly in an attempt to torque the ilium on the sacrum in an anterior direction. Gentle, rhythmic oscillations of varying amplitudes are then used, depending on pain and restriction.

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258

PELVIC LOCOMOTOR DYSFUNCTION

B

A

I

;...!.,� 2 �

�

't

3

)

/

C

Figure 6-8 Sacral mobilizations. (A) Central and unilateral posterior-to-a.nterior pressures. (8) (1) Outline of sacrum and indicated spots for posterior-to-anterior mobilizations; (2) caudally directed mobilization on iliac crest; (3) cranially di­ rected mobilization on sacral inferior-lateral angle. (C) Combination craniocaudal shear at SIJ.

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..

Mobilization

Figure 6-9

259

Anterior Torsion Mobilization

Posterior Torsion. The patient assumes the position described for the previous technique; however, the clinician reverses the contacts by cup­ ping the right hand over the ASIS and placing the left hand on the ischial tuberosity (Figure

6-10). By pushing on the ischial tuberosity and pulling

on the ASIS, the clinician can impart a posterior torsion to the sacroiliac joint. The movements in the above two teclmiques are subtle, with the intent of mobilizing the uppermost sacroiliac joint. Therefore, the motion should be directed locally without rocking the entire pelvis. General Flexion with Facilitation. In the side-lying position, the patient flexes the uppermost thigh as far as possible. The clinician stands in front of the patient, facing somewhat cephalad, and places the patient's upper­ most knee against his or her thigh. The patient is asked to press his or her

knee into the clinician's thigh for 8 to

10 seconds, thus contracting the hip

extensor muscles. The patient is then asked to inhale deeply and relax on the exhale, being told to "let go." Upon sensing relaxation, the clinician increases the patient's hip flexion by pressing with his or her thigh in a headward direction. When a new resistance is met at a higher angle of flexion, the procedure is repeated. The patient can remain passive during the stretching phase or can assist the stretch with an active contraction of

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260

PELVIC LOCOMOTOR DYSFUNCTION

Figure 6-10

Posterior torsion mobilization. Note hand placement reversal com­

pared to Figure 6-9.

the hip flexor muscles. The goal is to increase hip flexion to the point of stretching the hip and sacroiliac joints. This is a very effective technique to use during acute situations, as a premanipulative maneuver, or in work­ ing with chronic joint stiffness commonly seen in patients over

50 years

old. Often the patient experiences decreased pain and tension in the hip and sacroiliac regions after this procedure is performed. Sagittal Shear. The patient is placed in the side-lying posture with the clinician standing behind the patient at the level of the pelvis. The clinician places his or her left thenar eminence over the sacrum, and his or her right hand gently cups the patient's ASIS anteriorly. By stabilizing the sacrum posteriorly with his or her thenar eminence, the clinician attempts to im­ part a posterior shear of the ilium on the sacrum by gently pressing in an anterior-to-posterior direction through the ASIS (Figure

6-11). It must be

emphasized that the ASIS contact should be comfortable. To ensure this, the ASIS is cupped in the palm of the clinician's hand. Alternatively, the clinician can stabilize the ASIS contact and press from posterior to anterior on the sacral base. Lower-Joint Gapping Technique. The patient is in the same position as above, but the clinician stands in front of the patient facing the pelvis. By

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Mobilization

Figure 6-11

261

Sagittal-Plane Shear

getting into a low stance, he or she places his or her sternum over the patient's uppermost hip. The medial and most inferior aspect of the ischial tuberosity is contacted with the caudal hand's pisiform while the cephalad hand grasps the rim of the iliac crest. The elbow of the caudad hand is held below the level of the ischial tuberosity contact. Pressing toward the ceil­ ing with the ischial contact and pressing floorward with the iliac contact stresses the ilium in such a way as to gap the lower aspect of the patient's right sacroiliac joint (Figure

6-12).

These last five side-lying techniques are excellent maneuvers to perform when the patient finds it difficult to lie supine or prone, as, for example, during pregnancy. Supine Backward Lying with Torsion. This maneuver is similar to the examina­ tion technique performed earlier. It can be used as an effective stretching mobilization for the sacroiliac joint. The patient slumps back against the clinician and torsion is applied to the trunk (Figure

6-13). The ASIS is

pressed toward the table as the trunk rotation is accentuated. A slight lift­ ing traction is applied to the trunk so that a tractionlike torsion is applied

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262

PELVIC LOCOMOTOR DYSFUNCTION

Figure 6-12

Lower-joint gapping technique. Note low lifting angle of ischial con­

tact.

to the sacroiliac joint on the side of ASIS contact. This is particularly useful in pregnant women, especially during house calls or if they have difficulty reclining due to pain. Anterior-to-Posterior Shear. The patient lies supine with the right thigh flexed to 90 degrees and slightly adducted. The clinician faces perpendicu­ larly to the patient, standing on the patient's left side. The clinician grasps the patient's flexed knee with his or her right hand and pulls the thigh toward him or her so that the pelvis rotates up off the table slightly. He or she then contacts with the left hand the patient's right sacroiliac sulcus. Mobilizing oscillations are directed by the clinician's right arm down through the patient's flexed femur to create an anterior-to-posterior shear force of the ilium against the sacrum. The pelvis is rotated off the table only to the extent that the clinician's fingers of the left hand can gain access to the sacroiliac sulcus to monitor the mobilizing oscillations (Figure

6-14).

Pubic Symphysis Pubic symphysis (PS) fixations are suspected when asymmetry of the pubic tubercles is observed3.4 and when unilateral tension and tenderness

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Mobilization

263

are found in both the inguinal ligament and the short hip adductors (see Chapter

5, Figure 5-29). Sagittal-plane rotational movements at the sacro­

iliac joints appear to be hindered when PS fixations are presents Motion palpation of the PS is difficult to perform, and overall assessment of its functions is generally by clinical suspicion. Restoration of motion can be accomplished by simple mobilizations and facilitation techniques. The mobilizations are more like stretches. High-velocity maneuvers are usu­ ally not necessary.

General Countertorque Technique. This and the following technique are applied to both sides to cause a general mobilization of the PS joint. The

A

continues Figure

6-13 (A, B)

Backward lying with torsion. The ASIS is stabilized as the sac­

roiliac joint is tractioned and rotated on the side of contact.

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264

PELVIC LOCOMOTOR DYSFUNCTION

Figure 6-13 continued

B

patient is supine, with the right thigh and leg near the edge of the table and the other thigh flexed up onto the chest or as far as possible. The patient can hold the left knee up to the chest with both hands, with the clinician supporting it for control. The other thigh is allowed to drop to the table surface or, if the patient is flexible enough, off the table. The clinician ap­ plies a firm stretch to the right distal femur while stabilizing the left thigh upon the patient's chest (Figure 6-15). This is held for 30 seconds, with small-grade IV oscillations being applied afterward for another 20 to 30 seconds. The procedure is then performed on the other side. Countertorque with Facilitation. Since the above procedure stretches

the psoas muscle on the right, a facilitation technique designed to stretch

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Mobilization

265

Figure 6-14 Anterior-to-posterior shear. Note slight thigh adduction.

this muscle will accomplish similar results. The patient is placed in the same position as above but this time is instructed to resist gently the downward pressure on the right distal femur ("hold" or "pull up gently against my hand") for 8 to 10 seconds (Figure 6-16). He or she then inhales deeply and, upon exhaling, is told to "relax" or "let go." Only when the clinician senses relaxation in the right hip flexors after the isometric con­ traction and exhalation (postisometric relaxation) does he or she encour­ age or coax more hip extension on the right. The hip is extended until resis­ tance is met with, and the procedure is repeated again. This whole process is performed tlU'ee to five times, depending on the tightness of the hip flexors, and repeated on the other side.

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266

PELVIC LOCOMOTOR DYSFUNCTION

Figure &-15 General Pubic Symphysis Countertorque

Figure &-16 Countertorque Using Psoas Muscle Facilitation Stretch

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Mobilization

267

Abduction Facilitation. This maneuver and the next two are considered general "shotgllil" techniques to create mobility at the PS. The patient is supine with knees bent and feet flat on the table. The clinician holds the knees together to resist their active separation on the part of the patient (Figure 6-17). After several seconds of resisting strong abduction, the pa­ tient relaxes, and the pain and tension at the inguinal ligament and adduc­ tor insertions are reevaluated. Adduction Facilitation. The patient is supine, with knees bent and feet resting flatly on the table. The clinician places his or her forearm length­ wise between the patient's knees to act as a block to movement. The pa­ tient is instructed to adduct the knees strongly (Figure 6-18). After several seconds of contraction, the patient relaxes, and the pain and tension are reassessed at the inguinal ligament and/ or adductor tendon insertions. Adduction Facilitation with Thrust. The patient is positioned as above, but with knees held together. The clinician holds the medial aspect of each knee with his or her hands and instructs the patient to adduct strongly. The clinici.an applies a high-velocity, low-amplitude impulse thrust in an

Figure 6-17

Abduction facilitation. Clinician holds knees together against patient

resistance.

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268

PELVIC LOCOMOTOR DYSFUNCTION

Figure 6-18 Adduction facilitation. Clinician resists adduction of knees with fore­

arm.

attempt to separate the knees slightly (Figure 6-19). This maneuver at­ tempts to cause a gapping at the PS.

Hip Joint The hip joint is a large synovial joint capable of global motion. Mobiliza­ tion is directed at increasing physiologic as well as joint play movements. In addition, the combined movement of flexion with adduction is prob­ ably the most important movement to test and treat. If this maneuver can be performed painlessly, then mobilization in flexion and adduction per­ formed as separate movements is rarely needed.6 The physiologic move­ ments include flexion, extension, abduction, adduction, and medial and lateral rotation. The accessory movements include anterior, posterior, and lateral glides; long-axis extension; posterior shear at 90 degrees flexion; and caudal glide at 90 degrees flexion. Mobilization Using Physiologic Movements Combined Flexion/Adduction. Lewitl describes this maneuver in the

treatment of what is termed "ligament pain."B Two positions are assessed

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Mobilization

Figure 6-19

269

Adduction Facilitation with Impulse Thrust

and treated. The first is with the hip in 90 degrees of flexion, with strong adduction being applied (Figure 6-20A). This position stresses not only the hip joint but the iliolumbar ligament,? and pain may be experienced in the groin. The second entails flexing the hip maximally and then applying strong adduction (Figure 6-208). This tends to affect the sacroiliac joint ligaments, and the patient usually feels discomfort in the buttock that can radiate into the posterior or posterolateral thigh. In both of these positions, longitudinal pressure is applied along the axis of the femur by pressing on the knee. If resistance is met, postisometric relaxation can be used to over­ come it. This technique is usually W1comfortable when restriction is met, and care must be taken not to overwhelm the patient with discomfort, as this is quite easy to do. To perform this maneuver, the patient is supine, and the clinician stands opposite to the side in question. The clinician reaches across and flexes the hip to 90 degrees or maximal flexion, depending on which position repro­ duces the patient's symptoms more. The thigh is then adducted strongly but carefully. While holding this combined flexion/ adduction position, the clinician applies pressure back along the axis of the femur. The patient

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PELVIC LOCOMOTOR DYSF1JNCTION

A

B

Figure 6-20 "Ligament pain" mobilization. (A) Hip flexion at 90 degrees. flexion maximal. Adduction is applied in both positions.

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(B) Hip

Mobilization

271

is then instructed to abduct the thigh to resist the clinician's pressure of adduction for

10 seconds and to relax. Further adduction is then coaxed,

and the above process is repeated three to five times. Maitland6 describes a similar technique. The thigh is maintained in flexion/adduction as it is moved through an arc from of flexion (Figure

6-21A). An

90 to 140 degrees

abnormal arc of motion is indicated by a

painful restriction somewhere along its length. At such a point, thigh flexion can be advanced painlessly only if the thigh is abducted slightly. This is represented diagrammatically in Figure

6-21B

as a small peak in

the flexion/adduction arc traced by the knee. Mobilizations of various grades are applied at the point along the arc that is restricted and pain­ ful. Maitland6 describes three methods to use when approaching the painful point in the arc during mobilization. The first is to adduct the thigh directly into the center of the painful point, wherever it lies on the arc. Grade IV mobilizations can be used to increase the range of adduc­ tion at this painful point. The second method entails holding the thigh in the flexion/ adduction position but starting below the level of the painful point in the arc. While maintaining this combined position, the clinician flexes and extends the thigh in such a way as to "rub" back and forth over the painful spot along the arc (Figure

6-21C).

The amount of adduction pressure needs to be

monitored to create as little pain as possible. The third method is a combination of the first two and seems to be the most important.6 It has two parts. The thigh is adducted toward and just below the painfully restricted part of the flexion/adduction arc and then extended (Figure

6-210).

From this new position, the movement is re­

versed by flexing the thigh just to the level of the painful point and then abducting it back to the starting position, nudging the painful point from the opposite direction. The second part of this mobilization is the mirror­ image maneuver of the first part in that it moves toward and above the painful point in the arc as the thigh is flexed, rather than extended, upon meeting the painful restriction. This movement is then retraced by extend­ ing the thigh along the arc to the painful point and abducting it back to the starting position. This whole maneuver is repeated again, nudging the painful point first from below and then from above, observing for any change in signs and symptoms. Abduction. A position similar to the Patrick-Fabere test can be utilized to mobilize hip abduction. The only difference is that the foot of the flexed and abducted leg is placed along the medial aspect of the opposite knee, resting on the table. The clinician then oscillates the hip joint into abduction by

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PELVIC LOCOMOTOR DYSFUNCTION

A

continues

Figure 6-21 Combined flexion/adduction. (A) Normal arc traced to where knee has to be abducted back and forth over p ainful point. and below

(B) Bump in arc p oint. (C)

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-

on Mobilizati

273

p

u


-0


?

0

.S ....

C

0 u

;:j J,


�

.':9 ....

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PELVIC LOCOMOTOR DYSFUNCTION

pressing the knee toward the table. The opposite ASIS is supported firmly but comfortably (Figure 6-22). A facilitation technique can be performed using this same positioning. The patient presses the knee up against the clinician's hand for a count of 10 seconds. Upon relaxation, the clinician coaxes the knee closer to the table. This is repeated three to five times. Medial and Lateral Rotation. Even though rotation here is meant to ap­ ply to the hip joint, in reality it describes the motion occurring around the femoral shaft. A roll-and-slide movement actually occurs at the femoral head in the acetabulum. In other words, the baJl-like femoral head is not neatly spinnin g around an axis in the acetabular fossa. This is because the femoral head is offset from the femoral shaft's axis by the femoral neck. Medial hip rotation is usually more commonly involved than lateral ro­ tation, but assessment ultimately determines which motion or motions to treat. Three positions can be used to mobilize medial and lateral rotation, depending on the joint signs and symptoms.

Figure 6-22 Hip Abduction Facilitation

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Mobilization

275

In the first position, the patient is supine, with a pillow or roll placed under the distal thigh to relax the hip in a few degrees of flexion (Figure

6-23). The clinician grasps above and below the knee joint and gently rolls the knee medially from the neutral position, using the appropriate grade mobilization. This is a very important technique for treating painful hip joints when using grade I and II mobilizations.6 Gentle rolling of the thigh medially relaxes the patient, affords effective pain relief, and prepares the joint for further mobilizations. The knee can also be rolled laterally if so indicated by joint signs and symptoms.

Figure 6-23

Medial hip rotation mobilization. Note towel rolled under knee.

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PELVlC LOCOMOTOR DYSFUNCTION

A

B

Figure 6-24

Hip rotation, supine at 90 degrees flexion. (A)

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Lateral. (B) Medial.

Mobilization

277

The second to use for medial or lateral rotation is with the pa(Figure but with the hip and knee flexed to 90 tient TIle clinician supports the lower limb at the knee and ankle. By swinging the lower laterally around the axis of the situated femur, he or she rotates the femur medially. The reverse movement is used for latmobilization eral femoral rotation. The is ing on joint and symptoms. the prone and The third position involves placing the knee to 90 The clinician is on the same side and hand with his or her caudal hand. His or her grasps the the lower contacts and the internally. To he or she rotates the leg medially. Laterally femoral rotation, the leg is muscle and the sacroiliac joint. also stretches the The clinician stands on either Extension. TIle patient is placed side of the patient and grasps the flexed knee with his or her caudal hand. trochanter while he or she lifts His or her other hand contacts the the thigh off the table to extension This move is lesser can be best for grade IV mobilizations. If extension is performed in the position by supporting the knee and heel so that the hip and knee are in slight flexion (Figure 6-27). Lowering the knee to toward the table and lifting the heel away from the table allow the as gravity can be toward neutraL If the patient is extend the with the involved side close to the thigh and leg are then lowered off the table with edge of the table. mobilizing oscillations. Mobilization

Movement

refer­ technique we are of the neck to the axis of the femur. Due to the inclined in relation to the femoral true distraction of entails can be performed in directed mobilization. This prone pOSitions. Patients seem to relax more in the prone the lower just position, the clinician very with both hands. The is and tractioned along the axis of the femur 6-28). The tracthe tion can be sustained and combined with muscle facilitation by patient resist the traction gently and inhaling Upon exhaling, the Long-Axis Extension in Neutral, In this

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PELV1C LOCOMOTOR DYSFUNCTION

A

6

Figure 6-25 Hip rotation, prone, (A) Meclial. (6) Lateral.

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Mobilization

279

Figure 6-26 Hip Joint Extension Mobilization

( Figure 6-27 Supine Hip Extension Mobilization

patient is instructed to relax, and the traction is gently increased. The movements can also be oscillated according to joint signs and symptoms. This is an excellent technique to reduce joint irritability and pain if done gently with traction or lower-grade mobilizations. Caudal Glide in Flexion. The patient's hip is flexed to 90 degrees and the knee is flexed fully, if this is tolerable. The clinician kneels next to the

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280

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 6-28 Hip joint long-axis extension. (A) and (B) demonstrate different holds.

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Mobilization

281

and wraps his or her hands around the most hip, proximal aspect of the patient's thigh, encircling both the lower and If knee flexion is limited, the lower thigh or just the thigh (Figure over the clinician's near shoulder (Figure 6-29B). The can be the mobiliand clinician's body should move as one zation. The movement entails and (toward the pulling caudally with the hands clinician's shoulder The hands are almost performthe knee or distal femur slightly a motion. thigh is flexed to 90 ��,.. Lateral Glide with Flexion. The The clinician is to the side the hip joint. The The clinician encircles the proximal thigh with both hands the clinician's hands, shoulder, and chest thigh is while the clinician's trtmk and the move as one unit. As in by the above technique, a scooping action is orly (floorward) and laterally (Figure The above two techniques can also be used as thrust (grade V) n.��.

The clinician medial distal His or her over the most proximal femur, on with distal thigh is raised very slightly as trochanter. The trochanter toward the hand presses the the clinician's table 6-31). Posterior Glide.

Sacrococcygeal Joint This joint is often the site of either from local or reby ferred from the lumbosacral area. It is important to assess the palpation for tenderness in relation to imparted movements. Care must be from movement versus from palpation taken to pressure. Maitland! discusses the use of to the coccyx and transverse Contact on the coccyx is taken using the thumb pads, and mobilizing oscillations are enough to directed in various directions. The thumbs must be

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282

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 6-29

Caudal glide in flexion. (A) and (B) demonstrate different holds.

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Mobilization

Figure 6-30 Lateral Glide with Flexion

Figure 6-31 Posterior Glide

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283

284

PEL VIC LOCOMOTOR DYSFUNCTION

Figure 6-32 Anterior Glide

contact the coccyx, especially the lateral aspect when one is doing trans­ verse mobilizations. Gentle movements are used and modulated accord­ ing to joint signs and symptoms. States9 mentions a manipulative technique that can be adapted here for mobilization (Figure

6-33).

The patient lies prone, and the clinician places

his or her cephalad hand on the patient so that his or her thumb covers the coccyx and his or her fingers spread laterally over the iliac crest. The cau­ dal hand covers the thumbnail with a pisiform contact, and the fingers wrap around the cephalad hand's wrist. Tissue slack is removed in a ceph­ alad direction in such a way that the thumb slides onto the sacrococcygeal joint. Pressure is then applied in a cephalad and downward direction for mobilization. States9 mentions using a thrust technique, but this should be performed with care. Lewit7 describes a muscle facilitation technique using the gluteus maxi­ mus muscle to aid in mobilizing the coccyx (Figure 6-34A). The concept entails contracting the gluteus maximus muscle to facilitate levator ani muscle contraction. The patient is prone, and the clinician stands at the level of the patient's knees, facing cephalad. The clinician's hands are crossed to contact each buttock at the level of the anus. The buttocks are

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Mobilization

285

A

B

Figure 6-33

Sacrococcygeal mobilization. (A) Thumb contact reinforced by (B) pisiform contact.

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286

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 6-34 Postisometric relaxation of gluteus maximus muscle. (A) Clinician as­

sisted. (B) Patient home exercise.

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Mobilization

287

separated to tension by the clinician, and the patient is instructed to press the buttocks together for

10 seconds. The patient inhales and upon exhal­

ing is told to relax and "let go." The buttocks are then stretched further apart by the chnician, and the procedure is repeated three to five times. Afterward, the coccyx should be less tender to palpation. Patients can be instructed in performing this on themselves for home use (Figure

6-34B).

Another effective technique has the patient lying on his or her side (Fig­ ure

6-3SA). The clinician faces the patient from the front, leans over the

pelvis, and contacts the medial aspect of the "down" side gluteus maxi­ mus muscle with his or her caudal hand. The contact can be made as close to the coccyx as possible with the thenar eminence or pisiform. Traction is made toward the table, and a soft tissue pull is generated via the gluteus maximus fibers affecting the coccyx. Either sustained traction or oscilla­ tions can be used, depending on which is better tolerated by the patient. The patient can also assist by gently contracting the gluteus maximus against resistance while he or she inhales. Upon exhahng, he or she is told to relax, and pressure is applied to traction the gluteus maximus when relaxation is sensed. The patient is asked to lie on the other side, and the procedure is repeated. However, instead of turning the patient over, one

A

continues 6-35 Lateral traction on gluteus maximus muscle. (A) Downward trac­ tion. (B) Upward traction.

Figure

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PELVIC LocOMOTOR DYSFUNCTION

Figure 6-35 continued

B

can simply contact the medial part of the gluteus maximus on the "up" side and traction upward (Figure 6-3SB). Either a pisiform contact or fin­ ger contacts can be used to traction upward. Although rarely indicated, if the above teclmiques fail to bring about relief, then the coccyx may need to be mobilized per rectum. A well-lubri­ cated gloved finger is gently inserted into the rectum as per the protocol for performing a digital rectal examination. The coccyx is gently held be­ tween the intrarectal finger and the externally placed thumb. Gentle, mo­ bilizing oscillations are attempted in flexion, extension, side tilt, and long­ axis extension.

Chapter Review Questions •

What is the difference between mobilization and manipulation?

•

What are passive physiologic movements?

•

What are accessory joint movements?

•

What are joint signs?

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Mobilization

.. What are the d ifferent

289

of joint mobilization? conditions mobilized

.. How are painful, acute

from

chronic ones? movements to test

.. What is one of the most in

and treat

joint conditions?

.. Discuss the various

to mobilize the "e>,'rf'l['()(Y" ,,:'<'e>

REFERENCES 1. Maitland GO, Vertebral Manipulation, 5th ed. Boston, Mass: Butterworths; 1986.

2. Grieve GP, Common Vertebral Joint Problems. New York, N Y: Chu rchill 3. Bourdillion .IF, Day EA.

1 98 1 .

4th ed. Norwalk, Conn:

1 987. Medicine, Baltimore, Md: Williams & Wilkins; 1989,

4 . Greenman PR. Prinri,,,/p<

Chiro-

and Chiropractic Technic:

5. Schafer RC Faye LJ, Molion

Huntington Beach, C a l if: Motion Palpation Institute; 1 989. 6, Maitland GO, Peripheral

2nd ed. Boston, Mass: Butterworths; 1 977.

7, Lewit K. Manipulalive

Boston, Mass:

B uttenvorths; 1985. 8, Hackett GS, Join t Charles C Thomas,

Relaxation Treated by Fibro-osseous Proliferation. Springfield, III: 1956,

9. Sta tes AZ. Spinal and Pelvic Technics. 2nd ed , Lombard, Ill : National College of Chiroprac­ tic; 1967.

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Chapter 7

Manipulation

Chapter Objectives •

to describe what characterizes a manipulable lesion

•

to describe what

•

to review grade VI mobilizations

when a

is

•

to discuss the audible click sound

•

to discuss slack removal in joint manipulation

is a ner who wishes to become

in its use.

A weekend course in

does not qualify someone to

manual

tions any more than singing in the shower Manipulative

demands is

to work by

at

(1)

hypertonic muscles; and

one for a concert tour.

experience, and ability.

(3) disrupting articular or periarticular

adhesions.] Fibrosis of the periarticular tissues can be a result of trauma and inflammation, immobilization, or is defined as a

at the end of the usual

pulse directed at restoring joint range of motion, is

associated with an audible "click,"

of its speed, is not under the relation to the four

disease. low-amplitude thrust or im-

of

control of the patient. In the

290 Copyrighted Material

291

IV mobilization in

V.1t is similar to a

and position in the

but differs in the velocity of of mobilization """'''''''U�'") is a small-amplitude mobi-

A sixth

lization (IV) applied after a grade V

has removed the joint's This is further explained later in

elastic barrier (Figure

or long-lever. Short-lever

techniques can be

entail taking direct contacts near the

to be moved,

and transverse processes, whereas long-lever techniques take trunk and limb movements. Long­

of leverage gained

are performed in such a way as to localize a A classic

most shoulder is stabilized or

to create a moment

I-'L�<>v"'"

the thigh as the long lever aids in joints. There are numerous re­ on which joint and which of movement restriction are treated. WHAT CHARACTERIZES A MANIPULABLE LESION?

lesion. Among these are sublux-

Various terms describe the

dysfunction, somatic mental dyskinesia. A Since u">.:,u."",,

fixation, joint

characterize a

is a force that the mobility characteristics

.. ..

and

to restricted

and

the lesion should be assessed. In this

Elastic Barrier

II

VI Note that grade VI is a mobilization

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292

P ELVIC LOCOMOTOR DYSFUNCTION

Figure 7-2 Classic Side-Lying Positioning for Sacroiliac Joint Manipulation

regard, decreased regional and intersegmental motion should be a charac­ teristic of the manipulable lesion that is looked for. Included with this is a lack of joint play, termed joint

dysfunction, which is a central feature of

the

manipulable lesion. Soft tissue changes such as thickening or atrophy of the periarticular tissues can be present (see Chapter 4, the section "Soft Tissue Changes"). Pain and localized skin hypersensitivity also character­ ize the manipulable lesion, as do muscle spasm, especially if localized, and muscle imbalances. A positive response to manipulative treatment is a logical but not too often thought of characteristic. WHAT HAPPENS WHEN A JOINT IS MANIPULATED? A joint's total range of motion is divided up into three zones of move­ ment: active, passive, and para physiologic (Figure 7-3). An elastic barrier of resistance separates the joint's passive range of motion from the paraphysiologic space. The limit of anatomical integrity represents the ul­ timate barrier: that of the restraining soft tissues in the form of a joint cap­ sule and ligaments. Manipulation entails moving a joint with a high-ve­ locity, low-amplitude thrust that is outside the patient's control to

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Manipulation

:

293

'-'

'a'

Passive

0

0(1) 'iii

g >-0.. -am

Active

�


Exercise

c 0

Stretches

and Mobilization

:

N =>

0.. 'c <1l ::2:

EB

AB

7-3 Range of motion, EB, elastic barrier of resistance; AB, anatomical barrier.

yet accurate enough to enter the paraphysiologic space after all the "slack" is removed. "Slack" is the motion in the active and passive that needs to be taken up

to

the elastic barrier. It is

the sudden movement beyond the elastic barrier

resistance that is usu-

associated with the "click" sound common to manipulation. However, further movement would

upon the integrity of the joint's

soft tissue and risk a

the distance traversed during

is very

on the order of V8 in. Manipulation

is usually associated with an audible click or

due to a joint cavitation

phenomenon. Exercise works within the active fects more the passive

and

of

af-

neither affects the paraphysiologic

space. It is manipulation that affects the paraphysiologic space. MennelP states that exercise,

a

cannot restore joint

involuntary joint motion. The same can be said for passive niques. In fact, MennelP states that exercise will delay the recovery of a dysfunctional joint if the

is not restored first.

a

functional joint too soon in treatment can cause painful exacerbations and reflex muscle reactions. Exercise

is most important, even manda­

tory, especially in locomotor disturbances. However, it should be used only when joint

has been restored. To exercise without rp<,t(Yr,n

play would be

hinge by repetitively

door back and

squeaking and grinding.

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PELVIC LOCOMOTOR DYSFUNCTION

294

so, it occurs at the expense of the

movement is attained, and

It would make much more sense to oil the

structural

and then work it in with movement-movement that would be eter, and more in

with the hinge's structure. In the above analthe squeaking and grinding are pain, and

ogy, the movement is

the lubricating oil is the restoration of joint play. the

in the overall treatment of joint and joint

(paraphysiologic) ranges of motion must all be assessed.

Often the active and

ranges of motion are seen to increase after a

manipulation. A common example is an improvement on the raising test following a sacroiliac joint or hip jOint manipulation. This is muscles

due to tension in the

relaxed in response to are

arthrokinetic reflex action. Joint stimulated

to be

manipulation, and this in turn creates

muscle tone

in the muscles that serve the joint.

In 1947, two anatomists from Great

Roston and

searched joint

thrust.

the �HJ'V"'�

reaction to axial traction. The results were

examination the

plotted, and a load separation curve was graphically displayed. Tension and joint

was plotted on the horizontal

in millimeters

was plotted on the vertical curve illustrated by

The load the joint

is taken up, tension

7-4 demonstrates that as and at the end of a

sive range of motion, a sudden gapping of the facet surfaces occurs coexistent audible joint click. fluid and concluded that the

Unsworth et al5 evaluated the crack sound was due to a cavitation carbon dioxide that forms and

involving a bubble of (cavitates). A radiolucent intra-

articular space is also produced after the manipulation. It takes 20 minutes for the

to be absorbed and the joint to stabilize. During this is

audible click will not be heard if a second

unstable due to its

the joint is considered

the

force. Normally, the intra-articular is

an In

of synovial

and affords coaptive stability. For example, the

femoroacetabular joint can be

of all its

capsular, and

attachments, and the femoral head will still remain in the ac­ etabular

It is only upon

a hole through the acetabular floor

from inside the pelvis that the femoral head

falls out of the socket as

the subatmospheric coaptive force is released. In this regard, Sandoz6 states that it is good

to rest the joint approximately 20 minutes

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295

Manipulation

6

Reduction

S

(

,,/

e' ,§.

4

/

c:

,g !!! co

�

./

./

/

S,4mm

/"

Repeat Manipulation

4,sm

Paraphysiologlc Zone

"Crack" Join! Pathology (Sprain. Medical Subluxation, Dislocation)

3


Preliminary Tension

2

1,8mm

Resl

Limit of Anatomic Integrity

Load (Kg

z

NllO)

curve. An audible "crack" is heard at 8 of tension as and the paraphysiologic space is entered. Small of surfaces line denotes the release of tension, Note that the does not return to original The middle curve a second attempt at after the first one. No crack sound is elicited, surfaces are

Source:

from Chiropractic

by T.F.

D.H. Peterson and © 1993,

Lawrence, p. 289, with permission

manipulation before

activities are

lie down during the joint's

to have the

rptr",.·tn,,,,,

tivity for that time. Sandoz6 summarizes that the

events occur at the moment of

(1)

intrusion into the joint surfaces;

(2) an audible

a sudden

sound; and

diolucent space in the joint. Sandoz6 also mentions that

active and

after a manipulation as the

sive ranges are increased is added to them. main cautious when

of the

(3)

a

comments that one must reduring its

due

to the absence of the protective elastic barrier. The only barrier of resis-

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296

PELVIC LOCOMOTOR DYSFUNCTION

nrp'<:Pf1t in

such a situation is the limit of anatomical Force­ can risk injury to the soft elements of the

joint. GRADE VI MOBILIZATION

when one The loss of the elastic barrier can be used to an wants to mobilize manipulate!) these soft tissue restraints after a ma­ nipulation. Without the elastic barrier the capsuloligamentous tis­ sues can be directly stretched. Although the term is not used in the V I refer to this as a grade VI mobilization. The non removes the elastic and a gentle, oscillation afterward can stretch the articular tissues. Thus, a grade VI mobilization is analogous to a grade IV mobilization performed after a (V). This is particularly effective in chronically stiff hip joints, extension maneuver described later. Grade VI mobilizations sacro-ilio cross and anterior or posterior torsion techniques are also useful in chronic sacroiliac joint dysfunctions. Aside from the mechanical of a manipulation, it is ,.orA".'n, that effects can be attained via initiates It is thought that stimulation of the joint to the central nervous system, where neural connecan afferent effects to other structures. Kon-8 discusses how the nervous is physiologically situated between the somatic and visceral systems, possibly allowing one to affect the other. He nervous facilitation of the feels that chronic due to a somatic dysfunction (subluxation, fixation, somatic lesion) can of disease. It is not unusual for the create visceral enced manipulative to observe functional locomotor (somatic) function. in response to dyspareunia, enuresis, and functional bowel disturbances have been known to for which paafter treatment for joint at sites distant from the in the locomotor of midthoracic or cervical muscle spasm or primary area motion improving after administration of a sacroiliac manipulation. are mediated by the all-important nervous ,V'''''''"TI should not be as motion in a restricted Joint manipulation helps to reestablish the biomechanics of the while simultaneously stimulating the nervous locomotor via reflex

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Manipulation

297

joint to the nervous system on a reflex basis.

means of

functional jOints and soft tissues mal afferent

the nervous system with abnor-

that can

Such

mechanisms can be referred

and subsequent

can reduce its abnormal afferent beneficial

causes a

vasomotor

Manipulating a dysfunctional

and even subtle visceral effects and have

undesirable

muscle

input into the

even if it is not observable on the exterior.

WHAT ABOUT THE AUDIBLE "CRACK"? of a

audible "crack" during a manipulation is

Many manipulators feel that for to gap the

results it is

until it clicks. Others feel

it is not. In has been found to be

Mierau et rior to mobilization in

mobility. We need to keep to passive

rate the terms mobilization and manipulation. The former the

movements performed up to but not The latter entails

the paraphysiologic

ated with an audible

is

Similarly, Hadler et aJ15 showed than with mobilization.

It is commonly observed that

improve even when the manipu-

lative technique is not associated with an audible crack. Certain patients have

that

how often

of the force

do not "crack,"

are manipulated, or the expertise of the manipulator. joint's range of motion and idly when the

symptoms seem to improve more rapshould result in a

on every

the first

joint

is cavitated. That is not to say that

lation

the

" especially on

Nor is it to say that an audible click should be the sole

However, somewhere along the patient's clinical course, if manipulation is the cavitation phenomenon is should be "caressed" and

to move. If it never

can be attempted, but brute force

it does not, further be used,

welcomed.

if only to fulfill the near-neurotic whim of hearing an

audible click. Some manipulative practitioners have been accused of too rough by infamous "pop."

too

and fixated actually invite correction. who finds himself in a

in order to hear that

a some are too rough.

a practitioner

match with a

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that are stiff 1601b

298

PELVIC LOCOMOTOR DYSFUNCTION

In chronically stitt jOints, manipulation should be used carefuny. Years

of poor joint function, adaptive shortening of periarticular tissues, and fi­ brosis do not readily reward the practitioner with an audible click, at least not in the beginning. This is common in problems of the sacroiliac and hip joints, where some of the largest and most powerful ligaments in the body are found. Several visits over a few days using mobilization first and then manipulation may produce a joint cavitation. Meal and Scott16 mention how weather can affect the ability of a joint to make an audible crack. They observed that when a low-pressure weather system was present, the joints under study cracked more easily, with less tension and creating less noise.

Question for Thought How is it that weather can affect joint conditions?

SLACK REMOVAL Most of the work in manipulation involves taking all the slack out of the surrounding tissues while guarding neighboring joints that do not need to be manipulated. When a joint is taken to the end of its passive range of motion, right up to the elastic barrier, all slack is said to have been re­ moved. This "preparation" of the joint is culminated by the grade V thrust itself, which is directed at the joint, not the entire patient. More specifi­ cally, it is directed at the joint restriction. The amount of force needed is minimal, but the speed of execution is rapid so as to overcome the inertia of the restriction. The move incorporates finesse and feel rather than force. The quick, short impulse allows safe entrance into the paraphysiologic zone. The importance of removing all tissue slack and taking a joint to tension before manipulating it can be illustrated by a simple experiment (Figure

7-5).

Suppose a bedroom door is slightly stuck in its doorjamb and we

want to open it, but we want to do it in an unusual way. We tie a strong industrial rubber band to the door knob at one end and anchor the other end to a crank. Next, we crank up the tension in the rubber band just to the point where the door will fly open. The band is so tense that if we were just to flick it with our finger, the door would immediately fling open. Do you think it would matter from which direction we flicked the rubber band? Not really. As long as the rubber band was "preloaded" to the threshold tension needed to open the door, and as long as the direction of that ten­ sion was applied correctly, the door would fling open with minimal force

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Manipulation

299

uU Figure 7-5 Door analogy and slack removal. Arrows indicate the various direc­ tions of applying finger flick.

in the direction we wanted. What the finger flick would actually be doing would be supplying us with just enough force to overcome the inertia holding the door closed. The finger flick itself would not require tremendous effort, nor would the direction of its application to the rubber band be important. The only trung that would be important would be that it occurred, but in conjtmc­ tion with the correct preload tension. Most of the effort in opening the door would be generated by the rubber band. So, too, is slack removal related to joint manipulation. This is especially true when joints sur­ rounded by large, powerful muscles and ligaments are manipulated. Most errors in manipulation arise from the inadequate removal of tissue slack. Unforttmately, many people apply too much of the effort to the ac­ tual impulse thrust. The amotmt of tissue tension generated during slack removal is inversely related to the amotmt of impulse thrust required. If

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300

PELVIC LOCOMOTOR DYSFUNCTION

little slack is removed prior to a manipulation, one of two things will oc­ cur. Number one, the thrust will be dissipated in the extra slack that is still present, and the joint's paraphysiologic space will not be reached. Num­ ber two, the extra slack needing to be taken up will most likely be incorpo­ rated with the impulse thrust. This creates a high-velocity, high-amplitude thrust from the active and passive ranges of motion right up to and through the elastic barrier, resulting in a painful manipulation. This as­ sault and battery must be avoided at all costs. Problems with manipula­ tion arise when the overzealous or impatient practitioner takes the joint through active, passive, and joint play ranges all in one quick movement. The joint mechanoreceptors react too briskly to be "fooled," and reflex muscle guarding is usually recruited, resulting in an unsatisfactory ma­ neuver, to say the least. Traction and slack removal should be performed slowly and gently, with the practitioner being astute to any reaction from the joint, muscles, or patient in general. Needless to say, an uncomfortable position is not conducive to a relaxed patient. It is good practice to ask the patient if he or she feels comfortable just before the impulse thrust is delivered. Be mind­ ful of the patient who may be too embarrassed to volunteer this informa­ tion. The goal is to generate just enough tissue tension around the joint via slack removal so that a high-velocity, low-amplitude impulse is all that is necessary to "open the door." The vulnerability of the patient should be recognized and respected at all times, together with the realization that we manipulate living, feeling human beings, not just restricted painful joints.

CONTRAINDICA TrONS Mobilization and manipulation are indicated when one determines that a joint's accessory or joint play movements need to be restored. According to Maitland,2 hypermobile joints may need to be mobilized (not manipu­ lated!) to reduce pain and increase their function, not to increase their range of motion. In this regard, grade I and II mobilizations are used to stimulate mechanoreceptor activity and reduce pain. Manipulation, on the other hand, should not be used on hypermobile joints. Generally, mobili­ zation and manipulation are used to increase joint motion. However, there are instances when mobilization and manipulation techniques are con­ traindicated.I7 These can be grouped into absolute and relative contra­ indications and are listed in Exhibits 7-1 and 7-2. There are usually no arguments over the absolute contraindications, but the relative contraindications carry some disagreement among field prac-

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301

Exhibit 7-1 Absolute Contraindications to Manipulation

•

Malignancy

•

Infections

•

Fractures

•

Bone disease

•

Ruptured

•

Acute inflammatory arthritis with signs of cord compression

• •

titioners, depending on their experience. Relative contraindications de­ mand careful assessment if manual treabnent. What

are to be considered for

be a relative Conditions

clinician may not be one at all to an

such as osteoarthritis, osteoporosis, and pregnancy, although not contraindications, should be handled with care. Problems can be avoided as long as the movements are gentle and match the

of the joint mean just that-

structures treated. Small-amplitude thrusts or

at this

of movement. Control and

small %-in

cause difficulties.

any increase in pain

thrust demands reassessment before following

prior to

with a manipula-

tion. Women in the third trimester of

need to be handled judi-

rotation movements to

ciously.

pelvis and low back should

avoided. The imminent threat of

be

also

Osteoarthritis often responds well to gentle mobilizations and manipu­ lations. Commonly seen are plete with

pain,

throsis. These

with osteoarthritis of the hip, com-

flexor gait, and have usually been told that

Exhibit 7-2 Relative Contraindications to Manipulation

•

Bone demineralization

•

Bilateral root signs

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evidence of arwill have to learn

PELVIC LOCOMOTOR DYSFUNCTION

302

and are placed on anti-intlamma-

to live with their arthritis and

may

medications. Some are even told ment surgery. Yet very

some, if not many, re-

to manual

In addition to joint are

manipulations, soft tissue

mobilizations and np,"p"'''''H'"

total hip

their poor

and useful.

Obviously

ankylosis needs to be ruled out in the case of sacroiliac

joint manipulation, if for no other reason than the futility of trying to ma­ a fused joint. Plain radiographs are not sufficient enough at times to

sacroiliac joint

where

axial

'VA.UV)<"

phy is. What about the patient who is apparently in cation of manual techniques?

too acute for the appli-

pathology, this can treated as a relahowever,

on the clinician's

tive contraindication

common sense should prevail, and

such as

and medication, can be used. Grade I and II in

over a 2- to

pain and

can be accomplished

patiently

What may seem to be an miraculous maneuver to fix the acute

more often

untimely, painful, and SACROILIAC JOINT MANIPULATIVE

The more common sacroiliac joint manipulations are carried out in the The type nation

restriction found on

how to

the

for

sessment of sacroiliac joint motion, the

is asked to raise one knee at

a time while several bony landmarks are monitored via palpation. Attention is paid to

raised and which palpation landmark is observed

to be

iliac rule of thumb used to is to

in

sacral

or sac-

the patient properly for position the standing examina-

tion position in which the movement restriction was found. The palpation landmark found restricted in its movement is contacted for the thrust.

Upper-Pole Flexion Fixation for

a case in which the upper aspect of the right sacroiliac

joint is restricted in tlexion. As the examiner

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and observes for

303

Manipulation

iliac

movement of the right posterior

(PSIS) in relation to

he or she will notice lack of movement when the

the sacral

knee

7-6A). The examiner may also notice

motions made the buttocks out

the

and/or bending the weight-bearing knee. To that

that best

in a

the

manipulate this dysfunction, the clinician

In this case, the patient is

on the

flexed (Figure

The

is contacted and thrust upon to create motion in the upper the

sacroiliac joint. Reassessment should demonstrate the

to move more

when the right knee is raised.

Someone using the static model of "bone out of place" may be inclined to

"Why contact the PSIS from the

it

to ma-

Did not the motion assessment find a lack of

rior and inferior movement of the PSIS? Don't you want it to move instead?"

riorly and

to

a bone

that is out of place. We are

of motion. By

the PSIS, we gain to allow motion to occur. Second, moval determine the motion to be induced, In to

the ilium more anteriorly

case, we are not

taking a posterior contact on the

although it seems so. Instead, we are trying to impart motion to the thrust,

joint with an

The

of its static neutral and the patient's

thrust overcomes the

VV"HHJ'

removal, strongly favoring flexion, allow the motion to occur. Upper-Pole Extension Fixation of the

If the upper

sacroiliac joint is fixated in

the

examiner will notice a diminished excursion of the sacral tubercle in rela­ tion to the right PSIS when the patient lifts the left knee (Figure this

dial to the downside PSIS (Figure tion is with the left

To

the clinician contacts the sacral base by

The

the patient i n the

flexed

7-7C). The clinician should be

j./V"HHJ�

contact. Reassessment should when the patient

the sacral

raises the left leg.

Lower-Pole Flexion Fixation To assess a

flexion fixation of the right sacroiliac inferior iliac spine

multaneously while the

the

and sacral apex are palpated si-

raises the right knee (Figure

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7-BA), The

304

PEL VIC LOCOMOTOR DYSFUNCTION

A

B

Figure 7-6 Right upper flexion fixation. (A) Palpation. (B) Manipulation.

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Manipulation

305

A

B

continues Figure 7-7 Right upper extension fixation. (A) Palpation. (B) Point of contact. (C) Manipulation.

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306

PELVIC LOCOMOTOR DYSFUNCTION

Figure 7-7 continued c

examiner should observe the PIIS to move inferiorly and slightly laterally in relation to the sacral apex contact. Lack of this motion indicates joint fixation. To manipulate this joint restriction, the clinician contacts the right PIIS or ischial tuberosity with the patient in a left side-lying position (Fig­ ure 7-88). This essentially reproduces the standing palpation test in the side-lying position. Reassessment should show the right PIIS to move more inferiorly and laterally. Lower-Pole Extension Fixation

A lower-pole extension fixation is assessed by simultaneously palpating the right PIIS and sacral apex while the patient raises the left knee (Figure 7-9A). The sacral apex should move inferiorly in relation to the PIIS con­ tact. Lack of this motion denotes a loss of extension motion in the right lower pole. A pisiform contact is made on the downside of the sacral apex (Figure 7-98). The patient is positioned in the right side-lying posture with the left thigh flexed (Figure 7-9C). Reevaluation should demonstrate in­ creased inferior movement of the sacral apex when the patient lifts the left knee.

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Manipulation

A

B

Figure 7-8 Right lower flexion fixation. (A) Palpation. (B) Manipulation.

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307

308

PELVIC LOCOMOTOR DYSFUNCTION

A

B

continues Figure 7-9 Right lower extension fixation. (A) Palpation. (B) Point of contact. (e) Manipulation.

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Manipulation

309

Figure 7-9 continued c

In all the above manipulations, the thigh is maximally flexed to "preload" the sacroiliac joint. The patient's arms are crossed in front of the chest. The clinician grasps the patient's forearms or uppermost deltoid with his or her cephalad hand and tractions headward. The impulse thrust is delivered only when every trace of "slack" is removed and the patient is relaxed. The joint must be taken to tension before manipulating. The pisi­ form aspect of the caudad hand makes the contact on the anatomical land­ mark that did not move during the motion assessment. In the case of large or flexible patients, the leg and thigh are placed in front of the clinician's knee to facilitate slack removal (Figure 7-10). In a "body-drop" impulse, the clinician raises his or her torso a few inches and drops it suddenly to add inertia to the final impulse. The im­ pulse itself is the final motion of the body drop and fine-tunes the amount of thrust delivered. The action is analogous to the workings of a bullwhip. The arm of the lion trainer and whip handle move through a large range of motion as they send the whip through its travel. The tip of the whip is accelerated at the last second through a much smaller range of motion as its direction of travel is reversed. The snapping sound is actu­ ally a mini-sonic boom as the tip of the whip is accelerated immensely.

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310

P ELVIC LOCOMOTOR DYSFUNCTION

Figure 7-10 Alternative Side-Posture Position

Similarly, the manipulator'S impulse is the fine-tuned terminal motion of the body drop. A series of two to three thrusts graded in increasing intensity are deliv­ ered until the joint cavitates. The clinician is trying to coax the joint to move. The first thrust is light, followed by one of moderate intensity if a joint "release" was not experienced. If the joint still did not release, one last graded thrust of slightly more intensity can be tried. If a release is not felt or heard, the joint should be reevaluated for motion and not manipulated further. Often in such cases more motion is perceived on reassessment pal­ pation as a result of the attempted manipulations' acting instead as firm mobilizations. This format is better than trying to release the joint with one big thrust. Generally, if all joint and soft tissue slack is removed, the joint manipulates very easily with minimal force. Sometimes the joint releases just from removal of all the slack. Posttreatment soreness can be expected in some cases, and the patient should be informed of this. Painful flare-ups can occur, commonly in pa­ tients who exhibit signs of an unstable autonomic nervous system, stress, or an irritable joint in the vicinity of the manipulated joint. A flare-up may also occur if a few of the joint fixations present were not manipulated, be-

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Mani pulation

311

ing left unattended only to cause continued adverse reactions in the locoFor

motor

if one assesses only the

missed

of the

important joint

for

or slow clinical

may create

For this reason,

it is important to check both the upper and lower poles bilaterally for flexhow much pain and disability a

It is

ion and extension

a

missed and then the other without regard to

on one side

assessment is asking for less

than optimal results. At the least, provocative testing can be done to iden­ tify the problematic side, followed by the knee-raising test to delinea te further the fixations

on that side. Provocative

vers that stress a

entails maneu-

symptoms. The three best

tests used are the

nr ,mfl�r"

and Yeoman's tests. If two

out of three of these tests are positive and localize the pain to the same joint, a

of confidence in lateralizing to the correct side of in­

volvement is provided. Prone

Upper-Pole Extension A more direct way to the (Figure

and

extension in the sacroiliac joint is to the thigh at the hip with the caudad

The PSIS on the fixated side is contacted with the cephalad

hand and thrust upon. The thigh is lifted to tension, and the impulse is delivered when all jOint slack is removed. The hip

needs to be taken

transmitted to the ilium via the

to its end range of extension. iliofemoral

(Y-ligament

Bigelow)

sacroiliac joint. Caution needs to be exercised because

the

this technique and the possibility of affecting the

Lower-Pole Extension To affect the lower pole, the patient positioning is the same as in the but the sacral apex is contacted with the

of

in these two

the manipulating hand is light and '-V'.AU,"F,' Supine

General Flexion A

flexion manipulation can be used in the supine position. It is

not specific to either the upper or lower aspects

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the sacroiliac joint. This

312

PELVIC LOCOMOTOR DYSFUNCTION

Figure 7-11 Extension Manipulation of Sacroiliac Joint's Upper Aspect

works well in patients who have difficulty assuming the prone or side­ lying positions, ie, pregnant women. With the patient supine, the clinician stands on the involved side at the level of the pelvis, facing headward. The patient's thigh is flexed to 90 degrees and is slightly adducted with the caudad hand. The cephalad hand cups the anterior superior iliac spine and presses toward the table, taking up any slack. As the thigh is flexed to tension, a light body-drop impulse is delivered through both hands (Fig­ ure

7-13).

Caudal Glide Quite frequently, patients present with a history of stepping into a hole unexpectedly and jamming the hip and back. A maneuver that is effective

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Manipulation

313

Figure 7-12 Extension Manipulation of Sacroiliac Joint's Lower Aspect

in this situation is a long-axis extension or distraction on the entire leg. To affect the sacroiliac joint, the straight leg is lifted off the table to 30 degrees and pulled with an impulse thrust (Figure 7-14). In addition to these techniques, any of the maneuvers demonstrated in Chapter 6 for mobilization can be implemented for manipulation by using a grade V thrust. In all of these and the following techniques, manipula­ tion is used when joint dysfunction or restricted motion is found during the examinahon. HIP JOINT MANIPULATION Side-Lying Long-Axis Extension The hip can be manipulated in long-axis extension by placing the pa­ tient in a side-lying position with the involved side up (Figure 7-15). It is used when long-axis extension in the hip joint is restricted. The uppermost thigh is flexed to 90 degrees at the hip, and the knee is flexed to allow the foot to rest behind the other knee. The flexed knee is adducted toward the floor. The clinician stabilizes the patient on the table with the cephalad

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314

PELVIC LOCOMOTOR DYSFUNCTION

Figure 7-13 General Flexion Manipulation

hand. The clinician then places his or her knee and thigh against the patient's knee and thigh. The caudal arm is straight, and the greater tro­ chanter is contacted with the heel of the hand. Slack is removed by tractioning the patient's thigh floorward with the clinician's knee and thigh. A body-drop impulse is made on the greater trochanter with the caudad hand to distract the femoral head from the acetabulum. Prone Extension This maneuver is performed like the prone extension technique for the sacroiliac joint except that the greater trochanter is contacted by the ma-

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Manipulation

315

Figure 7-14 Caudal Glide Manipulation, Sacroiliac Joint

nipulating hand. All joint slack is removed by extending the hip to the end range, and an impulse thrust is delivered (Figure 7-16). This is not weI! tolerated in osteoarthritic hip joints and should be used carefully.

Lateral Rotation With the patient prone and the clinician standing opposite to the side of involvement, the leg is flexed at the knee to 90 degrees. The lower leg is pulled toward the clinician with the caudad hand to impart la teral rota tion at the hip joint. The cephalad hand contacts the opposite-side greater tro­ chanter. With the hip held in extreme lateral rotation, a series of three to five impulse thrusts are made with the manipulating hand (Figure 7-17).

Long-Axis Extension In this maneuver, the leg is grasped just proximal to the ankle. The clini­ cian then tractions the leg in a long-axis direction to remove all slack and applies an impulse thrust, keeping the entire leg and thigh on the table (Figure 7-18). Patients are able to relax very well in this position.

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316

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 7-15 (A, B) Hip joint long-axis extension in side-lying posture. Note clinician's leg contact.

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Manipulation

317

Figure 7-16 Hip Joint Extension Manipulation

Supine Long-Axis Extension This is the same maneuver as the previous prone technique except that it is performed in the supine position (see Chapter 5, Figure 5-42C). It differs from the sacroiliac caudal glide technique in that the leg and thigh remain on the table. An impulse tractional manipulation is applied. It must be emphasized that these techniques are to be performed gently and do not entail gross tugging. These are excellent techniques to follow up with grade VI mobilizations. That is, after the elastic barrier has been removed by a grade V manipulation, small-amplitude mobilizing oscillations are used to stretch the articular tissues further. This is very useful in treatment of chronic hip joint stiffness.

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318

PELYlC LOCOMOTOR DYSFUNCTION

Figure 7-17 Hip Joint, Lateral Rotation Manipulation

Figure 7-18 Hip Joint Long-Axis Extension

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Manipulation

319

Caudal Glide at 90 Degrees Flexion

The patient is supine, with the thigh flexed to 90 degrees and the foot resting on the table. The clinician kneels beside the table on the same side and encircles the most proximal part of the thigh with both hands. If the patient's knee can fully flex so that the heel can touch the buttock, then the lower leg and thigh can both be encircled by the clinician. The clinician's shoulder is placed up against the mid- and distal thigh, and the hands, shoulder, and thigh move as one unit in a caudal direction to take up slack. At the point of restriction, an impulse thrust is given. The shoulder is pressed slightly headward as the hands scoop the proximal thigh floorward and caudally. This imparts a scooping movement to the tech­ nique (Figure 7-19A). A

continues Figure 7-19 (A) Hip joint caudal gLide at 90 degrees flexion. (B) Lateral glide.

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320

PELVIC LOCOMOTOR DYSFUNCTION

Figure 7-19 continued

B

Lateral Glide at 90 Degrees This technique is similar to the one above except that the direction of traction and impulse is lateral. To do this, the clinician faces perpendicular to the thigh and encircles its most proximal aspect. The shoulder is placed up against the middle and distal aspect of the lateral thigh, and the hands, shoulder, and thigh move as one unit laterally. The shoulder leverages slightly medially as the hands pull slightly floorward and laterally. This imparts a lateral scooping action to the maneuver (Figure 7-198). Posterior Shear at 90 Degrees With the patient supine, the thigh is flexed to 90 degrees. The clinician places his or her leg nearest the patient on the table to afford a place on

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Manipulation

321

Figure 7-20 Hip Joint Posterior Shear at 90 Degrees Flexion

which the patient can rest his or her flexed lower leg. By leaning over the patient's bent knee, the clinician applies pressure down toward the table along the femoral shaft by resting his or her sternum on his or her hands, which are covering the patient's knee. After taking up all slack, he or she delivers a light body-drop impulse toward the table (Figure

7-20).

Chapter Review Questions •

vVhat are the effects of joint manipulation?

•

vVhat are short- and long-lever manipulative techniques?

•

vVhat are the three zones of movement in a joint's range of motion?

•

vVhat are the two barriers to movement in a joint's range of motion?

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322

PELVIC LOCOMOTOR DYSFUNCTION

What causes the audible dick heard during a manipulation, and

•

what is its •

What is the

•

Name the contraindications to manipulation and mobilization.

•

a

of "slack" removal

Describe a

side-lying

technique

for sac-

roiliac joint

REFERENCES L Shekelle PG.

1994;19:858-861. Mc1n1l1Ui,1t/()IJ

5th ed. Boston, Mass: Butterworths; 1986.

3. Mermell JM. Back Pain: Diagnosis and Treatment

Techniques. Boston,

Mass: Little, Brown & Co; 1960. in the

4. Roston JB, Haines RW.

joint. J Anal. 1947;81:165-

173. 5. Unsworth A, Dowson 0, Wright V.

a bic>enguleeri

of cavitation

in the metacarpophalangeal joint. Ann Rheum Dis. 1971;30:348-358. 6. Sandoz R Some physical mechanisms and effects

Ann Swiss Chiro

Assoc. 1976;6:91-141. 7. Palmer DO. The Science, Art Ilnd Pf1J,ln,nnIIlJ

nmll'Jr.fl.rrJ'r

Portland, Ore: Printing House

Co; 1910. 8. Korr 1M. Sustained sympathicotonia as a factor in disease. In Korr 1M, ed. The !VPl.lr(l.flIrl.lll<'1.r

New York, NY: Plenum

Mechanisms ill

Corp; 1978:229-268. 9. Lewit K.

in Rehabilitation of the Locomotor

Boston, Mass:

Butterworths; 1985. 10. Janse J.

and

Lombard, 111: National

All

of 1 L Sato A, Swenson RS.

nervous system response to mechanical stress of the

column in rats.

Maninulal'i1!f'

Ther. 1984;7:141-147.

12. Denslow JS, Korr 1M, Krems AD. Qualitative studies of chronic facilitation in human motor neuron

Am J

1947;105:229-238.

13. Kunert W. Functional disorders of internal organs due to vertebral lesions. Ciba Found 1965;13:85-96. 14. Gale PA. Joint mobilization. In Hammer WI, ed. Functional

Tissue Examil1ation by

Manual Methods. Gaithersburg, Md: Aspen Publishers, Inc; 1991: 194-214. 15. Hadler NM, Curtis P,

DB, Stinnett S. A benefit of spinal

live therapy for acute low-back 16. Meal GM, Scott RA.

a stratified controlled trial.

of the joint crack

simultaneous

of solmd and

Ther.1986;9:183-195. 17.

Assurance

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ChapterS

Inflammation, the Soft Tissues, and eneral Treatment Considerations

A common

dysfunctions is

to pelvic

of

tissue is general and

the associated soft tissues. The term

but

structures. Nerve and vascular

a whole

r("n'YIr,rm,pnt"

can be

written on each of the individual tissues involved,so for our contain our discussion to a brief review of connective tissue, don,and It is

locomotor

all one has to do is manipulate or mobilize a

especially since manual added attention must

affect the soft tissues.

affect their

be paid to muscle and ligament

soft tissues and vice versa. Even the novice practitioner trained in manual methods to locomotor

local and often distant

tissue

in reaction

These changes can be subtle or

(see

gross. Some subtle changes are

points unknown to the pa-

tient unless examined for and

restricted skin

323

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Some gross

324

PELVIC LOCOMOTOR DYSFUNCTION

to

are reflex muscle that

There is a

inflammation and

is movement and movement is life. This is and its soft tissues, and eStJeCldU

amply true of the locomotor

connective tissues like tendons and

of

on movement to assist in

they

rich blood ents throughout

extracellular compartment.

Immobility, on the other

creates the conditions in which and ligaments become "in-

erative processes can

jured" just from being immobilized. If you totally immobilize a perfectly normal hip

you will be hard

for several

joint without pain and

to move the fibrosis will

afterward.

be seen to infiltrate the framework of the tissues.

trauma

in-

flammation and repair will create scar formation and more fibrosis from the proliferation phase of inflammation. This is seen after immobilization serious trauma. But what about

who becomes "physiologically immobi-

lized"? Prolonged posturing, be it a lack of physical movement, such as

CH'"." 'r,n,

the body of what it is

and movement.

and fibrosis occur as tissues seek to accommodate to

tive

and more

applied. The tissues become less

amount of

physiologically immobile. More shortening and fibrosis occur, and the continues. Acute and chronic soft tissue changes can be observed on examination (see INFLAMMATION AND REPAIR occurs in the soft tis­ the

area. It

initially proclaimed the

was Cornelius Celsus, a

four clinical signs of acute inflammation: rubor, tumor,

and dolor.

and pain are due to the stereo-

of

typic hemodynamic changes that are the hallmark of acute inflammation, Virchow later added the fifth clinical sign of functio laesa, or lost function. Inflammation can be acute or chronic. Acute short

is usually of

by edema and exudation and a Chronic inflammation is of

re-

associated with the

proliferation of blood vessels and connective tissue and the presence of n",'v'r... " and It can occur after unresolved acute initself from

inflammation of

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standing.

the Soft Tissues, & General Treatment Considerations

The acute inflammatory

Soon

and fibroblasts

'UQ,UVH

nals the start of repair. Small tissue defects

union. This is associated and subsequent

with increased granulation tissue

(myofibroblasts) occurs to

Wound contraction by contractile the

the large defect.

tissue. This

rapidly with minimal scar-

large defects heal

process, the wOlmd is filled with

tissue, and more work

325

is laid down, laying the

remodeling and maturation of

cess takes a few days to a few

scar to occur. If the

pro-

the remodeling and maturation

months to years, depending on the tissue

cess may take and the extent of the

In the remodeling phase of

fibers are oriented to

line

a distinct in-

wound stress. In

crease in wound strength is observed. ab-

resolve, heal

Acute inflammation can either scess, or progress to chronic

(Figure

8-1).

Chronic inflambouts of

mation occurs after an unresolved acute inflammation,

unlike the

inflammatory

acute inflammations, or a traditional acute

its cellular

process. It is

connective tissue and blood vessels. A low-

response and proliferation chronic

for years,

brotic tissue and

down more fi-

more dysfunction.

Cantu and Grodinl discuss the differences between

and fibro-

of connective tissue. However, in the area tissues and is more the connective tissue by inflammation that spreads limits

nontraumatized tissues.

via exudates to the mobility directly and

any

tis-

adhesions with

sues. Fibrosis, on the other hand, limits mobility because of its expansive effect on most of the

tissue. An example would be capsulitis

of the hip joint, in which the entire capsule is areas of

not

specific

Fibrosis begins in response to an event noxious to the a fibrotic response include a neighboring indue to poor

ance, joint

or locomotor imbal-

immobilization

Once the process starts, it can progress and create a SeJlf-[)erDe cycle. As the chronic low-grade inflammation continues and connective tissue is laid myofibroblastic

the fibrotic front and restricts. Further

continued irritation to the tissues. The

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shrinks from

326

PELVIC LOCOMOTOR DYSFUNCTION

Acute Inflammation Vasodilation Edema/inflammation

Repair Granulation tissue Collagen

- -....

Unresolved

- - - - - - �

Chronic Inflammation More granulation tissue Fibrosis Lymphocytes/macrophages

Remodeling

1

Maturation Figure 8-1 lnflanunation Pathways

is produced. This continues until the inciting irritant is removed (Figure

8-2). IMMOBILIZATION AND THE SOFT TISSUES Immobilization creates fibrotic changes in the soft tissues affected.2-4 Fatty fibrotic infiltrates can be grossly observed in capsular folds, creating adhesions. More infiltrate is deposited with longer immobilization times. Loss of ground substance occurs without significant loss in collagen fibers. This allows for the collagen interfiber distance to diminish and consequent cross-linking to occur. Without any directional stress applied to the tis­ sues, new collagen is laid down in a disorganized, matted pattern. Tissue

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the Soft Tissues, & General Treatment Considerations

JoinVSof1 Tissue Dysfunction

327

Connective Tissue Proliferation

1

I

Restriction

Myofibroblastic Action and Shrinkage

~

/

Decreased Extensibility

Figure 8-2 Effects of Immobilization

more immobilization. Immobilization

distensibility diminishes,

affects all the tissues of the musculoskeletal system. seen after

with irreversible

8 weeks.6

Li�;
threshold.l Muscle mass

with a 20% loss

The maximal heart rate

and the

Voz max and

decrease.9 The downside is that the effects

immobilization occur or

much more quickly than the beneficial exercise. Muscle

is decreased 3% to 7% of only 1 % per

bilization, as compared to a

with immowith activity.lO

TISSUE STRUCTURE AND FUNCTION Connective Tissue Connective tissue is found throughout the

and is made up of cellu-

lar and extracellular components (Exhibit regular,

and loose

Clinically, we are in the form

fibrocytes make ture into the

orientations (Exhibit

mostly with dense

tendons and ligaments, and dense

sue, such as joint the fibers and

It is arranged in dense

cellular

connective tisFibroblasts and

aponeuroses, and

Fibroblasts produce

substance found in connective tissues and later mafibrocytes. In

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cells of the reticuloen-

328

PEL VIC LOCOMOTOR DYSFUNCTION

Exhibit 8--1 Connective Tissue Components

Cellular

Extracellular

•

Fibroblasts

•

Fibers: collagen, elastin, reticulin

•

Fibrocytes

•

Ground substance: water, proteoglycans

•

Reticuloendothelial cells

dothelial system are found in the connective tissues, especially during pathological conditions. Macrophages, mast cells, and plasma cells are among these. Macrophages fW1ction to phagocytize tissue debris, foreign material, and microorganisms, especially after injury. Mast cells release histamine and anticoagulants, and plasma cells produce antibodies for the body's immW1e response. The extracellular part of connective tissue is made up of fibers sur­ rounded by groW1d substance. The fiber types vary according to structure and fW1ction and are called collagen, elastin, and reticulin. Collagen is the main fiber type in connective tissue and is composed of four subtypes. Type I is the most ample form of collagen in the body and makes up a large part of the tissues affected by manipulation and mobilization, namely the joint capsules, ligaments, and tendons.)) It affords tremendous tensile strength, especially if aligned in a dense pattern, as in tendons and liga­ ments. Elastin and reticulin are specialized fibers that recoil upon release of a deforming load. They are less able to withstand tensile forces and are limited in their distribution in the body when compared to collagen. For instance, elastin is found in the ligamentum flavum, the ligamentum nuchae, and the elastic walls of arteries. Reticulin is found mostly in the support framework of viscera and glands. The ground substance secreted by fibroblasts forms the viscous matrix within which the cellular and fibrillar components of cOImective tissue are

Exhibit 8--2 Connective Tissue Types Dense Regular

Dense Irregular

Loose Irregular

•

Tendons

•

Joint capsules

•

•

Ligaments

•

Periosteum

•

Mesentery

•

Aponeuroses

•

Superficial fascia

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Subcutaneous

& General Treatment Considerations

Inflammation, the Soft

embedded. It is made up of mostly water

(70%)

329

bounded by

a gelatinous matrix. Hyaluronic acid and chondroitin with the former

sulfate are the two major types of water and the latter

mostly

a medium

This

wastes can occur. This is necessary because of the hypovascularity of con­ nective tissue. It also provides cohesiveness, and resistance to n"�)''';:,'''n By in the spaces between the substance additionally maintains the tance to

"",,,rl"'.,,r.

and adhesion.1

Connective tissue functions to support, hold together, and provide a framework upon which tissues and organs are built. It also exhibits special deformation characteristics in

to various loads applied. It dis-

both viscous and elastic

whereby loads ap-

plied will result in nonrecoil and recoil actions

In other

words, its viscosity allows deformation to remain after a

whereas

enables the tissue to recoiL

its Muscle

tension. An individual

Muscle tissue is "1-";LU'La muscle is composed

muscle

or

are grouped into bundles called

fasciculi. in the form of myofibrils

tractile in a variety

muscle fibers, that

Each myofiber contains the con-

8-3). Muscle fibers occur

on functional and metabolic characteris-

tics.12 These are summarized in

8--3.

Connective tissue surrounds

the fasciculi and muscle fibers and is called The connective tissue ally confluent and allow passage for

perimysium

and VTII/,om",,,, on all three levels are actulymphatic, and neural ele-

ments. Muscle is very vascular tissue, and its perfusion is During

to activ-

blood is directed through

capillary

While the muscle is at rest, blood is diverted directly to venulesP it is evident that muscle tissue and connective tissue are related. The external fascial investments are continuous with the connecting tissue surrounding the individual muscle fibers, the enTherefore, treatments directed at muscle or tures cannot occur without affecting both ments directed at

strucAlso, treat-

fascial structures can affect muscles and

fascia on levels. As discussed in

mentions how muscles of 4, tend to shorten and become In association with

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V,,,,U , ILO

330

PELVIC LOCOMOTOR DYSFUNCTION

2

3

8-3 Muscle tissue: (1) muscle belly; (2)

muscle

4

(4) myofibril.

"''''''UL!C,

that show a tendency to weaken.

ment can supply us with this information, to be used

exercises can be used on

weakened and inhibited muscles to reeducate them to

fWlCtion.

Muscles and Training A muscle's response to training depends on the and the principles of overload, specificity, and bers increase their capacity on a structural and extent that they are challenged by a adapt to the training demand imposed, a new demand of higher intensity is

n"',>n'::'n

stimulus is discontinued, the muscle becomes deconditioned, and attained in training recede.

the gains in structural and Low-intensity, high-repetition

induces muscle endurance if

performed for 30 to 60 minutes on a

basis. The intensity must be of

an

as must the duration of ap-

sufficient magnitude to Endurance

increases the oxidative capacity of muscle

and the percentage of

muscle fibers.16

Exhibit 8-3 Striated Muscle Fiber

Fiber Type

Characteristics

Type r

Slow-twitch,

Type IIA (fast red)

Fast-twitch oxidative, faster than

resistant I but less fatigue

resistant Type lIB (fast white) Type llC

Fast-twitch

O'lv,rnl\lllr.

fast contraction, fatigues easily characteristics of UA and 11B

Type lIM

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the Soft

& General Treatment Considerations

331

creates muscle hypertrophy and increases in

una"'-rAnnu

fiber's diameter. Due to the

occurs via an increase in the muscle during this type of train-

loads

ing,

recovery to occur. Mechanisms

Clinically relevant injuries to muscle tissue are contraction or exercise and ischemia. Strenuous exercise and eccentric

strain,

contractions are known to injure muscle

in more

Eccentric contraction

soreness 1 to 3 days after the

tension than isometric or concentric contractions and is associated with more myofibrillar damage and consequent sive endurance exercises can ischemia. 18 Strain

soreness.17 Inten­

muscle from metabolic

and

commonly occur after overstretching or a strong eccentric

contraction. Injury

occurs at the musculotendinous junction.19 The

reason for consistent

to occur at the

junction

is not clear but may be related to its structural makeup. Garrett and TidbalP9 discuss a study by Garrett et al in which and nonstimulated rabbit muscles were subjected to tensile The electrically stimulated muscles

failure and the effects were failed at the same

as the nonstimulated muscles but were able to

sustain a

stretching. Garrett and Tidball19 comment

that this is a significant

demonstrating the ability of muscles to

protect themselves and joints from injury. This are better able to afford protection from injury and

implies that muscles control if

can

absorb more kinetic Contusion injuries are caused by nonpenetrating blunt trauma. Inflammation occurs with hematoma formation. If severe into osseous

the hematoma

a condition called

blunt injury

In-

faster in rat muscles that were mobi-

lized than in those that were not,20 Clinically, cross-fiber massage mobilization and works well after the acute

in

from blunt trauma to muscle. As soreness and the muscle's tension

relaxation and

stretching aid greatly in recovery. Increased pressure in and bone can create nerve

formed

tough fascial sheaths

and decreased vascular

in ischemic damage. Crush injuries,

re-

or edema in a

rapid pressure buildup with

"LUJ"".�'

at pressures lower than arterial pressure.12

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332

PELVIC LOCOMOTOR DYSFUNCTION

This is potentially an emergency situation, with early recognition neces­ sary since the amoW1t and duration of pressure increase are proportional to the degree of injury. Tendon

Tendons are the strongest soft tissue structures in the musculoskeletal system, owing to their high--collagen fiber composition and its dense par­ allel arrangement. Connective tissue organization in tendons is similar to that of muscle, with small bundles of fibers surrounded by an endotendineum, larger bW1dles by peritendineum, and the tendon itself invested in epitendineum. As in muscle, these layers of connective tissue are confluent and serve as passage for blood vessels. However, vascular injection studies have demonstrated avascular regions in tendon.21 Tendons are designed to withstand and transmit high tensile forces smoothly without any appreciable loss of energy, even though the Latin word for tendon is tendere, which means "to stretch." Observed longitudi­ nally under light microscopy, the relaxed tendon demonstrates a regular wavy appearance, termed "crimping," that is a characteristic of the col­ lagen fibers. Loads applied to tendons straighten out the crimping appear­ ance (Figure

8-4A).

Crimping apparently functions to dampen the shock

from loads applied suddenly. Most tendon injuries involve avulsion from bone or in-substance transection. Failure along the tendon's length is rare; disruption due to tensile forces more commonly occurs at the myotendinous junction.19 Healing of tendon injuries has been shown to be greatly influenced by early intermittent passive mobilization22 and continuous passive motion.23

In one study, the mobilized tendons demonstrated greater strength than those of a control group in which mobilization was delayed.22 The inflam­ matory stage in tendons lasts about 3 days, and full maturation of the in­ jured area takes 2 to 3 months. Ligament

Ligaments, like tendons, are cords or bands of dense regular connective tissue (Figure

8-4B).

However, they display less W1iformity to their paral­

lel arrangement.24 They also exhibit crimping, which is thought to add elasticity to ligament tissue.25 The word ligament is derived from the Latin word ligare, which means "to bind," and thus relates to their function of checking and stabilizing

Copyrighted Material

Inflammation, the

& General Treatment COrlSiderations

visible. (8)

Figure 8-4 (A) Tendon without

333

,--")',anl""

excess joint mo-

motion at tion and

Acting as

also play a neurosensory

sensory

the neuromuscular reflex

afferent signals

with

proprioception. Ligaments are hypovascular;

hypometabolic structures and consequently heal slowly when to other stretch

tissue structures. When partial tears, or

they suffer tears.

are more

prone to in-substance failure than to avulsion from bone.26 Acute inflam­ mation in

lasts about

72 hours.

Copyrighted Material

this are the repair

334

PELVIC LOCOMOTOR DYSFUNCTION

and

about 6 weeks. Maximal remodeling

and maturation require up to

12 months or moreP

Ligament contraction has been observed to occur after sive and active mechanisms have been postulated to traction.

held

at a shorter

restructuring and

maintaining that length. Dahners28

onstrated active shortening mechanisms whereby actin, a contractile pro­ Interestingly, when nor­

tein, contributed to the contraction of mal

electrical potentials are simulated, this active contraction is inhibited.27 It seems that tissues normally emit

su'es15-g:ener,:I(ea electrical potentials with mechanical loading and that a may signal the contraction process.

reduction of these

Myotendinous Junctions A recent area of intense study in musculoskeletal tissues is the junctions. Biomechanical studies have consistently shown nt'>rt:u'<>

between muscle and tendon is the weakest link in the

contractile unit.19 Tension

in the muscle is transmitted to the

tendon across the myotendinous junction, a highly specialized structure. and overcontraction

Indirect injuries, or

more

at the

tend to occur

than at other sites, The ends

of the muscle fiber do not terminate as smooth conical insertions in the connective tissue matrix of the tendon. The membrane of the myofibril is allowing greater surface area contact with the tendon colthe terminal portions of the

8-5).

are less extensible and therefore more prone to

Insertional Sites Another area of weakness in the

is tendon, ligament and capsu-

lar insertion sites to bone. A transitional zone of only lows the

from

zone, a blend

different tissues occurs such that

1

to bone to occur (Figure

mm in width al-

8-6).

Within tIus

progresses to

fibrocartilage, calcified fibrocartilage, and finally bone.29 These sites are also

on tissue diffusion for nutrition.

dysfunction,

pain

4).

are the most common pathologic conditions are caused

rapid loading

Copyrighted Material

of-

and even distant locomotor

ten become painful in response to

Avulsion

insertion sites. These

applied to the insertional inter-

Inflammation, the Soft Tissues,

&

General Treatment Considerations

335

Figure 8-5 Myotendinous Junction. Source: Reprinted from Tidball, J.G., Myotendinous Junction: Morphological Changes and Mechanical Failure Associ­ ated with Muscle Cell Atrophy, Experiml?nts in Molecular Pathology, Vol. 40, pp. 1-12, with permission of Academic Press, © 1984.

face, resulting in its failure. Rarely does separation occur within the junc­ tion itself. More commonly it occurs on either side of the junction, in the soft tissue or bone. However, junction or bone avulsion failures have a better outcome than failure in the soft tissues.29

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336

PELVIC LOCOMOTOR DYSFUNCTION

Figure 8-6 Insertional Site. T, tendon; BV, blood vessel; AC, articular cartilage; TM, tidemark; C-FC, cartilage-fibrocartilage; B, bone; FC, fibrocartilage. Source: Reprinted from Benjamin, M., Evans, E.J., and Copp, L., The Histology of Tendon Attachments to Bone in Man, Journal of Anatomy, Vol. 149, pp. 89-100, with permis­ sion of Cambridge University Press, © 1986.

Stress and joint motion are significant factors that support the functional integrity of insertion sites, whereas immobilization has deleterious effects. Woo et a]29 mention that biomechanical studies using animal tissues show that immobilization causes a rapid decrease in soft tissue-bone junctional strength. Conversely, insertion sites become stronger with exercise. The activity must stress the specific insertion site to have a beneficial effect on its strength. CLINICAL CONSIDERATIONS FOR TREATMENT

In treating soft tissue lesions, it is important not only to localize therapy correctly to the tissue involved but to identify where in the healing process the lesion is. Is it an acute, subacute, or chronic problem? This guides us in administering the appropriate treatment (see Exhibit

8-4).

Acute Phase

The acute phase is marked by the signs and symptoms of inflammation mentioned earlier. Mennel1 terms this the healing phase.30 Due to inflamma-

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Inflammation, the

Tissues,

&

337

General Treatment Considerations

Exhibit 8-4 Phases of Healing

Acute

Subanlte

Chronic

•

Inflammation

•

Inflammation less

•

•

Pain before end-feel

•

Pain with end-feel

•

•

Anti-inflammatory modalities

•

Ice/heat

!, II mobilization

•

I, II mobilization

•

Ill, IV mobilization

Gentle transverse

•

Increased transverse

•

modalities, ice • •

friction massage •

Passive range of

•

motion •

Scar/fibrosis Pain after stretch, end-feel

(V)

friction massage

Deeper transverse

Passive, active range

friction

of motion

Isometrics

•

motion

Increased isometrics •

movement of the structures is

Isotonics, stretching

early in the range of

any tissue resistance is encountered. The patient comments

motion

that the area involved stiffens with rest and loosens with movement How­ ever, too much movement exacerbates the condition. This is an important clue to the

and its

of this phase. The treatment and

rest the

structures involved tissues in as near a physiologic state as possible.

the neighboring For

heralds the exit

of this

muscle or r",r,nn,n

if the lesion involves

should be avoided at this time.

tions and

can be performed within a

of motion (grade I and II

range of motion to maintain some level of mobility in the related Electrical muscle stimulation or isometric muscle contractions can be used with the muscle in neutraL This causes contraction and

of the muscle upon

mobility in the forming scar tissue.31 Gentle trans­

verse friction massage mobilizes the soft tissue scar Rest from function does not mean what is termed yet moved 10

11

active rest.

immobilization but refers to

If a healing

causes

can be moved

10

then that joint should be

Immobility creates more

and poor healing play an

soft tissues and joints. Cryotherapy and

part

in the acute and subacute phases and are described below. Overtreatment results in continued even at rest, and continued

after a treatment session for of inflammation. Easy

also occur and warn the clinician to slow down and ease up.

Copyrighted Material

and

338

PELVIC LOCOMOTOR DYSFUNCTION

Cryotherapy and is used to reduce pain and

is beneficial in its abil-

For the most part,

to limit what is called

When a tissue is in-

hypoxic

results in cellular destruction, with result-

jured, the primary site of

ant inflammation and hemodynamic stasis. The tissues adjacent to the area suffer from

stasis and

injured from

sues in the secondary hypoxic injury zone in

become

these tis-

in effect,

their

metabolism. This allows them to survive the lower oxygen tension of the

and

inflamed tissue. The net effect is a decrease in further tissue resultant decreased inflammation

There are many diverse opinions of ice

but a sur-

that one that works

vey of the literature

is 30 minutes of

application every 2 hours. Some may be concerned about the which is

fect or cold-induced AU'<"",'"

this

to occur after

was found to be artifactual and not a factor in

effect and

icing.32 The real value in cryotherapy is its

induction of hypometabolism

the

ef-

15 min-

the

tissues. Most importantly,

will allow exercise and movement to be used more

The combination of cryotherapy and and is valuable in

area with an initial

can be started for 3 to

of

15

active exercise is called After

the

to 20 minutes, light active exercise

5 minutes until the numbness wears off. If no pain is and a slightly higher 5

the part is renumbed in 3 to

level of exercise can be used. Patients motivated to self-treatment will do well with this For

a cryotherapy protocol can be used on sacroiliac joint First ice is

that is adapted from Knight's work on ankle

applied to the painful area for 20 minutes or until numbness is

enced. The

ov ....arl_

is then asked to perform non-wE�llllt1t-be;annll

hip flexion while supine for only

3 to 5 minutes. The

is also

this is tolerable, the patient renumbs the painful area for 3 to 5 minutes and to the next level of

standing and

this is tolerable and

Copyrighted Material

one's fJCU'Hl<"" u,

&

Inflammation, the Soft

General Treatment Considerations

339

renumbs the area again and progresses to the next exercise and so on. The idea is to numb the area to allow exercises to occur painlessly. If the exercise is enced, even

active

pain will be

and the patient will have gone as far as

he or she can

for that session. Two to 3 hours

the series

exercise with intermittent icing is tried again to see if the patient can nr,,,,,, ,' , ';:,,,

increases after each

further. The exercise difficulty

pf()!!I'eSi,es to the next level of is exercises

A

is shown in Exhibit 8-5. The

an acute sacroiliac

is encouraged to perform at least two sessions per pain, overtreatment

if the

list of the preferably three.

and continued signs of inflammation signify the need to slow down.

Subacute Phase in which inflammation is sub-

is a and

continuing. Painless range of motion is increased, but

is commensurate with the tissue resistance at or near end range. More in the tissues, with transverse friction massage

motion can be

used with

and isometric contractions

Smallde-

mobilizations are still used, and pending on the clinician's

If signs and symptoms

han are minimal, articular dysfunction is very evident, and the patient can then a

and full slack

tolerate

Keep in mind that Va in. Cryotherapy and strength

can be movement tra-

is an

are to be used. As motion and to isotonics.

isometric exercises can be

Chronic Phase Menne1l30 terms this the

healed

In contrast to the acute phase, pa-

tients in this phase will remark that they do not stiffen with rest but hurt more with motion. Pain on

comes after the end­

feel is reached as the tissues are stretched. Ke'meJdlel scar tissue are

Restoration of function is

ment and includes manipulation,

<.:rr,,",u·,,,

nr,C)(Ylrp"';::",TP

exercises. Heat and ice applications can be used to and ease posttreatment soreness

Copyrighted Material

Pain

resistance stretching

more than 4

340

PELVIC LOCOMOTOR DYSFUNCTION

Exhibit 8-5 Cryokinetics Program for Acute Sacroiliac Sprain

Instructions Apply initial icing W1til numb. Exercise for 3 to 5 minutes, with renumbing between levels. Stop at level that causes pain.

Exercise Sequence Supine hip flexions Renurnb for 3 to 5 minutes Standing weight transfers Renurnb for 3 to 5 minutes Alternate knee raising when standing Renumb for 3 to 5 minutes Walking without limping Renumb for 3 to 5 minutes Sit-downs and stand-ups Renumb for 3 to 5 minutes Upstairs/ downstairs

hours after treatment sessions or signs of swelling and decreased strength signal overtreatrnent.33 Soft tissue scarring, decreased range of motion, and muscle weakness all need to be addressed in this phase. Transverse friction massage and more vigorous mobilizations (grade IV) are used, and the patient is taught passive and active stretches to increase tissue distensibility. Patients who are treated from the acute phase to the chronic phase are often easier to manage than those who initiate treat­ ment in the chronic phase. But such a situation is ideal at best, for many patients present after months of no formal diagnosis or treatment in a state of pain, stiffness, and weakness. Clinical depression is often a factor in chronic conditions and can unfavorably modulate the clinical picture. It is often necessary to tell patients with chronic conditions that they may not become pain free, despite functional improvements. Setting realistic goals at the beginning of therapy will offset disappointment if

100% suc­

cess is not achieved. CONCLUSION

The soft tissues make up a diverse, complex group of structures that are crucial to the stability and proper function of the locomotor system. Joint dysfunction and soft tissue changes go hand in hand. Immobilization itself is detrimental to the normal health of joints and periarticular soft tissues.

Copyrighted Material

Inflammation, the Soft Tissues, & General Treatment Considerations

341

Manual methods, by their very nature, affect these soft tissues directly, speeding their recovery during healing.

Chapter Review Questions •

Describe the acute

•

What is the difference between

•

response. and fibrosis?

What effects does immobilization have on the musculoskeletal structure?

•

What information from the patient's history characterizes the of a condition?

acute •

How does cryotherapy affect the tissues?

•

What is

•

What information in the

history tells us that the acute has been entered?

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Inflammation, the

& General Treatment Considerations

343

J, Textbook of Orthopaedic Medicine, London: Bailliere-Tindall; 1984.

31,

32, Knight KL nooga

and

Tenn: Chatta-

1985,

33, Zohn 0, Mennell JM, Musculoskeletal Pain: FYIl�rIl1!p''' of Treatment, Boston, Mass: Uttle, Brown & Co; 1976,

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and

Chapter 9

Treatment of Myofascial and Soft Tissue Structures

Chapter Objectives •

to discuss common myofascial pain syndromes and their treat­ ment through such methods as postisometric relaxation, ischemic compression, and stripping massage

•

to describe the treatment of tendon and ligament lesions, particu­ larly the use of transverse friction massage

•

to describe forms of length-strength treatment, includ ing CRAC and postfacilitation stretching (PFS)

This chapter discusses the more common soft tissue problems of the pel­ vic and hip regions that are encountered in clinical practice: myofascial trigger points, tendon and ligament lesions, and shortened, tight muscles. The discussion covers both general methods (postisometric relaxation, ischemic compression, stripping massages, transverse friction massage, length-strength treatment) and treatment of specific muscles, tendons, and ligaments.

TREATMENT OF MYOFASCIAL PAIN SYNDROMES Myofascial pain syndromes share with joint dysfunction the distinction of being one of the more common etiologies of pain afflicting the locomo­ tor system. The pelvic girdle and hip area are very common sites of myofascial trigger points. Most of the material covered in this chapter is derived from the monumental works of Travell and Simonsl,2 and Zohn and MennelJ.3 Their contribution to the understanding of myofascial pain syndromes is immense and must be reviewed in depth for insight into the importance of this problem.

344

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Treatment of Myofascial and

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345

Unlike muscles containing myofascial trigger points, normal muscle tis­ sue does not exhibit tight, painful spots that refer pain on palpation or stretch. Myofascial trigger points

are defined as hyperirritable that refer

in bands of skeletal muscle or muscle

in

often at a distance from the TP. Their location in a

consistent

given muscle is specific and predictable, and they may occur in any skeletal muscle. They occur in all

of individuals, sparing no occupation,

One

from "growing point as the

TPs can be active or latent. An active 11" is The referred

and

from the TP is described as deep,

and dull. This

pain can be elicited by a few seconds of sustained digital pressure on the TP. Patients are usually more aware of the referred itself. The referred

than of the TP

from TPs is unique and is not dermatarnal,

myotoma!, or sclerotomal. Active 11:>s are made worse pressure, strenuous muscular use, and a sustained shortened

ice

stretch, cold and damp of the muscle. Patients say

feel better after a hot shower,

if they stretch slowly. to erupt. It is painful on

A latent TP is like a dormant volcano,

palpation and exhibits all the other characteristics of an active TP, yet it is to pain. Although

clinically silent with

the latent TP can

cause stiffness and weakness of the affected muscle. Latent TPs are the more common TPs found. They can very ap'Dll,catIofls or cold

state by acute or chronic muscle sustained

and emotional

trauma,

stress. Satellite TPs are myofascial TPs that become activated because they are located in the pain reference zone of another active TP. A common exis the gluteus minimus TP that arises from an activated quadratus lumborum TP because it lies within its

referral zone. A secondary TP

is one that becomes active because its muscle is overloaded from activities that are synergistic with or antagonistic to those of another muscle with a primary TP. For example, piriformis or gluteus medius muscles can develop

TPs as

to

for a

minimus that

has active TPs in it. In both these

the primary TP must be inac-

tivated along with the satellite or

TPs.

On

palpation will find a band of muscle fibers

that harbor a small, discrete area of exquisite pain: the TP. If the palpating finger plucks across the may cause the

muscle fibers, a local twitch will occur and to

from

a

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PELVlC LOCOMOTOR DYSFUNCTION

weak on testing. As stated above, sustained pressure on the TP refers pain into a specific area characteristic for that muscle. Referred tenderness is also associated with TPs. Structures within the pain referral district are tender to palpation and may erroneously be incriminated as the etiology. Autonomic phenomena may also be observed in the referral zone. These include skin sweating, piloerection, and vasomotor changes. Skin rolling over the area of a TP is restricted and painful. Joint dysfunction of nearby articulations is common and can be a cause of, or a sequel to, the TP. Strong and near-unequivocal findings leading to the diagnosis of myofas­ citis are a local twitch response to plucking of the muscle fibers and a re­ production of the patient's symptoms, with radiation of pain into the char­ acteristic referral zone.

Inactivation of Trigger Points IPs can be inactivated by lengthening the taut bands that harbor the TP through various stretching procedures and enhancing the local circulation with hot moist applications. This is followed by several active muscle con­ tractions by the patient to reestablish neuromuscular "awareness" and sig­ nal the muscle that it is all right to function normally again. However, a muscle with a painful active TP in it cannot be just passively stretched. A counterirritant or facilitation technique is often needed to break the pain­ spasm cycle. In this regard, Fluori-Methane vapocoolant spray or postisometric relaxation can be used respectively. There is a concern about Fluori-Methane's effects on the atmosphere's ozone layer, as with other fluorocarbons. Ice can be used in its place, or other procedures for inacti­ vating TPs, such as postisometric relaxation, ischemic compression, or stripping massage, can be applied with great success. For an in-depth dis­ cussion of Fluori-Methane stretch-and-spray technique, the reader is strongly urged to read Travell and Simons' work.1,2

Postisometric Relaxation Stretching a muscle with a TP to its full, normal length is the most im­ portant factor in inactivating IPs. An easy and effective method to accom­ plish this is described by Lewitl and is called postisometric relaxation (PR). It is also used to lengthen shortened, tight muscles found on exami­ nation that do not harbor TPs. Postisometric relaxation is gentle, comfort­ able for the patient, and effective. It can be used on the oldest patients and even on the young. As its name implies, relaxation and stretch are insti­ tuted after an isometric contraction of the muscle. The muscle is posi­ tioned so that light tension can be induced in the bands of muscle in-

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Treatment of Myofascial and Soft Tissue Structures

valved. A

347

isometric contrac tion is performed by the patient, with After 10 seconds, the patient is told to relax or "let

the clinician

go," and the clinician s tretches the muscle only after relaxation is sensed. occurs in the direction that stretches the muscle.

The

are used to facilitate the contrac tion and relaxation

Phases

phases of the stretch. Patients are asked to inhale deeply and slowly while they contrac t the muscle. while the clinician

the clinician is contin-

until a resistance is met. This could take several

and

ued

are then told to exhale and relax the B.c'"","'the stretch.

seconds. The range

motion

at the end of the stretch is main-

tained, and another cycle of contraction-relaxation is performed. The pro­ cedure is performed three to five

with the

the

to

muscle fully. At no time should the patient occurs if the stretching is performed too

or firmly. The time of con­

traction can be lengthened to 30 seconds, and a harder contraction can be used to aid in

the muscle. After relaxation is attai.ned, several

of active muscle contraction should be

the new

range. Whether Fluori-MeU1ane man situa tions. One is when the The structures.

guarding a joint with damaged ligaments or

the joint is insulted

is temporarily

When the

pain will result. These two situations can be used as as

tic indicators rather than viewed as nician realizes the reason for exacerbation. Ischemic Compression

Ischemic rrnTInrPC,,,,rln cation of direct pressure on the TP until the referred pain is It is termed ischemic

because immediately after the compres­

sion treatment the skin blanches white before i.t reddens. After palpating for and area of

a band of

muscle fibers, the clinician searches for the

pain within the band. Often an area of firmness or a nod-

ule will be found that is

painful,

into the TP's on the TP with

characteristic pattern. At the thumb, the knuckle, the

or a blunt device until the pain starts to

refer. At all times the patient must be relaxed and able to tolerate the pressure without wincing,

or

the muscle to

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PELVIC LOCOMOTOR DYSFUNCTION

the pressure. After a few seconds of sustained pressure, the pain will sub­ side, and the patient will be able to tolerate an increase in pressure. This will again create pain, both locally and referred. This new level of pressure is maintained until the intensity diminishes. The process is continued for approximately 1 minute until the TP does not refer any more pain when pressed firmly. Mild, moist heat is applied to increase circulation in the area and help reduce posttreatment soreness. It must be stressed that at all times the patient is to remain relaxed. The clinician must keep in constant communication with the patient. Such questions as "Am I hurting you? Is this too much? Where do you feel the pain now? Is the pain less now?" should be asked repeatedly until the pro­ cedure is done. Instructing patients to focus on their breathing while relax­ ing on the exhale helps immensely. Working within the patient's tolerance is a must. Months of pain and dysfunction are not going to be cleared up in one painful session. The clinician, too, must be relaxed and not in a hurry. After ischemic compression and heat application, a full, gentle passive stretch should be attempted, with active muscle contractions being per­ formed after this. Stripping Massage For this procedure, a lubricating lotion is applied to the skin so that the thumbs, fingers, or elbow can glide over the tight band of muscle and TP. Starting lightly at first, the clinician progressively deepens the strokes as the muscle is stripped along the length of the tight muscle band, toward the TP, and through and over it. The strokes are repeated until the muscle "lets go," the pain reduces, and the TP becomes less palpable. Again, the depth of the strokes and generated discomfort must stay within the patient's tolerance. This procedure is also foIlowed by heat, passive stretching, and active range-of-motion muscle contractions. Failure to inactivate TPs when using the above techniques commonly occurs if the muscle is not stretched fully or, conversely, if the treatment is too vigorous, causing overstretching and pain. Painful pressures or stretching prevents patient relaxation and affords ineffective stretching. Failure may also occur if the clinician does not use heat or active range-of­ motion contractions after the treatment. Travell and Simons dedicate an entire chapter in their book to factors that perpetuate TPs. They comment: "This is the most important single chapter in this manual; it concerns the most neglected part of the manage­ ment of myofascial pain syndromes."l(pl03) Mechanical stresses, nutritional inadequacies, metabolic and endocrine inadequacies, psychological fac­ tors, and chronic infection are listed as common perpetuating factors.

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Treatment of Myofascial and Soft Tissue Structures

349

Treatment of Individual Muscles affected

This section concerns the treatment of the more muscles and their trigger ernie

are described. The

and stripping massage

reader is referred to the works of Travell and Simonsl,2 for information to Joint conditions are

either for

biomecharrical or with TPs in lumborum, and erector muscle

and

inactivation are

sacroiliac joint mo-

occurs more often in younger individuals, including

tion children.

commonly occur with

rninimus and medius

the latter. The tensor fascia lata and hip adductors are also Hip adductor and iliopsoas TPs often masquerade as hip f!

since their referred pain

extend into the

If

ar­

Pubic sym­

problems are also associated with tension and TPs in the hip ad-

Gluteus Minimus This muscle is a very common source of buttock and a sciatic condition, the so-called

..,,,'CU'"VL

Simons2 state that referred pain into the limb from sacroiliac joint

is most commonly from activated gluteus minimus TPs.

Of the muscles commonly involved about the hip and pelvis, it refers often to the lateral

the

of the ankle and rarely to the foot.

fibers refer different

The anterior and anterior fibers are

as the patient lies

fortably extended.

pain. The with the thigh com-

part of the gluteus minimus that lies anterior to the

tensor fascia lata is explored for TPs. Tllis is achieved by first anterior tient

the

and the tensor fascia lata. By

iliac

contract the tensor fascia lata with resisted medial rotation of

the hip, one can define the borders of the muscle.

is performed

the tensor fascia lata. Pain from the anterior

anterior to the to the

buttock and down the lateral

of the

and even ankle of the muscle is best palpated in the side-lying position, involved side

The thigh is lightly flexed and allowed to adduct

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PELvIC locOMOTOR DYSFUNCTION

Figure 9-1

Gluteus minimus trigger point pain pa tterns. Trigger point in the ante­ rior fibers is shown on the right. Trigger point in the posterior fibers is on the left. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2, by J.G. Travel! and D.G. Simons, p. 161, with permission of Wil l iams Wilkins, © 1992.

toward the table. An imaginary line connecting the most superior aspect of the greater trochanter and the upper free border of the sacrum (near the posterior inferior iliac spine) is used to identify the gluteus minimus and piriformis TPs (Figure

9-2).2 It

is called the "piriformis line" and for the

sake of localizing TPs is divided into thirds. The gluteus minimus muscle and its TPs lie above the line; those of the piriformis are below. Pain from the posterior fibers of the gluteus minimus is referred to the posterior and medial buttock, posterior thigh, knee, and proximal calf (Figure

9-1).

To stretch the gluteus minimus muscle using PR, the patient is placed in the side-lying position, involved side up (Figure

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9-3). The

anterior fibers

Treatment of Myofascial and Soft Tissue Structures

351

Figure 9-2 The pil'iformis line runs from the superior aspect of the greater tro­ chanter to the posterior inferior iliac spine. It represents the upper border of the piriformis muscle.

are stretched by placing the upper thigh and leg behind the patient and off the table. The limb is allowed to drop freely until tension is developed in the muscle. The clinician stands behind the patient, places his or her hand just proximal to the lateral aspect of the knee, and gently resists the patient's efforts to abduct the thigh. The patient is instructed to inhale slowly and deeply and to maintain the mild contraction for about 10 sec­ onds. Afterward, the patient is told to exhale and relax or "let go" of the leg so that it descends toward the floor, thus putting the gluteus minimus on stretch. The clinician aids the passive stretching only upon sensing the muscle's relaxing. In this position, gravity greatly assists the process. The procedure is performed three to five times, depending on how tight the muscle is and the response to stretching. The posterior fibers are stretched by dropping the leg off the table in front of the patient and repeating the above procedure. Ischemic compression of the gluteus minimus is difficult due to its deep location. To be effective, the point of the elbow should be used on larger patients or both thumbs together on average- and smaller-sized patients

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PELViC

LOCOMOTOR DYSFUNCTiON

Figure 9-3 Gluteus Minimus PR Stretch

(Figure

9--4).

Pressure is increased gradually until pain referral is elicited,

and then it is maintained. As the referred pain diminishes, the pressure is increased until the pain reappears. This is repeated over a period of about

1 minute, staying within the patient's tolerance for pain at all times. Heat is applied afterward, and the muscle is actively contracted several times by the patient. On very painful TPs, PR can be used first, followed by is­ chemic compression. Patients can be instructed to use a tennis ball or rounded door knob to press into the TP while at home for self-treatment. They can also use grav­ ity-assist PR by dropping the leg behind or in front of them off the bed, inhaling deeply and holding for

10 seconds, and allowing the leg to de­

scend more on exhaling. Ankle weights or a heavy winter boot can be worn to facilitate the stretch. As stated before, this muscle very commonly harbors TPs in association with sacroiliac joint dysfunction. Other causes of activation and perpetua­ tion are prolonged side lying and standing, intramuscular injections, trauma, lumbar radiculopathy, and overload. Additionally, TPs in the quadratus lumborum muscle commonly activate satellite TPs in the ante­ rior fibers of the gluteus minim us.

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Treatment of Myofascial and 50ft Tissue Structures

353

Figure 9-4 Ischemic Compression of Gluteus Minimus

Gluteus Medius

This muscle harbors TPs in three locations that refer pain relatively lo­ cally to the lumbosacral region and along the posterior part of the iliac crest (Figure 9-5). One TP is near the posterior superior iliac spine and refers chiefly along the sacroiliac joint, sacrum, posterior iliac crest, and buttock. Another is located just below the midpart of the iliac crest and refers pain into the lateral buttock and sometimes the posterolateral proxi­ mal thigh. The third TP is also below the iliac crest but near the anterior superior iliac spine. It refers pain along the crest, lumbosacral, and sacral regions. To palpate for gluteus medius TPs, the patient is placed in the side-lying position with the upper thigh slightly flexed in front of the lower. Gluteus medius TPs are located superior to those of the gluteus minimus, being closer to the iliac crest. Additionally, the gluteus medius TPs do not refer pain as extensively as the gluteus minimus. Postisometric relaxation of the gluteus medius is performed in the side­ lying position and is identical to that of the gluteus minimus. Lewitl dem­ onstrates an alternative position with the patient supine. The involved thigh and leg are adducted across the table under the opposite leg. Isch­ emic compression is also effective in inactivating these TPs.

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PELVIC

LOCOMOTOR DYSFUNCTION

Figure 9-5 Gluteus Medius Trigger Point Pain Patterns. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2, by J.G. Travel! and D.G. Simons, p. 151, with permission of Williams & Wilkins, © 1992.

Factors that activate or perpetuate TPs in the gluteus medius muscle include lower lumbar, sacroiliac, and hip joint problems, leg-length insuf­ ficiency, direct trauma, and one-legged stance. Patients frequently com­ plain of trouble sleeping on the affected side. Travell and Simons2 mention the importance of a short first metatarsal bone (Morton's foot) in the acti­ vation and perpetuation of gluteus medius TPs. These TPs are commonly found in martial arts athletes, dancers, and especially deconditioned people starting an aerobics program while doing vigorous and repetitive hip abduction moves. Gluteus Maximus

Although not as commonly involved as the other two gluteal muscles, TPs in the gluteus maximus muscle do occur often enough, with pain re-

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Treatment

11lOfas(:zal and

Tissue Structures

355

that need to be differentiated from sacroiliac and

Han,

referral from other TPs. The muscle

has three distinct areas that

TPs (Figure 9-6). One TP is located

lateral to the sacrum and refers pain along the medial part of the cleft and sacroiliac

and

the gluteal fold (Figure 9-6A). Another

more commonly found TP is just superior to the ischial tuberosity and refers pain

the whole buttock and lower sacrum and even to the The third TP lies near the coccyx and is in the

lateral crest

maximus (Figure 9-6C). It refers

most inferomedial fibers of the

a source of coccydynia. The first two TPs can be for

maximus muscle fibers,

across the

pain referral and a local twitch response. The third TP can be identified between the thumb and index fin-

pinching the most inferomedial gers and noting for

r",('r''';y�>",

PR can be used to stretch the

Ischemic and index finger and To differentiate the three

muscles and their TP involvements, the

TP location, pain referral, and fiber directions need to be taken into ac­ count. Whereas the gluteus minimus commonly refers pain distally and below the knee, and the

medius refers pain near the iliac crest,

lumbosacral region, and sometimes the proximal and midthigh, the gluteus maximus pain referral is more

to the buttock and very infre-

quently extends into the thigh. The

maximus TPs are more super-

ficial than those of the glutei minimus and medius.

flexion is limited

in active gluteus maximus TPs, whereas adduction is restricted with glu­ teus medius and minimus TPs. Activation and perpetuation

maximus TPs arise from direct

trauma; prolonged sitting;

uphill or

when

up stairs; and sitting on a

wallet. Sacroiliac

dysfunc-

tion will also perpetuate these TPs.

Tensor Fascia Lata as trochanteric

from this muscle is often

joint arthritis. The tensor fascia lata TP is located just beto the anterior

iliac

is asked to rotate the thigh

To

the

while the clinician gen-

resists. The muscle and its contour become more

Copyrighted Material

this

and palpa-

w Ul Q\ ""d

tTl r

:5 n r<

R �

@ Al

o -< (f)

�

z n -;

(5 Z

Figure 9-6 Gluteus Maximus Trigger Point Pain Patterns. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2, by J.G. Travell and D.G. Simons, p. 133, with permission of Williams & Wilkins, © 1992.

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Treatment

1\1,,/()t"'�r1nl

and

Tissue Structures

357

tion of its fibers will elicit the TP's pain referral and local twitch response. The

from the tensor fascia lata TP is referred into the hip joint area to the knee

the anterolateral

and

PR is used to stretch the tensor fascia lata. the a tight iliotibial band clinician while the

9-8A). The

knee is cradled by the

is extended

allowed to adduct to-

ward the table. Meanwhile the patient

the pelvis and lumbar

by holding the downside knee up to

inducing hip the clinician's light re-

patient is then asked to raise the thigh sistance and inhale for

the clinician

as for the Ober's test used for test-

10

the patient is told to

seconds. Upon

and the thigh and

are lowered to stretch the muscle. This is

formed three to five times. The muscle can also be stretched same position to stretch the

the

minimus

\

( 9-7 Tensor Fascia Lata MuotaS:Clal Pain and The p.218,

Point Pain Pattern. Source: Adapted from Travell and Point Manual, VoL 2,

&

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PELVIC LOCOMOTOR DYSFUNCfION

A..------

B

Figure 9-8 (A, B) Tensor Fascia Lata Postisometric Relaxation

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Treatment of Myofascial and

Tissue Structures

For ischemic compression, the the

359

with

thigh and

Pressure is directed into the TP

maintained as explained in the above

sections, Heat is applied afterward, and active muscle contractions are pel'rormea by abducting and

the thigh,

points in the tensor fascia hip

are activated and

nplrnp,tl

disturbances, tightness in the iliotibial band, prolonged

a low seat that shortens the

and strenuous running in

tioned people. The tensor

lata TP is commonly activated

the anterior fibers of the IVH
TPs in

minirnus muscle.

Paresthetica (Painful

Because of its pain

a tensor fascia lata TP can be confused condition due to

with meralgia paresthetica, a

of the

lateral femoral cutaneous nerve. The entrapment usually occurs as the nerve exits the pelvis either over, near the anterior

or under the

iliac of the psoas

near the spine as it enters the

within the pelvis by a tumorous mass. On exiting the muscle, it hooks

and proceeds over the sartorius muscle,

sometimes penetrating it. This is another potential site

al-

though rare,2 Symptoms include burning pain and tribution of the lateral femoral cutaneous nerve. with

and

extension6 and relieved

Meralgia paresthetica is often seen in individuals with a men, ie, from

or

Tight

with it.o

waist are also

will be noted in the an-

terolateral thigh, and nerve conduction studies sensory conduction in the nerve where it exits the Because of its close association with the psoas

sartorius muscles, the

lateral femoral cutaneous nerve may be affected if Lewitl mentions that tension in the psoas can be created and even

the lumbosacral and thoracolumbar segments, hip coccyx, He also states that ducing

muscle

relieving the locomotor disturbance and rethe patient with

can be

helped.

Piriformis The

can consist of

VUH�!LU:U"

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360

PEL VIC LOCOMOTOR DYSFUNCTION

nerves exiting the greater sciatic foramen.2 The signs and symptoms of all three may appear separately or overlap to form a complex clinical presen­ tation.8 The more common components found are the myofascial pain syn­ drome and sacroiliac joint d ysfunction.

Myofascial Component.

Myofascial TPs are located by palpating the

muscle in the side-lying position and referring to the imaginary line, the "pirifonnis line," described earlier with the gluteus minimus muscle. It connects the top of the greater trochanter and posterior inferior iliac spine and corresponds to the upper border of the piriformis muscle. TPs are usu­ ally found in the medial and lateral aspects of the muscle and can be pal­ pated externally through the rela xed gluteus maximus. Travell and Simons2 recommend internal examination via rectal palpation for the me­ dial TP if the clinician is in doubt as to its presence.

f�' I>' /

'

';�:

Figure 9-9 Piriformis Trigger Point Pain Patterns. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2, by J.G, Travell and D.G. Simons, p. 188, with permission of Williams & Wilkins, © 1992.

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Treatment of MyofasciaL and Soft Tissue Structures

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,The medially located TP is fOW1d just lateral to the sacrum and refers pain predominantly to the sacroiliac region (Figure

9-9).

The TP in the

lateral part of the muscle is located just lateral to the joining of the lateral and middle thirds of the piriformis line. Pain referral from this TP extends to the buttock and posterior hip joint region, with some spread into the posterior proximal thigh (Figure

9-9).

Aside from pain and tension in the muscle on palpation, resisted isomet­ ric contraction of the piriformis in the sitting position by holding the lat­ eral aspects of the knees with the hips at 90 degrees of flexion exhibits pain and weakness. A positive response and strong indication of piriformis in­ volvement is called the Pace abduction test9 (Figure

Figure 9-10 The Pace Test for the Piriformis

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9-10).

A tight pirifor-

362

PELVIC LOCOMOTOR DYSFUNCTION

mis muscle from TPs can display external rotation of the lower extremity by at least 45 degrees while the patient is resting supine.s Characteristic pain referral and local twitch response on muscle palpation help distin­ guish myofascial involvement. To stretch the muscle, PR in the prone position is easy and effective, especially when combined with ischemic compression.4 With the patient prone, the knee is flexed to 90 degrees, and the lower leg is pushed later­ ally, thus rotating the hip joint internally until the piriformis is brought to slight tension (Figure 9-11). The patient is asked to inhale and gently to press against the clinician's laterally directed hold on the lower leg. After 10 seconds, the patient is told to exhale and relax, and the leg is pressed further laterally when the muscle is felt to let go. This is repeated three to five times. Care is taken not to stress the knee or send the muscle into spasm by too vigorous a stretch. Heat is applied afterward, and the pa­ tient is asked to contract the muscle actively several times. This is best ac­ complished with the patient side lying and the upper thigh and knee flexed to 90 degrees. The upper extremity is raised against gravity several times. An alternative stretch maneuver entails placing the patient supine and flexing the thigh to 90 degrees while adducting it across the body to stretch the piriformis (Figure 9-12). Groin pain Signifies hip joint problems and can be most uncomfortable to the patient. PR is conducted by having the patient isometrically resist abduction while the clinician increases the ad­ duction stretch upon relaxation. A third way to stretch the piriformis is also performed in the supine position (Figure 9-13). The hip joint is held in less than 60 degrees of flex­ ion, the thigh is adducted to tension, and the hip is internally rotated until resistance is met. PR is performed in this position. The patient gently con­ tracts into abduction and external rotation while the clinician supplies counter-resistance. Upon patient relaxation, internal rotation and adduc­ tion are gently increased with a careful stretch. Ischemic compression is effective but must be used carefully so as not to injure the sciatic nerve. Symptoms of shooting pain or tingling down the leg should warn the clinician of this. The clinician must be sure of the TP locations. The point of the elbow can be used, especially on large patients, whereas a double-thumb contact works well on average- and smaller­ sized patients. Factors that activate and perpetuate piriformis TPs are overload, pro­ longed shortening, blunt trauma, a fat wallet in the rear pocket, and sitting in a slouched position. Positions that shorten the piriformis occur when the hips are flexed and abducted, as in obstetrical examinations and when a woman is supine during sexual intercourse.2 •

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Treatment of Myofascial and Soft Tissue Structures

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Figure 9-11 Piriformis Stretch Using PR

Sacroiliac Joint Dysfunction Component. Sacroiliac joint dysfunction

often occurs with piriformis TPs and can contribute to the clinical picture of the piriformis syndrome.s Signs of joint dysfunction are present, ie, ar­ ticular blockage and positive provocative testing, and must be treated in conjunction with myofascial treahnent of the piriformis TP. Neurovascular Entrapment Component. Approximately 85% of cadavers

studied by Beaton and AnsonlO revealed that both the peroneal and tibial portions of the sciatic nerve exit the greater sciatic foramen in front of and below the piriformis muscle. However, in 10% of the cases, the peroneal part passed directly through the substance of the muscle while in 2% to 3% of the cases the peroneal part passed over the superior border before descending down into the leg.

In 1%

of the cases, the entire sciatic trunk pierced the

piriformis muscle. Because of the above anatomic anomalies, the piriformis muscle can entrap the neurovascular structures that accompany it in the greater sciatic foramen. These include the superior and inferior gluteal nerves and vessels, the sciatic nerve, and the pudendal nerve and vessel. Gluteal nerve compression can cause symptoms of pain and paresthesias in the buttock, whereas pudendal nerve compression can create perineal pain, dyspareunia in women, and impotence in men.s Entrapment of the sciatic nerve can appear as a lumbar disc syndrome by causing posterior thigh,

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 9-12 Piriformis Stretch, Sup ine

Figure 9-13 Piriformis Stretch, Supine, Using Adduction and Internal Rotation

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Treatment

Jnt�lar1"1

and foot pain.

Tissue Structures

studies

nerve conduction at the painful

and

slowing of a taut and

sciatic foramen coupled

muscle incriminate nerve entrapment by this muscle. which

is involved can be difficult but the fol-

lowing can serve as a guideline. A myofascial formis consists of the characteristic f/WW.U,.H

365

syndrome of the

referral pattern of this muscle, a

and weak Pace abduction test, and a taut, tender Sacroiliac

muscle

dysfunction is characterized that is

motion, and iliac joint dysfunction. Neurovascular paresthesias in the region of the nerve localized to the sciatic foramen via

Because of its

location, the iliopsoas is an often-overback and hip conditions. It is often short-

looked muscle in its role in ened and

studies.

especially in

problems.

who sit much or have chronic

joint

myofascial TPs are often found with thoracolumbar

and sacroiliac joint dysfunction,

the former. Lewit4 is more and psoas

cWc and relates iliacus TPs t o

Travell and Simons2 describe the palpation of three TP locations in the iliopsoas muscle. The more distal one is in the musculotendinous of the psoas muscle just before its insertion into the lesser trochanter and is ,"UOJ',"",-""

just lateral to the femoral

below the

this TP is referred to the low

ligament. Pain

groin,

anteromedial thigh

9-14). A second TP is found in the iliacus by to raise the

attempts

inside the rim of the

9-15). If the

iliac

iliac crest near the anterior

off the table, the iliacus will be

Pain is usually referred from this TP to the sacroiliac

bulge on and low back. A third TP is

through the abdominal wall Pressure is

rectus abdominis muscle at the level of the umbilicus or

applied downward first and then inward toward the spine. The asked to

raise the

off the table, and the

usually be felt to contract.

is more

is

muscle in obese and muscu-

lar individuals. The patient must be relaxed, and the palpation must be and slow. Pain is referred the

to the low back.

appears

hematomas This can be visualized

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PELVlC LOCOMOTOR DYSFUNCTION

,

•

f

Figure 9-14 Psoas Trigger Point Pain Pattern. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2, by J.G. Travel! and D.G.

Simons, p. 90, with permission of Williams & W ilkins, © 1992.

Figure 9-15 Iliacus Palpation

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Treatment of Myofascial and Soft Tissue Structures

367

Stretching the iliopsoas with PR is very effective and is accomplished with the patient supine (Figure 9-16). The patient extends the affected thigh and leg off the table while holding the opposite thigh up to the chest. The clinician supports the patient by holding the flexed thigh and gently applies pressure floorward on the extended thigh to stretch the iliopsoas muscle. The clinician can let the foot of the patient's flexed thigh rest against the clinician's thorax to apply a better stretch. The resistance and breathing protocol explained earlier for PR are used. Bilateral involvement is common and should be looked for. TPs in the quadratus lumborum are commonly associated with iliopsoas TPS.2

continues Figure 9-16 Psoas PR while supine. (A) Pre-positioning before hel ping patien t down. (B) Assessing hip flexor length. (C) Stretching. Note that patient's foot i s against clinician's thorax.

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PELV1C LOCOMOTOR DYSFUNCTION

Figure 9-16 continued

B

c

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Treatment of Myofascial and Soft Tissue Structures

369

Ischemic compression can be applied at all three TP sites. The transab­ dominal ischemic compression should be gentle and more akin to firm . massage along fibers of the muscle. Factors that activate and perpetuate iliopsoas TPs include vigorous hip flexion as in sprinting, shortening from prolonged sitting, rapid hip exten­ sion, and hip, thoracolumbar, and sacroiliac joint dysfunction.

Quadratus Lumbonlln Due to its location and consequent difficult accessibility, this muscle is very commonly overlooked when clinicians are considering myofascial sources of lower back pain. TPs in this muscle are commonly associated with thoracolumbar and sacroiliac joint disturbancesY The superficial and deep fibers refer pain to the sacroiliac, hip, and lower buttock regions, simulating other disorders. This is an extremely important muscle to ex­ amine routinely. Pa lpation of the quadratus lumborum muscle in the side-lying position is discussed in Chapter

5 (Figure 9-17). The upper and lower aspects of the

muscle commonly harbor TPs both medially (deep) and laterally (superfi­ cial). The upper lateral TP is near the 12th rib attachment and refers pain to

Figure 9-17 Quadratus Lumborum Palpation

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PELVIC LOCOMOTOR DYSFUNCTION

the lateral iliac crest and lower abdomen (Figure 9-18A). The abdominal pain referral can be mistaken for visceral disease or inguinal hernia. The upper medial TP refers pain to the sacroiliac joint and is a common cause of misdiagnosed lumbosacral and sacroiliac joint problems. The lower lateral TP refers pain mostly to the region of the greater tro­ chanter, whereas the lower medial TP refers pain to the sacroiliac and lower buttock regions (Figure 9-18B). These pain referral sites are often tender and cause one to think mistakenly of trochanteric and ischial bursi­ tis respectively. Factors activating TPs in the quadratus lumborum involve unguarded tnmk movements, sustained poshlres, and activities that demand lumbar spine stabilization. The muscle has attachments to the 12th rib, so vigorous and prolonged coughing can also irritate TPs in it. Combined bending and twisting movements of the trunk are a big offender in stressing the quadratus lumborum. Scrubbing floors, vacuuming, and washing the hood of a car are common mechanisms of TP activation.12 Side lying while propping the trunk up on an elbow, as in reading or lying on a beach blan­ ket, will stretch the lowermost and shorten the uppermost quadratus lumborum muscle. TPs can activate if this posture is assumed too long. Structural asymmetries, such as leg-length inequality and small hemipelvis, create a situation in which quadratus lumborum TPs will be perpetuated. Joint dysfunction in the thoracolumbar and sacroiliac joints should be manipulated, since these are often associated with quadratus lumborum, especially the former.12 The quadratus lumborum commonly initiates satellite TPs in the glu­ teus minimus, which in turn can create thigh and leg pain.2 The ipsilateral psoas muscle and contralateral quadratus lumborum often develop sec­ ondary TPs in response to a primary quadratus lumborum TP and should be assessed accordingly. To stretch the quadratus lumborum, Fluori-Methane stretch-and-spray technique in the side-lying posture, as performed by Travell and Simons, works welP DeFranca and Levine12 use a standing lateral bending stretch­ and-spray technique that they find effective with larger and/or very acutely painful patients. PR can also be effectively used for TP inactivation, with a similar side­ lying position used for stretch and spray or the PR stretching of the gluteus minimus muscle (Figure 9-19A). The patient is placed side lying with the involved side uppermost. A bolster or roll cushion is placed under the waist. The upper thigh and leg are allowed to drop behind the patient off the table while being supported by the clinician. The patient holds the head-end of the table with the uppermost arm to afford better stretching.

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Tissue Structures

371

I;J

A

/

,

lumborum trigger point patterns, (A) Lateral or sufrom points. (8) Media l or d eep trigger points. Source: and Myofascial and Dysfunction: The Trigger Point Manual, Vol. 2, by J.C. w ith of Williams & D.G. Simons, p. © 1992. ,-
until tension is felt in the

is lowered behind the tus

The patient then isometrically holds the thigh at that level.

The clinician helps to support the thigh to avoid overloading the muscle. After

the

10

and, upon exhaling, and

by the patient, and

This new length and stretch is again held

The clinician can apply an effective

the above procedure is

on the

stretch chanter fibers

iliac crest or

on the thoracic cage

thigh and

.".aA,e"

further toward the floor.

troThe

are then lowered in front of the

the quadratus lumborum.

Lewitl performs a flex away from

PR, which is an excellent home exercise to Patients stand with feet apart and

teach tight

lumborum. They then inhale

aid isometric contraction of the quadratus lumborum. Looking up with

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PELVIC LOCOMOTOR DYSFUNCTION

A

B

continues

Quadratus lumborum PR in the side-lying position. (B) Separat­ ing the iliac crest and rib cage. (C) Standing PR stretch.

Figure 9-19 (A)

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Treatment of Myofascial and Soft Tissue Structures

373

Figure 9-19 continued

c

the eyes only and not the head also assists in the muscle's contraction.2 They then look down with the eyes, exhale, and relax into more lateral bending. This is performed three to five times. Sitting PR stretching can also be performed by laterally flexing the pa­ tient away from the involved quadratus lurnborum until it is placed on stretch (Figure

9-20).

The patient resists isometrically for

10

seconds, re­

cruits phases of respiration to assist in stretching as above, and relaxes as the lateral bending is increased. This is more effective in medium- and small-sized patients. Ischemic compression is performed in the same side-lying position that is used in searching for the TPs. The uppermost thigh and leg remain on the table behind the patient, and the uppermost arm holds onto the table

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 9-20 Sitting PR Stretch of Quadratus Lumborum

above the patient's head. This allows the iliac crest and 12th rib to separate sufficiently to gain access to the muscle. The entire palpable length of the muscle is explored for TPs that refer pain to their characteristic regions. Ischemic compression is applied untli relaxed, since any muscle guarding response elicited is counterproduc­ tive. Ischemic compression can be performed first, followed by PR stretch­ ing. Heat is applied, and the patient performs active muscle contraction afterward by hiking the hip upward while standing. Hip Adductors

The hip adductors often acquire TPs in response to hip joint dysfunc­ tion, especially in osteoarthritic joints. The muscles involved include the

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Treatment of Myofascial and Soft Tissue Structures

375

brevis, magnus, and the "fourth adductor," the

adductors

The adductors brevis and longus refer

to the

and

9-21). They also refer pain distally to an area

anteromedial thigh

just above the knee. The adductor magnus usually harbors a TP at its midthat refers pain

the medial thigh from the groin to the knee. Its a

upper fibers send referred pain deep into the pelvis,

U"'�"HlUlC

visceral involvement. TPs in these muscles can become activated after sudden muscle pulls; and after activities

as in sitting

after prolonged that demand excessive

use, such as

ers who

and ice on waxed floors in

feet or on ice can

injure

adductors. Hip joint and pubic symphy-

sis problems can activate these TPs as well.

�'

o

I

\

Figure 9-21 Hip Adductor

Point Pain Patterns. Source: Adapted from Tr igg er Point Manual, Vol. 2, by J.C. Travell and rm'''''',()n of Williams & Wilkins, © 1992.

Myofascial Pain and Dysfunction: D.C.

p.

with

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376

PELVlC LOCOMOTOR DYSFUNCTION

The short adductors can be stretched using PR, with the patient supine and the thigh abducted, flexed, and externally rotated as in the Patrick­ Fabere test; however, the foot is placed on the table medial to the other knee (Figure 9-22). Using PR protocol as described before, the clinician presses the knee toward the table to stretch the adductors brevis and lon­ gus. To stretch the adductor magnus, the knee is pressed toward the table and then slightly headward. The straight leg can be abducted to stretch the adductors when using PR. To stretch the adductors brevis and longus, the abducted thjgh is pressed floorward (Figure 9-23A) . To affect the adductor magnus more, the abducted straight leg is flexed head ward, as if performing an abducted straight-leg-raising test (Figure 9-23B). Ischemic compression can also be employed to inactivate these TPs (Figure 9-24) . TREATMENT OF TEN DON AND LIGAMENT LESIONS

An effective method for treating soft tissue lesions in tendons and liga­ ments is transverse friction massage, also called cross-fiber massage. One can­ not do the topic any justice by briefly mghlighting its main poin ts; how-

Figure 9-22 PR of Short Hip Adductors

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Treatment of Myofascial and Soft Tissue Structures

377

A

8

Figure 9-23 (A)

PR of add uctors brevis and longus. (8) PR of adductor magnus.

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 9-24 Ischemic Compression of Hip Adductors

ever, the reader is referred to an excellent reference written by Hammer.B Hammer emphasizes the need for accurate assessment by using selective tissue tension examination. The structure at fault needs to be diagnosed by functional examination rather than by massage based solely on the painful spot's locale. One needs to determille if a tendon, ligament, or muscle is illvolved. Once the structure is identified, then finding the tender spot be­ comes more meaningful . The mechanism of action of transverse friction massage is to break down adhesion formation in healing or healed tissues and to create a reac­ tive hyperemia.14 The technique is thought to aid ill the realigning of col­ lagen fibers in the developing scar tissue (Figure 9-25). Transverse friction massage is to soft tissues what mobilization and manipulation are to joints. In the acute stages of inflammation, when collagen fibers are being laid down, light transverse friction massage imparts the early mobiliza­ tion so important in reducing scar formation and hastening healing. In chronic conditions, deeper more vigorous transverse friction is needed to break down interfiber adhesions and create mobility between the injured structure and surrounding tissues.

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9-25 Transverse Friction

379

'Vi""'"''l'.'''

Four areas where transverse friction massage can be used are the erector spinae insertion site on the sacrum and

the

abductor tendons at

trochanter, the hamstring muscle origin at the ischial tuberos-

the

and the adductor

tendon or its

These tendons or insertions are are

on active and resisted

are

painful when put on stretch.

is identified, the most tender UW'''' ':>« ;;'''

first.

to contractile tension and thus of motion on examination. They the painful tendon or insertion

in that tendon is

occurs across the fibers at

2

to 3 minutes of

painful, allowing

,'l"r"'C_, M

at the tissue becomes less This process is continued

" c;,::".., <>,.

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380

PELVIC LOCOMOTOR DYSFUNCTION

' , ,,, ,, " r m t_rrlA t.An

treating these

Hammer!3

and

ac-

exer cises . every o ther day, with most

overuse syndromes responding in 2 weeks to 2 months. The addition of manual treatment to any articular dysfunctions or

TPs is also

commonly TREATMENT OF TIGHT, SHORTENED MUSCLES

law tells us that muscles need to be at an optimally. Although i t

L _ ,..,, _ L_<�

to include skeletal muscle. In the muscles are muscles are muscles that are not a daptively or painfully shortened, but are and func­

for optimal

at their

or overstretched. "Short" to a shorter-than-usual

other hand, are ones that have can be caused

which even a fter painful

inactivated can leave a "memory" of dysfunction ; when joint

a" av·" ".o"

..

or

causes a reflex spasm that lasts for

months; or lack of use o r chronic postural overload, as in the case of the who s i t far too much. In all these

muscles of becomes

n

unable to function

function elsewhere. And in all these instances, the muscle can be reeducated to lengthen Length-strength treatment is trea tment of muscle length o r distensibiland any related weakness. As discussed i n muscle groups i s short and tight, the

4, when one s e t of

set is often found to be

observed that when the

weak and inhibited. It i s

Contract-Relax-Antagonist-Contract Technique

This form of facilitation stretch utilizes both

and

Autogenic inhibition refers to a muscle's " .. c"•• n o-

I"'lP('A n m n a

a sustained isometric contraction. This is what

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Treatment of Myofascial and Soft Tissue Structures

occurs with PR.

Reciprocal inhibition

refers to a muscle's

to its

m

dimension CRAC

inhibited

contracting. This is

to a stretch. As its name

381

the

ad ded to be

stretched is contracted strongly for about 7 to 1 0 seconds followed by a relaxation

The

contraction is about 75% maximal c:trp,,,:rth between 50% and 80%

However, a

maximal contrac-

patient is then instructed to contract the antagonist to

tion can be

a fford active s tretching and reciprocal inhib i tion of the

The

muscle is held at this new length and rested for 10 seconds before another cycle of

is initiated.

from PR

CRAC

nist contraction and active

a

ago-

supplied by the antagonist

This fonn of stretching can be used when trying to lengthen tight who can tolerate

especially i n

hamstrings and adductor

must be

agonist contractions. The hand so that the patient knows what to

Hamstring Muscle Group As a whole, this muscle The

is

the clinician raises the

the hamstrings come under slight tension (Figure instructed to push w i th about half to m a x i m u m the

clinician's countering resistance. After 10 to relax slowly while the clinician stabilizes the

so that no movement

occurs. When relaxation is sensed by the clinician, the patient is asked to contract the antagonists and move the

to stretch the in order

In this case, the patient is told to

recruiting the hip flex-

and raise the

to recru it the

gets a double "dosett

the

inhibition. The

is maintained for 10 seconds. The procedure i s three to five times.

Exhibit 9-1 PR and CRAC CRAC

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382

PELV1C LOCOMOTOR DYSFUNCTION

A

B

Figure 9-26 CRAC using the hamstrings, (A) Muscle is contracted, (8) Stretch is applied and held,

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Treatment of Myofascial and Soft Tissue Structures

383

Hip Adductors

The adductors are stretched as a group using CRAC. The patient is su­ pine with the clinician supporting and abducting the involved side to ten­ sion (Figure 9-27). The opposite leg is dropped off the table, with the foot resting on the floor to help stabilize the pelvis. CRAC is performed as above, but with abduction increased as the hip abductors supply the active stretch. Dysfunctional glutei or tensor fascia lata muscles ma y cramp if overshortened by their own contractions. On the other hand, if they were being inhibited by tight adductors, reexamination of their contraction strength will show improvement. Rectus Femoris

Normally when the patient is prone, the heel should be able to touch the ipsilateral buttock if the rectus femoris is of normal length. To lengthen this muscle, PR is used rather than CRAC, since the hamstrings often go into a cramp if actively contracted while in a shortened position. It is com­ mon to find patients with pelvic joint dysfunction exhibiting short rectus femoris muscles tha t create a tethering tension to the anterior pelvis. Trig-

Figure 9-27 CRAC Using the Adductors, Supine

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384

PELV1C LOCOMOTOR DYSFUNCTION

ger points in this muscle refer pain down the anterior distal thigh to the knee (Figure

9-28).

To stre tch this muscle using PR, the pa tient is placed

prone with a rolled-up towel placed under the distal thigh to impart slight hip extension (Figure

9-29). Grasping the distal leg, the clinician flexes the

knee and puts the rectus femoris on a slight stretch. The protocol for PR as described previously is followed. Full lengthening can be attempted by lifting the thigh off the table more when the knee is fully flexed. This tech­ nique should only be used with caution in the presence of knee joint prob­ lems. Caution should be used with a very tight rectus femoris, for it will cause the pelvis to tilt anteriorly when being stretched, and pain may be experienced in the sacroiliac or lumbar facet joints.

o

\ I

•

Figure 9-28 Rectus Femoris Trigger Point Pain Pattern. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Ma nual, Vol. 2, by J.G. Travel! and D.G. Simons, p. 250, with permission of Williams & Wilkins, © 1992.

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385

Figure 9-29 Rectus femoris PR stretch. Note rolJ under distal thigh.

Postfacilitation S tretching

Another type of stretch that can be used to stretch chronically shortened and tight muscles is postfacilitation stretching (PFS). It takes advantage of the inhibition period after an isometric contraction to aid in stretching a muscle. The key aspect to this procedure, as its name implies, is stretching. The muscle is posi tioned at midrange and contracted strongly for 10 sec­ onds; then it is immediately placed on a quick, strong stretch for 20 sec­ onds. The patient must immediately be able to let go completely after the contraction to afford full relaxation. Since it is a strong stretch, the patient should be told beforehand that he or she will experience pins and needles, numbness, and even discomfort for the duration of the stretch. After the stretch, the muscle is allowed to relax for 30 seconds, and the procedure is repeated 2 to 4 more times. Three sessions of stretching per week for 2 weeks is a suitable trial. The difference between PFS and PR is that the isometric contraction is much more forceful, as is the passive stretching. In using CRAC, the stretching is actively initiated by the patient, whereas in PFS it is totally passive. An example of using PFS on the adductors is shown in Figure 9-30. The patient is in the side-lying position with the

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386

PELVIC LOCOMOTOR DYSFUNCTION

A

B

Figure 9-30 Postfacilitation stretching using the adductors, side-lying. (A) Con­ traction phase. (B) Stretch phase.

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Treatment of Myofascial and Soft Tissue Structures

387

involved side up. The upper thlgh is passively abducted toward the ceil­ ing until tension is met. The patient tries to adduct the thigh strongly against resistance provided by the clinician. After 10 seconds, the patient relaxes, and the thigh is strongly stretched more into abduction. This is performed three to five times. PR can also be performed in this position. M I SCELLANEOUS CONDITIONS Iliotibial Band Syndrome

Tight, shortened iliotibial bands are very commonly associated with chronic sacroiliac and hlp joint dysfunction (Figure 9-31). They also per­ petuate TPs in the hip abductors, tensor fascia la ta, adductors, and quadratus lumborum. Ober's test is positive (see Chapter 5), and the groove the band forms on the lateral aspect of the thigh deepens. It is im­ portant to treat these structures early, since they are very difficult to re­ lease once they have adaptively shortened. Iliotibial band friction syn­ drome is seen at the lateral aspect of the knee due to a tight ilio tibial band rubbing back and forth over the femoral condyle. The snapping-hlp syn­ drome is commonly attributable to a tight iliotibial band, and reduction of

Figure 9-31 Tight iliotibial band. Note the d istal end of the band.

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PELVIC LOCOMOTOR DYSFUNCTION

symptoms often occurs after sacroiliac joint manipula tion and band stretching. IS Before stretching tight iliotibial bands, joint dysfunctions and myofascial TPs in the region should be treated. Interestin.gly, locomotor disturbances in the lower extremity and foot are commonly present, and their treatment often facilitates the progress of the more proximal dysfunc­ tion. The iliotibial band is a thick, tough band of connective tissue that can be hard to stretch. It is often tender to palpation, and the overlying soft tissue often contains small painful nodules. Moist heat applied to the iliotibial bands beforehand facilitates stretching. Next, longitudinal stripping mas­ sage strokes can be used until the tenderness subsides (Figure 9-32). The A

continues Figure 9-32 (A, B) Iliotibial Band Stripping Massage

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389

Figure 9-32 continued B

patient is placed supine, with the involved side up and flexed at the knee. The leg is slightly adducted, and the foot rests on the table. The stripping massage strokes start distally at the femoral condyle and proceed toward the greater trochanter. A lubricating lotion can be used but is not neces­ sary. The stripping massage is performed using both thumb pads, with the thumb tips touching, or using the soft part of the proximal forearm. The distal end of the band can be exquisitely painful, and care should be taken to stay within the patient's tolerance. After longitudinal stripping massage, transverse stretching of the band along its entire length is done, one section at a time. The patient is placed in the above side-lying position. Standing behind the patient, the clinician places the thumbs on the posterior border of the band, thumb tips touch-

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PELVIC LOCOMOTOR DYSFUNCTION

ing, with the fingers placed on the anterior side. The fascial band is pulled over the thumbs, using the fingers in a motion like that of bending a stick. The thumbs act as a fulcrum over which the band is stretched (Figure 9-33). In this way, the anterior border of the band is put on a localized stretch. After stretching the entire length of the band in this manner, the procedure is repeated, but this time with an attempt to lift the band off the underlying tissues. Next, the clinician stands in front of the patient and stretches the poste­ rior border of the band in a similar way. The stretching session is finished with skin rolling over the length of the band three to five times. Transverse friction massage is often needed over the femoral condyle and greater tu­ berosity and should be performed on a separate visit. In conjunction with a ttending to any articular and muscular dysfunctions in the area, this pro­ cedure needs to be performed several times over 2 to 4 weeks. Stretching exercises are also taught to the patient and are discussed in Chapter 11. Sacrotuberous Ligament Pain

The sacrotuberous ligament is an often-overlooked source of trouble in the case of pelvic joint and muscle dysfunctions. It is not seen with much

Figure 9-33 Transverse Stretchin g of Iliotibia l Band over the Thumbs

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Treatment

391

it can cause much pain and disability for

but when it is

and frustration for the clinician who is unaware of its importhat can be traumatized from di-

tance. This is a thick, rect falls on the

Case History A 44-year-old man

to sl ide down a sliding board with his 4-year-ol d

o n h i s lap. When

reached the end of the

the father landed o n His lower back and

the ground on his right buttock, falling about 2 0 i n t o the

buttock h u rt for 2 weeks and gradually subsided, but h e was l eft with a deep buttock ache that bothe red him most with sitting. The pain

down t h e back of his prolonged sitting. Walk-

thigh almost to his knee. Nothi n g really bothered it

and deep pressure into his buttock seemed to help. Examination revealed right sacroiliac joint

and g luteus medius/m i n i m u s trigger points. However,

d irect pressure on his sacrotuberous ligament elicited h i s t h i g h . Sacroiliac

pain referral down his

and caused

manipulation and

stretching helped, but most relief was attained aft e r direct pressure were applied to the sacrotuberous ligament.

Another patient, a woman, complained of a ment after

sitting o n a hard Women commonly

av,,, o,',o,v'a

a nd

Men usu a l ly suffer women,

not immune from traumatic of prolonged

tive to the adverse

seem more sensi-

in addition to

birth. refers

The sacrotuberous

in the lower buttock and

into the proximal and mid posterior

9-34).

achy, sometimes

scribed as a long periods of

It is

de-

discomfort, especially a fter

Getting in and out

a chair is difficult, and the

to stand.

patient

postural evidence

On

parent, but so is it in many in its lower

restricted,

is nonnal ex­

cept for restriction due to hamstring tension. The Patrick-Fabere test lateralizes to the side

involvement;

the prone

palpation of the

pain. The

is shortened and

this is not

In

will reproduce and will feel firm to

and almost To treat the

directly,

inactivate any TPs present in the gluteal

and

is applied to stretch it and Contact is taken

is

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inside the

392

PELVlC LOCOMOTOR DYSFUNCTION

Figure 9-34 Sacroruberous Ligament Pain Referral Pattern. Source: Adapted from Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2, by J.C. Travell and D.C. Simons, p . 292, with permission of Williams & Wilkins, © 1992.

several points along the length of the ligament (Figure 9-35). Some au­ thors recommend treating the ligament though the rectum,16 but exter­ nally applied pressure can be just as effective and more comfortab le. Strong pressure is maintained for 30 seconds at each point along the liga­ ment or until the referred pain diminishes, whichever is less. Sacroiliac joint manipulations greatly improve the condition, and the patient is coun­ seled in exercises to promote suppleness in the pelvic ligaments (see Chap­ ter 11). Interestingly, pelvic organ dysftmction is noted to occur regularly in chronic dysfunction of this ligament.16 Probably because of the stress of childbearing, women experience sacrotuberous ligament problems more often than men. Dysmenorrhea can also be initiated or worsened after a sacrotuberous ligament problem starts and is commonly observed to lessen in most of the cases treated.

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Figure 9-35 Sacrotuberous Ligament Pressure Techni que

CONCLUSIO N

Muscles commonly become dysfunctional in association with pelvic joint problems. This typically manifests as myofascial pain syndromes or adaptive shortening of select muscle groups about the pelvis. Postisometric relaxation, CRAC, and postfacilitation stretch are stretching procedures that can be used to treat these muscles effectively. Ischemic compression and s tripping massage aid in inactivating TPs. The sacrotu­ berous ligament can be an overlooked source of pelvic, bu ttock, and poste­ rior thigh pain and should be assessed for involvement. The i liotibial bands commonly shorten in the presence of chronic pelvic joint problems and must be addressed therapeutically.

Chapter Review Questions

•

What are myofascial trigger points? How are trigger points inactivated?

•

How is postisometric relaxation performed?

•

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394

•

PELVIC LOCOMOTOR DYSFUNCTION

What is the "piriformis line"?

•

Differentiate the clinical presentation of trigger points in the three gluteal muscles. Differentiate the myofascial from the neurovascular aspects of the piriformis syndrome. How does transverse friction massage work? Why is the iliotibial band an important structure clinically?

•

How does a patient with a painful sacrotuberous ligament present?

•

•

•

•

Contrast postisometric relaxation, CRAC, and postfacilitation stretch.

REFERENCES 1. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1 .

Baltimore, Md: Williams & Wilkins; 1983. 2. Travell JC, Simons DC. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 2.

Baltimore, Md : Williams & Wilkins; 1992. 3. Zohn

0, Mennell JM. Musculoskeletal Pain: Principles of Physical Diagnosis and Physical

Trea tment. Boston, Mass: Little, Brown & Co; 1976. 4. Lewit K. Manipulative Therapy in Rellabilitation of the Locomotor System. Boston, Mass:

Butterworths; 1985. 5. Ghent WR. Meralgia paresthetica. Can Med Assoc f. 1972;631-633. 6. Edelson JG, Nathan H. Meralgia paresthetica: a n anatomical interpreta tion. Clin Orthop. 1977;122: 255-262. 7. Butler ET, Johnson EW, Kaye ZA. Normal conduction velocity in the lateral femoral cuta­

neous nerve. A rch Phys Med Rehabil. 1 974;55:31-32. 8. Retzlaff EW, Berry AH, Haight AS, et at. The piriformis syndrome.

I A m Osteopath Assoc.

1974;73:799-807. 9. Pace JB. Commonly overlooked pain syndromes responsive to simple therapy. Postgrad

Med. 1975;58:1 07-1 13. 10. Beaton LE, Anson BJ. The sciatic nerve and the piriformis muscle: their in terrelationsh.ip

as a possible cause of coccygodynia.

I Bone loint Surg (Br). 1 938;23:686-688,

1 1 . Nino-Murcia M, Wechsler RJ, Brennan RE. Comp uted tomography of the iliopsoas

muscle. Skeletal Radiol. 1983;10:107- 1 1 2 . 1 2 . DeFranca GC, Levine L J . The quadratus lurnborum a n d low back pain.

I Manipulative

Physiol Ther. 1991;12:142-149. 13. Hammer W. Friction massage.

In: Hammer W, ed . Functional Soft Tissue Examination and

Treatment by Manual Methods. Gaithersburg, Md: Aspen Publ ishers, Inc; 1991:235-249. 14. Cyriax J. Textbook of Orthopaedic Medicine. London: Balliere-Tindall; 1984. 15. DeFranca CG. T11e snapping hip syndrome: a case study. Chiro Sports Med. 1988;2:8-1 1 . 16. Midttun A, Bojsen-Moller F . The sacrotuberous ligament pain syndrome. In: Grieve GP,

ed . Modern Manual Therapy of the Vertebral Column. New York, NY: Churchill Livingstone; 1986:815-818.

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Chapter 10

Clinical Considerations

Chapter •

to discuss treatment categories

•

to discuss abnormal movement

•

to describe

and their treatment

associated or linked

and the

primary as well as

importance of finding and

c.ar'rmJi

dyshmctions •

to discuss the manipulation of transitional segments

•

to discuss

•

to discuss treatment of children

•

to discuss the possible effects

treatment of the locomotor system

on somatovisceral d isorders •

to describe postsurgical or "flat-back" syndrome

•

to list

In

preventive measures

joint and muscle problems, various situations moduIs the

young, with a traumatic first-time involvement associated

with a with tissue

and

sites of problems? Are there

ing factors that need to be addressed? Is the pelvic o ther

of the locomotor

affecting

and vice versa? Is the patient relatively

and in good physical condition or in a deconditioned s tate, and leading a s tressful lifestyle? The latter situation is not uncommon and presents many therapeutic volve

the

health. In this chapter, observations that

most of which in-

to take more clinical

to the above situations and others.

395

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for his or her are discussed

396

PELVIC LOCOMOTOR DYSFUNCTION

TREATMENT CATEGORIES

in

joint dysfunction is to restore normal joint

and

the

is full range and pain free, ie, myofascial

in treating muscular

syndromes, and con-

tive shortening, injury, etc, is to restore normal

of the affected muscle, Patients are often treated until their pain and then treatment is

is gone or much

This works well

in patients suffering from acute conditions, However, their pain can be the tip of the clinical

It is

deeper, more chronic

common for patients to seek clinical attention for

conditions that

are actually compensatory reactions of the locomotor

to a more

primary, chronic problem, For example, chronic hip

dysfunction

by osteoarthritis is commonly associated with COlnpen:sa lumbar

sacroiliac

can cause consequent painful muscle reactions or hip joint symptoms, yet itself remain silent to the to reduce

symptoms,

Although it is important

are often only

of the problem, Sole in the case of

often results in

treatment of

locomotor disturbances, Treatment termed p assive care pertains to therapy applied by the or receives to a patient, who electrical modaliice, Passive care is

in the acute

of injury;

use fosters physician dependence and chronicity, to treatment

"active" involvement and re-

of the patient.! Exercise is the foundation of active care and includes

and stabilization exercises. A

key factor in effective treatment is

when and how to shift a

to active care.

tient

and chronic conditions necessitate somewhat An acute exacerbation of a chronic condition often

treatment

occurs and is managed by treating the acute phase first and then focusing on the chrome dysfunctions that were responsible for the Quebec

describes the acute

the subacute

The

over the first 0 to 7

as

the 7th as beginning after the 7th week

Acute Phase

commonly follows trauma from either extrinsic or intrinsic causes,

the latter,

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and

Clinical Considerations

397

in some cases, but many patients present with nate in the clinical loss function. The acute symptoms may be new to the may be similar to past but due to a recent injury. repeated occurrences, devoid of extrinsic trauma as a precipitating etiology, indicate even more an acute is further raised if the This exacerbation of a chronic condition again in the same manner as in the or in a manner similar. guidelines,l an initial 2-week trial of manual n-LLV1UJLlIl'. to the be started at a frequency of three to five visits week. If therapy no documented improvement is seen, a second 2-week trial can then be after a total instituted a different treatment p lan. Failure to of 4 weeks of treatment necessitates a referral or that would If improvement is seen and no complications are to 6 to 8 weeks with up to three treatment can delay to reach times per week visit status. factors that can increase treatment time hibit 10-1 and should be used for Pf()gTlOSOCC3.tll Treatment are to reduce symp toms disability and to predeveloping. Treatment by mobilization and if indicated, should commence lation of joint on in to do so Joints exist to move and should be of the joint in question and the C,"r,.Ol1n'; further to soft tissues. movement does not mean grade V mamoved with gentle injured nipulations. An can be I and II mobilizations to stimulate override of dysfunctional as the manipulation will not disturb the Often, mobilizations are performed on the joint for a manipulation without the patient can tolerate the tolerated well. How­ if it increases when

Exhibit 10-1 Factors

Treatment

of symptoms over 8

or

conditions

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398

PELVIC LOCOMOTOR DYSFUNCTION

joint slack is taken up, a

V manipulation is not

time. Often, the patient nr':>
with acute sacroiliac

can be instructed in the

stretch discussed in the next

This is very helpful in cases

is stretching

acute pain can often be instructed in or on a house calL

over the

can ambulate better and tolerate treatment after

more of an examination and

the

stretch. Daily applications of ice for 30 minutes every 2 hours are used on the area, and if the

can be motivated to follow a plan

such a plan can be instituted. This can be nothing more than ice applications until numb,

several minutes of walking. See

8 for a more specific treatment of joint

nv'tl",n and myofascial trigger

conducted as explained in

is

on a daily basis for 2 weeks. If the first visit,

dramatic improvement occurs in 24 hours visits during the second week suffice.

"'.<';""''''''0'<

treatment in the short term is effective. The term nm),1'",c<:i,"" of visits and not to the

increased

ment. Children rarely need 2 weeks

care and usually resolve on a motion, including

reduced schedule of visits.

muscle contrac-

provocative testing, and normal tion

and length signal clinical resolution.

Acute cases seem to respond better when the clinician restricts treat­ ment to a few selected problems per visit rather than attempting to treat every finding in

in sight. Attempts to treat order to

the patient's pain in one visit can backfire with more pain

due to overtreatment. Confusion of the clinical

on subsequent as­

sessments can occur with such an approach. a case in which a

sacroiliac joints and thora-

are manipulated, the

lumborum and gluteus

points are treated, and the

are mobilized all in

the patient returns for assessment and treatment on the one of three things is observed: the clinical picture is the or takes a turn for the worse. come, but

of the out-

if the patient worsens, the clinician will be hard

to determine what has helped or harmed the case. All of the above areas treated can shotgun

similarly when to treatment can often

What is worse, the clinician is unable to tell if the the treatment or in

of it

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themselves. This

Clinical Considerations

therefore, is to

painful

in treating the pain

399

and stabilize the situation. If the case is not clear at of

become clear as the

tissue focus in the average are based on

is pain, treatment success and it is also the responsibility

pain

the clinician to re­

to avoid the development of a

store normal function as quickly as chronic condition. Subacute Phase

the next 7

After the acute phase, the subacute phase weeks.2 Treatment frequency should be from

to 7

to two visits per week A

care to more active care should be

and stabiliza-

tion and rehabilitation exercises should be implemented. The Mercy describe this period as

6 to 16 weeks, with treatments

not to exceed twice weekly. Patients with abnormal illness behavior and tendencies toward chronic

behavior should be identified at this time

(see below). Chronic Phase

The chronic phase of care can start or 16 weeks.4 There is pain of more than 3 or 4 Hence the

from 7 weeks2 to 12 weeks3

agreement that of those over 50% will be

of

Vel.:J"UJ,l"\.<

and

chronic conditions and is defined as a patient's

or

response to a physical

complaint.? Factors that typify abnormal illness behavior are hibit 10-4. A

or in

is indicated in such cases, and a be made.

psychosocial Chronic joint

are characterized

stiffness,

and soft tis-

Often bony changes are observed radiologically, as in osbut

findings correlate poorly with subjective

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400

PEL VIC LOCOMOTOR DYSFUNCTION

Exhibit 1(}-2

• •

for Patients at Risk of Becoming Chronic

Somatic pain symptoms static for 2 to 3 weeks Functional abuse (recreational or

• •

Warning

Emotional distress

TI1e focus in chronic situations is on stiffness and poor funcpain and spasm can occur in an

tion rather than pain and spasm.

are commonly associated

case. Chronic

injuries that have healed either poorly or with .nc'hr,nc as sequelae. In

work and lifestyles create, as

well as perpetuate, chronic locomotor disturbances. seen, with ligament,

Involvement of multiple tissues is

recovery of

and/ or articular

than the rule, due to

chronic joint problems is the fibrosis, and

tive

and muscle dysfunction: the

hallmarks of a chronic situation. A

of the above is a

in his 50s who has recurrent

pains for 15 years, sits 8 hours a day, and does not Examination commonly reveals painfully stiff joints muscles laden with

Such patients can but, more

or just stfi fness.

function needs to be restored, exercise and stretching need to and advice needs to be

to offset the daily postural perpetuating

needs to be Treatment lnf'nn",

involve

back into the area. Any

exacerbations

and exercising care should be directed at acute

with active care in the form of exercise and advice demand in the

Exhibit 1(}-3

•

of treatment and exer-

The Five "D's" Often Seen in Chronic Pain Patients

Drug abuse: abuse of pain medications )pn,pn,cjprlrv' "'''''''''In!

deIJre,;SlCm helplessness

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Clinical Considerations

401

Exhibit 10-4 Characteristics of Abnormal Illness Behavior

to cope

upon the involved tissues and

cise needs to be to cause a

long

in jOint mobility, soft tissue extensibility, and

strength. Unfortunately, blood supply to many articular structures is Modalities and pro-

infertile grounds for

part will thus aid

cedures that enhance circulation to the

aggn�ss.lve conservative management is

to establish

functional restoration in chronic cases. Even though c hronic joint and well to manual treatment, some cases re-

muscle

is all one can hope

Sometimes a 50%

spond

for someone who has had chronic dysfunction and disability for years, even this is a welcome

The focus should be placed on active

care so that

versus

patient is actively involved in his or her

own treatment. reactions are

and

multiple tissues are

present. These can confuse the clinical picture, especially if they are treated all at one time. As in acute conditions, 2 to treatments are directed at the COlnponents involved. As treatment ment allow one to continue with

3 weeks of daily or

joint and soft tissue observation and assessthat

and to

those that have no effect or exacerbate the condition. As mobility should diminish, and the

subside, treatment taught

and

ditions usually last

exercises.

should be when acute con-

treatment of chronic joint and muscle conditions

takes \-veeks and even months to restore function satisfactorily. individuals may be able to tolerate only

visits or

visits twice weekly. If no improvement is seen in 2 weeks followed other 2-week trial of treatment, then the chances of

the

with manual treatments are very minimal. However, suspending treat­ ment for 2 to 3 weeks after an unsuccessful initial clinical trial is sometimes followed

of improvement. Treatment can then be reinstituted af­

ter reassessment of the sihlation. This also occurs after weeks of therapy when a patient reaches a

and appears to be clinically static. Sus-

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402

PELVIC LOCOMOTOR DYSFUNCT[ON

for 2 to 3 weeks and then

pending

the situation often

facilitates continued improvement. It is common to find

tight

and

muscles in

muscles and weak about the sacro-

joint conditions. The

iliac and hlp joints are usually tight and limit motion. These tissues must be rehabilitated to afford functional return to the area and, more important, to

recurrences and aid the patient in

lem. Radiographs of the

sacroiliac joints not only is

of the sacroiliac joints. Manipulating tile but may

the probankylosis

should be taken to rule out

unwarranted movement to the neighboring lumbosac-

ral Acute Exacerbation of a Chronic Condition A common nrt'",,,,'nt,,

is that of a patient with a chronic pain syntolerable but is punctuated by

drome that is

of

is one of an acute presentation, but it is an dysfunctional condition that has chronically the

is treated and the acute

and

needs to be assessed for chronic are an important

of treatment. Con-

therapeutically or have healed Recurrent exacerbations of a chronic fac-

condition indicate continued poor locomotor function. overload, hypermobility,

tors such as

and stress need

of treatment in this case are to treat the underly-

to be addressed. The

about

chronic dysfunction, educate the try to control any

and limit or

factors. Continued frequency of exacerba-

tions indicates lack

or

failure.

ABNORMAL MOVEMENT PATTERNS AND TREATMENT

and muscle function are searched for

During the examination,

and then treated with passive and active care methods to restore normal function. Poor movement points.

muscle

out of the acute

often coexist with joint dysfunction and should be examined for when the

In the pelvic region, the three movement

examined for are hip extension, hlp abduction, and trunk flexion, and the overactive and underactive muscles (see are

5) are identified and treated. to

articulations.

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Clinical Considerations

and exercises are

searched for and treated """l-�DT-n

403

to

muscles. Correction of the poor

the

facilitates treatment of the

joint

in recurrent conditions. enhance peripheral in

input are very helpful et al8 had

the nervous

walk in balance shoes for 3 minutes five times a day. The shoes were san­ attached to the bottom of them.

dals with a

found that in

increases in

1 week, as measured on EMG.

input can also be en­

hanced by use of wobble or balance

home instruction

involves using a broomstick handle and a 10

x

1S-in

pl)"
axis in the

under the pl)"
to balance himself or herself When the stick's axis is placed under the

tries to maintain balance using anterior-to-pos-

coronal plane, the terior

The balancing movements should come from the

ankles and

the trunk. A much more difficult

and not from

attached to the bottom of a board. This

balance board uses a

forces the patient to maintain balance around an axis enhance

360

To

input from the peripheral

remove visual for

stratecenter but in the

cues

their eyes. Another

to perform at home is to see how long a

stance with

eyes closed can be held. If,

the

of the

extension movement

movement,

contraction sequence are

a

search for the cause is performed.

one will find tight, overactive

iliopsoas, rectus femoris, erector

and hamstring muscles and a relax­

weak, inhibited gluteus maximus muscle.

should be used first to

appropriate ver­ over the inhibawareness. The come aware

is taught how to be-

the inhibited muscle and is instructed in

Additionally,

it

and lumbar joint

searched for and treated. The

demonstrates overactive

abduction movement

tensor fascia lata, hip

and

lumborum muscles and an

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404

PELVIC LOCOMOTOR DYSFUNCTION

underactive, inhibited gluteus medius muscle. Facilitation stretching of the tensor, adductors, and quadratus lumborum should be performed first, followed by activation of the gluteus medius. Joint dysfunction should be searched for and treated in the hip, sacroiliac, and lumbar joints. The trunk flexion movement pattern usually reveals poor lumbopelvic stabilization, with weak abdominal muscles being substituted for by over­ active iliopsoas muscles. Weak and inhibited gluteus maximus muscles are usually present. Overactive erector spinae muscles also inhibit the abdominals and should be assessed for tightness. These tight, overactive muscle groups should be stretched using muscle facilitation stretching techniques. The abdominal muscles should then be facilitated with vari­ ous pelvic tilting exercises, verbal cues, and tactile stimulation designed to enhance abdominal and gluteus maximus contractions.

ASSOCIATED DYSFUNCTIONS (CHAINS) As a multilevel system in which all levels are functionally interdepen­ dent, the locomotor system exhibits fairly consistent reactions to dysfunc­ tion, especially chronic dysfunctions. These seem to occur in chain-reac­ tion fashion, being linked together in function and dysfunction through reflex phenomena. Finding one should lead the clinician to look for the others. Correction of related dysfunctions, if found, is necessary to prevent recurrences of the pelvic joint disturbance. No part of the locomotor sys­ tem functions without affecting parts elsewhere. However, confusion arises if one is unaware that pelvic joint and muscle dysfunctions can have far-reaching effects on the locomotor system. How can functional disturbances of the pelvis affect structures as distant as the upper cervical spine? Why is it that if you stomp on someone's foot, the person will scream "ouch" and his or her pupils will dilate-both re­ sponses occurring quite distant from the site of physical insult? The nervous system and its intimate relationship with the locomotor system are what allow these reactions to occur. Often these reactions ap­ pear unrelated. For example, as incredible as it may seem, it is quite com­ mon to note functional changes in the craniocervical region in response to manipulation of the pelvic joints, especially in children. On the other hand, correction of upper cervical joint dysfunction is often noted to affect pelvic joint function. Sacroiliac joint disturbances are often associated with joint dysfunctions in the lower two lumbar segments and/ or ipsilateral hip joint, especially in adult patients. More common, however, are coexistent craniocervical and thoracolumbar joint dysfunctions, especially the former. Conse­ quently, upon finding pelvic joint dysfunction, the clinician should assess

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Clinical Considerations

for associated disturbances, In

these

405

more than in

is commonly linked with sacroiliac joint is manifested by treat-

Interdependence of the locomotor

one end of the spine with manual methods and noticing functional at the other end, On the other only to have the patient

iliac joint

after, In such a case, functional assessment often demonstrates a painfully blocked

cervical

that

rapidly to

with

the associated areas of dysfunction are the middle or up­ per thoracic

here

Often, previously dysfunctional

can be observed to move more freely after

joint manipulation, In

association with this is often a painful

of the right T5-6 costojoint

transverse articulation that self-corrects after correction of the

it occasionally can worsen and needs direct treatjOint dysfunctions are commonly found in association Most

affected are the proximal tithe ankle and

the anchor point of the dosed kinematic chain during

will force compensatory reactions in more cephalad strucstubborn pelvic

hires, Strangely

dysfunctions often

joint disturbances, This is

to correction of lower

served in runners and people who stand for most of the day. Subtalar and midtarsal joint function should be routinely assessed, Plantar-to-dorsal joint restrictions in the calcaneocuboid articulation are another important dysfunction to assess. Their correction often has favorable effects on pelvic and

function, In

tight iliotibial bands with

fl''''A''''';'

in the tensor fascia lata frequently coexist with joint dysfunction. Muscles typically harboring minimus

tently seen with sacroiliac joint lumborum,

and medius,

and psoas major. As men-

tioned before in Chapter 4, tight and shortened iliopsoas and erector muscles are often associated with weak and inhibited gluteus maxioveractivation is

mus and abdominal muscles also seen with weak

maximus muscles.

muscles are usually associated with overactive and tensor fascia

and quadratus lumborum muscles, Lewit identified par-

ticular levels of joint dysfunction associated with tions

medius hip

If dysfunction in these

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muscle

406

PELV1C LOCOMOTOR DYSFUNCTION

Exhibill0-5 Joint and Muscle Associations

Joint

Muscle

T-10 through L-2

Quadratus lumborum, psoas, abdominais, thoracolumbar

L-2, L-3

Gluteus

L-3, L-4

Rectus femoris, lumbar erector

L-4, L-5

Piriformis,

L-S, 5-1

iliacus,

erector adductors

lumbar erector

adductors

lumbar erector spinae, adductors

51

adductors,

iliacus, medius Levator ani, gluteus maximu5,

iliacus

Adductors

Hip

muscle disturbance will continue to occur. Often just treating the joint function will obviate the need to treat the

or muscle involve-

ment. joint disturbances are often associated with tight hip adductors and points in the hip abductors often coexist and need hypotonic

maximus muscle is usually present,

in coxarthrosis. can coexist with

Lumbar facet and disc

disturbbut as combination

as

ances, not

lesions. Treatment of pelvic and

joint dysftmction aids in the healing of

these conditions. Bilateral sacroiliac and/ or hip joint dysfunctions create more of a demand

motion at the L-4 and L-5

than normal.

This can result in painful compensatory reactions degenerative

there. Restoration of pelvic and hip joint function

may prevent this decompensation of the lumbar spine and is important in low back pain

the

PRIMARY VERSUS SECONDARY LESIONS When one finds

joint dysfunction, especially that of long stand-

one should assess the abovementioned areas for associated dysfunc­ tions. It is also common to observe adverse reactions in these areas after pelvic

manipulation, particularly if the pelvic dysfunction is a com­

pensatory reaction and not a primary problem. The following case history serves as an

Copyrighted Material

Clinical Considerations

407

Case History A 37-year-old woman tennis player with thoracolumbar of 6 months' duration. Pain was exacerbated by playing tennis, prolonged sitting, stand­ It was alleviated by stretching the trunk with rotation and ing, and repetitive extension. The pain was described as a "migraine headache" in her back. The examination revealed a painful dysfunctional thoracolumbar associated with extremely stiff sacroiliac joints Quadratus lumborum and psoas trigger points were palpated, eliciting tenderness that reproduced her symptoms. The was thoracolumbar joint dysfunction with an associated quadratus syndrome. lumborum and psoas Treatment on the first entailed manipulation of the thoracolumbar ".(:>(1m,:>nf Within an hour posttreatment, the patient experienced extreme pain and spasm. such a feelHer back felt weak and vulnerable. The following day she of instability she could not out of bed. Two days later she nr':.,,(:>,nt&>rt for treatment. Electrotherapy and myofascial stretching were periormed with mini­ mal relief. On the following reassessment revealed the same clinical picture as her initial visit. This time, her sacroiliac joints were first mobilized and then ma­ nipulated with dramatic relief. On subsequent visits, her sacroiliac joints were treated, and exercises were given to improve joint and muscle function. The above case history illustrates the "AY"'''',"!' ary body's ability to r"'fTIn.C)"e results. It is not uncommon for a compensatory

exacerbation

dysfunction or secondary lesion to be painful and therefore receive thera­ peutic intervention. the clinician should refrain from treat-

This brings up two too many to a shotgun

on in the case. This fosters confusion due and makes assessment difficult. Second, there is no

substitute for clinical

to keep in mind

In

that the thoracolumbar and even lower lumbar sate painfully for sacroiliac and

often compen-

If these are treated symplook toward the

exacerbate or remain

sacroiliac joints as a possible primary dysfunction. It is always difficult for the clinician to face

who have

exacerbated from his or her to them the dynamics of com-

versus

and to tell them that clinical trial

is often important to determine the nature of their particular biomechan­ ics. This is especially important in chronic musculoskeletal dysfunctions, reactions become further

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with time and

PELVIC LOCOMOTOR DYSFUNCTrON

408

Primary dysfunctions are those that are more central in the overall loco­ motor disturbance. There can be more than one. The pelvis is a very common site for primary motor

often

A

other parts of the loco-

or what Gillet and Liekensll and

Schafer and

is characterized by more chronic limi ted by shortened

signs of mentous tissue

a major or "ligamentous" fixation. the most restricted. Motion is

biomechanical dysfunction is

blocked in most of the joint's ranges of motion.

blockage in all

the joint's range of motion is termed an articular fixation, with a worst-case scenario being bony ankylosis.12 Major fixations require the locomotor system to make biomechanical adaptations to tions. These compensatory

articular fixa-

often become

and

the patient to seek treatment. An example is a sacroiliac

ful,

that becomes painfully hypermobile i n reaction to the other sacroiliac joint's hypomobility. Lumbar facet and

often react this way to sacroiliac

joint fixations.

Major or primary manipulation and often need mobilization initially. are noticed nearby in the form of atrophic skin changes and hypotonic, weak muscles. These fixations are often stiff and end-feel.

with a very firm or stressed

are not

a provocation examination. In these fixations yields only

in range

elsewhere in the locomotor system are often seen to occur. In response to treating major

to

fixations, which are

mary fixations, are noted to

weeks and sometimes

of

over a

direct treatment.

without

will the

stiffened joint adapt to the motion induced by treatment and fixation

exercise. As long as a

the patient is at risk for conelsewhere in the 10-

tinued exacerbations

are usually compensatory reactions to major fixations; however,

can occur by themselves, especially in acute con­

ditions or younger patients. They are also called muscular fixations, due to the muscular response associated with them. The muscle's sponse creates a seen i n a

but one that is not as or articular fixation.

fixations are not as

restricted in their range of motion as primary dysfunctions. They are usually

and respond readily to manual

noticeable short-term relief.

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their

'''T1rnr,t''n'I�,tJ r

Clinical Considerations

ten draws attention away

409

chronic major dysfunction.

an

a clue that one is dealing with a secondary problem is its ten­ dency to recur not only quickly but an exacerbation

This situation occurs in the

fixations found elsewhere. Another clue is

presence of major or

of treatment. Some-

within 24

the clinical

times within minutes the

will

of

or spasm, even in

areas remote from that treated. The presence of these clues should lead t o If minor

further assessment and search for more primary fixations are

in the absence of

TRANSITIONAL SEGMENTS The mere presence of

r{)T'O"�>n

a sacralization with a

criminate them as

pseudoarthrosis can become symptomatic just like any other joint. Pelvic and

dysfunction will exacerbate such conditions and need to be transitional

throses, can become irritated with overzealous is not a fault of the

as much as its

Spondylolisthesis of L-5, although not considered congenital tional

conven­

can be treated the same way. Instead of trying to reposi­ joint

tion L-5 back onto the sacrum, one should try to correct any with

Lower back pain in

and muscle

sis responds well to thoracolumbar,

and hip joint

if these areas are dysfunctional. As with congenital anomalies, seldom does the spondylolisthetic

itself have to be directly manipulated.

HYPERMOBILITY Certain situations are associated with joint hypermobility. to lax

mobility

may be found as a or it may be due to lo-

condition throughout the calized trauma or

Sometimes it is related to rare,

conditions such as Ehlers-Danlos syndrome and Marfan's syndrome. 5% of adults fit criteria that enable them to be called ranges of mo-

in

tion in their joints. Travel] and Simons14 mention that hypermobility is associated with mitral valve prolapse, pelvic floor and abdominal wall

and thin, extensible skin prone to striae.

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410

PELVIC LOCOMOTOR DYSFUNCTION

Muscular weakness, degenerative changes, compensatory reactions, and excessive joint manipulation can contribute to localized hyper­ mobility. A dull ache follows activities that place the ligaments under strain. The onset of symptoms is usually delayed, but as the condition worsens, pain occurs soon after the offending posture is assumed. Joint clicking can be heard and is usually referred to in the history as a "catch" occurring during movement. Palpation will reveal excess motion, clicking, crepitus, and pain with sustained overpressure. Muscle spasm may be present to guard any instability. Typically, hypermobile joints tend to cause recurrent problems until they are stabilized, either therapeutically or through natural progression. In constitutional hypermobility, the patient is able to touch the palms to the floor, hyperextend the knees and elbows, and dorsiflex the fingers to the distal forearm. Pregnancy and the menses can create physiologic hypermobility or exacerbate existing hypermobility. Regardless, manipulation and strong mobilizations are contraindicated in joints tha t are hypermobile. A joint that "clicks" on its own is not in need of further external manipulation. Neighboring joints that are hypomobile can be manipulated, affording relief to the hypermobile joint that is com­ pensating for the hypomobility. In the pelvis, this can be the opposite sac­ roiliac joint, the other pole of the same sacroiliac joint, or one of the hip joints. Lumbar joint dysfunction should also be sought for. Myofascial trigger points in regional muscles are commonly present and require treat­ ment. However, strong myofascial stretching across a hypermobile joint is contraindicated, and stripping massage or ischemic compression should be applied instead. Patients with hypermobile joints are sensitive to sustained postures and prolonged stooping. They need to exercise the regional musculature to in­ crease strength and dynamic support. Sustained static postures need to be avoided. Hypermobile sacroiliac joints can be supported with a trochanter belt during acutely painful episodes. The belt is tightened just below the iliac crest and is worn during physical activities over a period of 2 to 3 weeks. To be effective, the belt should be 2 to 3 inches wide, inelastic, and placed about 2 inches below the iliac crest. A chair test can be used to de­ termine the need for a trochanter belt and to determine if the person has pelvic ring dysfunction.15 The chair test is a simple procedure that tests the functional efficiency of the pelvic ring. Difficulty in performing the chair test is a positive result and indicates pelvic joint and muscle dysfunction, including hypermobility. Wearing a tight-fitting trochanter belt usually makes it much easier to per­ form the test, since it affords stability to the pelvic ring. The patient literally

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Clinical Considerations

411

feels as if he or she is stable in front of a chair, with arms are held crossed in ttPrnr,tc: to sit down slowly and

feet are kept 6 in

smoothly while keeping the back straight.

Af-

ter sitting down, the person must return to the without

The test is normal if the person sits

before sitting down and the back is without any jerkiness or

should be performed

arising, the person should maintain an erect forward to about the

noted. Upon

and not try to lean or

momentum. Problems with the

ing difficulty with this test will arise jutting the the trunk in an effort to

or muscles A patient hav-

will make this test difficult to

and chin forward, or

himself or herself out of the

off the thighs with the hands. a few

have the patient

If the test is

and then have him or her

sacroiliac

nplrtnrrn

Almost always an improvement in the test is felt. awareness and educational

and

importance of exercises. The same response is seen if a trochanter belt is worn. CHILDREN

children not

pay the

for the

adults but, like their parents, are unaware of

of

hidden costs. This is espe-

cially true in the case of functional locomotor disturbances. Parents and clinicians alike must realize that children can suffer from and joint

is a common occurrence in

Pelvic joint

children and is seen more frequently as they enter and their seats. or exercise to

It is most likely due to excessive children are not

the

locomotor disturbances of the

in

through designed

way to sit, It is incredibly

important to assess children for pelvic and hip joint dysfunction early on so they do not develop chronic dysfunction and suffer the consequences later. To

the

and muscle

from

latent and therefore asymp­ tomatic. Functional assessment

should be performed to iden­

tify these dysfunctions, since they are a potential source of future trouble.

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412

PELVIC LOCOMOTOR DYSFLNCTION

Olsen et

in a study of 1242 children between the ages of 11 and

that 30.4% of them had a

of low back

and that one third

limitation of activities due to their pain. The authors

of those

also observed that low back after the age of cence.

started early in childhood, increased no-

and continued to increase throughout adoles-

state that

low back

a serious

public health problem. In 1988, Balague et aP7 studied 1715 Swiss children ages 7 to 17 and found a

of back

in 46% of them. Most of this

lower back. TI1ey noted an increase in low back

was in the

as the child

Also identified was a correlation between low back and time spent watching television.

sports, female Mierau et

studied 403 students and found 22.8% of the

schoolchildren and 33.3% of the secondary schoolchildren to have histories of low back pain.

88% of those with a

demonstrated sacroiliac

of low back

on examination, strongly

SUj:;gt�snng a correlation between low back pain and sacroiliac joint dys-

These studies contradict the

notion that low back

is not a

problem in children. Yet when one considers the daily events in a child's life that can contribute to dysfunction, it should be no surprise that chil­ dren suffer lower back tocks

Contemplate the numerous falls on the but­ at school or

the early months of walking, the hours of with

in front of a television set, the time games, or the

trauma associated with competitive

potential for injury and dysfunction is just as great as in adults. The following case

illustrates this:

with a "pulled grOin muscle" as A young ballerina 6 years of age nosed" by her dance instructor. She was told to stretch it out and assured that it would loosen up. After 4 weeks of continued proximal medial thigh and ness, she sought help. On questioning, it was determined that forced stretching to increase her ability to perform "splits" started the problem. However, 1 week prior, she had fallen off her bike and landed on the same hip and causing hip that lasted 2 She seemed fine until she attempted to stretch her adductors for dance class the next week. On examination, she had sacroiliac and joint dys­ function, with a painful point in the adductor longus muscle. Postisomelric relaxation with gentle ischemic compression of the trigger pOint followed by heat was done on the first visit, with only partial relief. The following her sacroiliac and hip joint dysfunctions were manipulated, and the case was completely resolved. Children who take dance lessons at a vic and

with pelwhen

stretches that make them vulnerable to

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nPlrt"rrn

extreme

this young

413

Considerations

girl's fall and subsequent ductors that precluded

Forced

her adductor

yet she did not complain of hip or

clinical

This is a

pain on

example of how underlying joint

functions can remain silent while the patient presents with the more of the adductor muscles was

reactions.

symptomatic

and resolution did not occur for this little

to no joint

until

were corrected. who suffer from dysfunction of the pelvic joints and muscles with minimal intervention. For the most part, their tissues are more

and heal faster.

the chronic tissue

may still suffer from a chronic joint

a

function.

patients do not

that we see in adults with

problem of 5 or more

duration. techniques similar to those

The actual treatment of children used with adults

for some modifications. The hand contacts and

positioning will differ slightly. For instance, when manipulating sacroiliac contacts instead of a

joint dysfunctions in small children, one uses

for

The small child can lie on top of the flexible and may

can be

a

Children

if all

removed. However, an audible crack is not

heard with

ma-

in children, it should not be the

and, as in adults but

in treatment. Increased joint mobility is achieved after a successful assess-

which should be confirmed ment.

with

A very common complaint in youngsters is a

of trauma or sickness. If pathology is of

the infamous

is traditionally be-

stowed. The child is told that he or she will grow out of and that there is nothing to worry about. The parents is welt yet the child still experiences the painful reminder that he or she is hip, or lumbar joint

growing. Such little patients often exhibit 'YH'hr",,,

that readily correct with

results. Myofascial

in the hip adductors and abductors are surprisingly common and contribute to the clinical Pelvic

associated with

dysfunction in children is

craniocervical joint

so much so

one necessitates is an example:

looking for the other. The follOWing case A

girl complained of lower back

for 3 months after

off her

and landing on her buttocks. Since then, her lower back had bothered her whenever she would run hard while serious injury and had

Her family physician had ruled out any stretching exercises and heat. Upon further

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PELVIC LOCOMOTOR DYSFUNCTION

414

questioning, she did state that after her fall she started to experience mild subocand parietal headaches for 8 weeks. Her parents thought these were due to her eyes and the need for but an eye examination failed to show any problems, and a medical workup was negative for any disease. Physical examina­ tion revealed sacroiliac and lumbar joint dysfunction. Manual treatment directed at these dysfunctions afforded only temporary relief. It was not until a painfully stiff craniocervical region was mobilized and manipulated that she experienced lasting relief from both her headaches and her lower back results in func-

Often a manipulative correction at the top of the

and vice versa. Lewit discusses these very

in the

tional

younger, more

spine/pelvis

made to the locomotor served when

to func-

These

pre- and postmanipulative assessments.

Another very common childhood to transient or

synovitis

of limping and pain in the hip

is acute pain attributable the hip. It is the most common cause

children in the United States.

It is usu-

of exclusion and self-limits in 7 to 10

ally a

L<:;;",,,,-,,-,:u"·A-I ·'''''''�h'''''

,-<""ca,,,,,,

and slipped capital femoral epiphysis must

be ruled out first.

occurs in middle child­ a limp, and restricted hip

on

the stage of the disease. capital femoral 10 years of onset can be external

occurs in children older than

and is

male sex, and black race. Its

but is

or painless limp with

rotation and loss of internal rotation in a child during the vul­

nerable years

a slipped

femoral epiphysis. Ra­

findings are is held in

any condition an antalgic

rotation.

it is common in ditions, therefore In transient synovitis of the years old, male, and

are

n1"''''::>'''"''

nant. The hip may be held in an antalgic

and

is limited, although less than that found in

arthritis. The sedimenta-

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range of motion

Clinical Considerations

415

tion rate, white count, and X-ray findings are normal. The condition sometimes follows upper

infections. Traditionally,

rHAl<,,,,'r

'''!T"t1n�'''tYl

and the condition self-remits

care and rest are often

are not found, and the

of inflammation and

clinical picture is one of an atraumatic acute onset of pain without any demonstrates

of disease. Functional examination

joint trac-

in long-axis extension. Sustained

I oscillations of long-axis extension and me­

relieves iliac joint dysfunction commonly occurs on manipulated if it

on follow-up visits. should be assessed for congenital

with clicking

Infants who

to dislocate and relocate itself.

in

locations occur more

of the hip

to the easy

dislocation. This misnomer really

cases, the dis-

to 6 weeks the femoral head can

remain outside the acetabulum. After 3 to 5 months, relocation becomes more difficult, if not impossible, without orthopedic intervention. The vast majority of infants with congenital

dislocation

self-correct

no intervention.

within the first month of life and tendency to dislocate persists and

if the

the femoral head remains displaced,

will occur. Normal coaptation in the proper

is

hip joint

and formation of the femoral

and ac-

etabulum. Dislocation precludes the formation of normal ture and must be corrected. Clinical rants a to 90

of a

dislocatable hip at 6 weeks of age war-

to an orthopedist. With the infant the thigh is abducted while pressure is

upward on the greater trochanter. A click sound dislocation and is a positive Ortolani's hip can adducted at 90

To test

and the hip flexed medially and reduction of a ease at w hich the

the reverse Ortolani or Barlow test is used. The hips are the knees of flexion. A

shear

up and

which

sensation

can be reduced by performing Ortolani's test. Other at:ib,UClldU,:U congenital

dislocation are decreased normal

creased

to abduct the on the affected

fully while at 90 and uneven

SOMATOVISCERAL REACTIONS A most interesting and n<'lrt<"v''''';

controversial observation by clinicians ex-

with manual treatment of the locomotor

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is

in

PELVIC LOCOMOTOR DYSFUNCTION

416

the viscera. When treating

problems, clinicians of-

ten notice changes in concurrent

conditions such as dysmenor-

lower-bowel

and prostatic

seen are those that relate to function rather than

no clinical trials have been done to substantiate claims of PCT1(',"U"J of the

but functional

viscera do occur frequently in treat­

ment of concurrent pelvic joint and muscle rAr'ocrn'O''''rl

The most well­

problems, with dysmenorrhea

changes relate to

Although not as consistent as with in the character and symptoms related to functional prostatic cur after

im-

of bowel movements and in has been known to oc-

pelvic joint dysfunctions. This is not an h""·",...,,

as a treatment of choice for

certain conditions seem to be

favorably, and this observation should

further. Women with

in the absence of gynecologic disease often

respond favorably to pelvic joint manipulation. Manipulation of sacroiliac joint

in which sacral contacts are used seem to have more of a

favorable effect. In

middle and lower lumbar

are often

found to be dysfunctional. Lewit9 states that menstrual and labor

felt

in the lower back in the absence of disease are usually of locomotor origin and can

the

of locomotor disturbance.

clue to the

locomotor disturbances cause gyne(:01ogLC disease.

that is mistaken for

visceral disease can manifest as somatic with lower

pain and must be ruled out. For example, a woman

relief only after a uterine fibroid was

back pain removed, A

significant correlation is found between back

labor."20 The

in

parturition, also called "back

pregnancy and subsequent back pain

in both of these situations can be significantly reduced

when manual methods are

to

and muscles, This is a most desirable situation,

are reluctant to give medications to

most

found are sacroiliac and lumbar joint trigger points are regularly observed in the minimus and with bor.

lumborum,

and tensor fascia lata. Back labor can often pressure squatting and

during labor can ease delivery

compared to the dorsal lithotomy Manipulation in third-trimester and

only in the presence

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eased

to the sacrum during la-

must be

Clinical Considerations

of this area during this time makes it susceptible to

417

from an over­

zealous technique. Gentle mobilizations are very beneficial and can be used in

of

when

is

A case ex-

woman in her 8th month of pregnancy who pre-

ample is a

sented to me with severe sacroiliac joint pain after a vigorous sldle-l)O�;tl manipulation was performed by another practitioner. Pain was enced shortly after a click sound was heard during the manipulation. She sharp

found it

difficult to bear weight,

per

the sacroiliac joint. The upper

in the up-

mobilization to the re-

was tender and appeared hypermobile. of both sacroiliac

stricted lower

of

of her sacroiliac joint afforded her dramatic

contraindicated in this case. of manipulative

the ment of enuresis, yet

in the treat-

remain unsubstantiated. In my experience, re­

sults seem to be equivocal at best and 171 enuretic

to say the least. In a study

LeBoeuf et aF! achieved minimal results

therapy. More studies need to be done before opinions on both sides of the issue are confirmed.

POSTSURGICAL OR "FLAT-BACK" SYNDROME

stiffness and lower back

afterward. The locomotor

very prone to trauma and

from static posturing

der general anesthesia due to reflexes. One will

of muscle tone and find dysfunctional lumbar and sacroiliac

joints that need to be chances are

anesthesia often ex-

surgery with

Patients who have nOIClOT,rt>

In cases of lumbar

the

was present before the pro-

that

cedure, but postsurgical

relieved when treatmotion to dysfunctional

ment is directed at

lumbar joints. Abdominal or thoracic surgery involves of the

and

causes lower back

Often termed the "flat-back syndrome," this condition state that

nn'.::: p'nt.::: with an achy, stiff lower back, and

they feel as if they have been run over postsurgical back but many never had back

a truck. Some

have had a history of lower back

with before

not. A common presentation is someone who has before,

abdominal or thoracic surfor weeks or months after

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PELVIC LOCOMOTOR DYSFUNCTION

418

PREVENTION The ideal for any trea ts.

.-. '-"A"" " .>r

First among maintaining a

functioning locomotor system. Second,

need to realize that a lack of pain is not a good indicator of function. tunate ly, people have been indoctrinated into believing that no m e ans no problem. This resu l ts i n silent

persisting into

symptomatic, chronic dysfunctions. Third, to assume that the locomotor ,"""P,....

exercise and

is not in need of

nature's fundamental laws

i s to ignore one o f

existence. Indifference to this l a w will need to be more

sooner o r later, in poor ftmction and ...

... .." J� ' W " U "

for their own health and more

in their own heal th

takes on too much responsibility, with about noncompliance

task of nagging the

blame when thera-

and being set up

with exercise or lifestyle failure eventually occurs.

Besides exercises, a ttention must be given to tic

and stress levels. For I n ,,,;, r,,,,, r",).,ti ti ,

d iet,

o r static loading o f the can

especially in the

useless for a patient to

in treatment of pelvic

or muscle dys-

for 8 to 1 0 hours is not addressed. Walk-

function if his or her 30 minutes a day, doing

stretching

extension and pelvic

periods of sitting at one time will go far

and limiting in

"'Or"'c"" "r",

a locomotor d isturbance. It is

serve to

painful

locomotor disturbances.

A mattress that is too hard or too soft will

trigger patients

and l umbar, hip, and sacroiliac point problems. will awaken stiff and sore every

The

and about for a short tom

and then

abate

the next morning. The

itself

a fter

feel fine. The sympmust be

a l lo wed to depress into the mattress enough to maintain neutral alignment when recumbent.

"in" later than usual can

and muscle symptoms, and sometimes patients state that to

out of bed because of the

joint cannot wait

symptoms they know they will

good multicoil mattress that is no t too firm should suffice. Foam rubber matting can soften a m uch too firm m attress, and a sheet of Y2-inch or ¥a-inch plywood can firm up a The

most important factor in status is

mJury o r

exercise. The locomotor

with muscles

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regular active

Clinical Considerations

to maintain good

needing

motion, and

chapter.

order. This is discussed in more detail in the even though the onus of prevention falls they are often mendations.

419

on patients'

with exercises and o ther recom-

continue to

in

and trauma-inducing sports. There is a locomotor disturbances in these situations. In

the patient af­

flicted w i th a chronic locomotor dysfunction that continually exacerbates regardless of

measures requires

Manual methods can be applied as a preventative measure to locomotor disturbances,

for the screening of

and muscle

in the young and for the management of chronic dysfunctions in older Children and patients.

adults need to be assessed less often than once

and

should be assessed every 6 to 1 2 trauma

their school years,

after falls o r lower

and more often if

are

vigorous sports. functional

and treatment of those

dysfunctions found seem to report fewer

and recurrences. This

Adults who receive

is optimized if the clinician reviews or revises previously recommended The

exercises and s timulates further commitment to a healthy is for the clinician to treat less as function is maintained more The need for and

the

are determined

by the presence of chronic dysfunctions,

structural

or

forcing compensatory adaptations in the locomotor

congenital system. These

inclu d e

chairs and those walking with a

disabled

in wheel-

limb who are

con-

tinued dysfunction from postural, locomotor, or compensatory mechaabuse from

sports activ ities,

in

levels, creates a need for re-

and treatment.

Chapter Review Questions the acute, subacute, and chronic clinical

,.. :> ,cpunr1

as

to treatment. is abnormal illness behavior? associated

nf'T1fH'"

are usually found in each of the ab­

about the

Copyrighted Material

420

PELVIC LOCOMOTOR DYSFUNCTION

are rr>rnITI,,.,n

region that

of dysfunctions in the linked or associated,

•

What is the difference between

and

•

What is the significance of hypermobility?

•

Discuss dren.

•

Give an

joint and muscle

CDr',.", ,.. ,>

lesions?

as they relate to chil-

of a pelvic somatovisceral reaction.

REFERENCES 1. Haldeman S, Chapman-Smith D, Petersen D, and Practice Parameters, 2,

Md:

WO, LeBlanc FE, Dupuis M, et aL Scientific ap proach t o the assessment a n d maoof

spinal d isorders: a monograp h for cl inicians,

3

4.

of the

7):51-S59.

Task Force on Spinal Disorders.

brvmovpr J, Back pain and sciatica, N Engl l Med. 1988;318:291-300. T, G a tchel R. Functional Restoration for Spinal Disorders: A Sports Medicine J'tfJl'Jl"" LfI. Pa: Lea &

1988.

5. VaJlfor B. Acu te, subacute, and chronic low-back pain: clinical symptoms, absenteeism and working environment Scand J Rehabil Med, 1985; 1 1 -97. 6, Brena S, Chapman SL The learned

l. A

7.

Postgrad Med, 1981;69:53-64,

classification of abnormal i l l ness behavior. By I

PsychiaL

1979;51:1 31-137. 8. Bullock-Saxton JE, Janda V, Bulock MI. Ret1ex activation of gluteal muscles in Spine, 1 993;18:704-708. 9. Lew i t K

in Rehabilitation

Locomotor

2nd ed, London:

B utterworths; 1991 , 1 0. Lew i t K Cha i n reactions in d i s turbed function o f the motor system. Manual Med, 1987;3:27-29. 1 L Gillet H, Liekens M, Belgian

Research Notes. Huntington Beach, Calif: Motion

Palpation Institute; 1984. 12. Schafer RC,

LJ. Motion Palpation and

of Dynamic Chin'J-

Technic: Institute; 1989.

praclie. Huntington Beach, Calif: Motion

13, Grahame R. The hypermobility syndrome, A n n Rheum Dis. 1 990;49:197-198, The

Pain and

14. TraveU JG, Simons DG.

Poillt Manua/. Vol 2,

Ba l t imore, Md; Williams & W i lkins; 1992, 15, Imrie D, Barbuto 1. The Back Power

Toronto: Stoddart; 1 988.

16, Olsen TL, Anderson RL, Dearwater SR, et al. The eDide-mlO]C)!;!V of low back pain in an adolescent 17.

T , Dutoit G ,

Am J Public Health, M , L o w back pain i n school children; a n eL'i'UeU lIUIL'''l-

SCIlnd J Rehubil Med, 1988;20:175-179.

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Clinical Considerations

421

18. Mierau DL, Cassidy JD, Hamin T, Milne RA. Sacroiliac jomt dysfunction and low back pain in school aged ch i l d ren. / Manipulat ive Physiol Ther. 1984;7:81-84. 19. Eilert RE. Orthopedics. in: Kempe CH, Silver HK, O'Bren 0, eds. Current Pediatric Diagno­ sis and Treatment. 6th ed. Los Altos, Calif: Lange Medical Publishers; 1980:534-556. 20. Ostgaard HC, Andersson GBJ. Previous back pain and risk of developmg back pam in pregnancy. Spine. 1991;16:4;432-436. 21 . LeBoeuf C, Brown P, Herman A, Leembruggen K, Walton 0, Crisp TC. Chiropractic care of child ren with nocturnal enuresis: a prospective outcome study. / Manipulative Physiol Ther. 1991;14:1 1 0-1 1 5 .

Copyrighted Material

Chapter 11

Stretching and Exercise Linda J. Levine

Chapter Objectives • • • •

to discuss general aspects of stretching and exercising to describe passive stretching to describe dynamic range-of-motion stretching (DROM) to describe stabilization exercises

GENERAL ASPECTS OF STRETCHING

This chapter briefly discusses the various aspects of exercises and stretches that assist patients in becoming more effective and therefore more empowered in their own treatment. Joint manipulation serves as a powerful tool in restoring joint function and simultaneously influencing muscle tone. A joint exhibiting joint dysfunction needs to be manipulated first to restore arthrokinematics and offset unwanted arthrokinematic re­ flexes from occurring. Otherwise recovery can be delayed if exercise is started too early. However, the inexperienced practitioner must be careful not to become overly impressed with the powerful therapeutic effects of joint manipulation lest he or she be lured into thinking that manipulation is all that is needed in the care of joint and muscle dysfunctions. Attention must also be directed to assessing muscles for proper length and strength. From this an appropriate exercise regimen can be formulated. Exercise in­ struction is a must in the overall care of patients. In a review article on exercise and manipulation and their effects on low back pain, Twomey and Taylor1 comment that the evidence for exercise in aiding low back pain patients is overwhelming. The relationship between joint and muscle function needs to be acknowledged and addressed when treating patients with locomotor disturbances.

422

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Stretching and Exercise

and muscle dysfunctions tend to recur if

423

np1",,,'t,

not addressed. Chronically shortened muscles and that

perpetuate articular and muscular

need to be taught stretches and exercises that prevent maintain muscle tone, and foster self-reliance. muscles also occur in reaction to overactive and tight muscles and need to without teaching

be treated. To use joint

how to

care for themselves with exercise is self-defeating and invites the recurrence of dysfunction.

with joint and muscle dysfunction,

C;"L"C,-'''H

those who lead a sedentary life or sit too much at work, have no to exercise regularly to avoid continuing bouts of

Exercise instruc-

tion serves as a tool to enliven those muscles that have been via

lifestyles. It also

ciated articulations.

motion of the assothe nervous

is

bombarded with afferent proprioceptive input while it is

a

neurophysiologic reeducation. However, this assumes that poor move­ ment patterns have been corrected. In addition to

and muscle stretches,

couraged to walk at least 30 minutes a day to motor activity in their lives. This applies older individuals. An aerobic exercise program is a conditioning.

a patient with self-esteem and sense of

It also elevates a

must be taught stretchexercises for

muscles and

exercises in this sense,

for the weak, inhibited muscles. The

to "teach" the

are actually reeducation or remedial exercises

again. Muscles that have been shortened due

muscle to contract

to be shown that they can painlessly lengthen

to spasm and

These muscles are

again and function control from

or maladaptive

grammed on a

nrr.r,"c"

basis.

Remedial exercises assist in muscle involved.2 For

movement for the a tight, overactive tensor

muscles, muscles. The or

movement in abduction. The in order to release its

lata muscle

minimus and medius

will overpower and inhibit its neighboring needs

intact and

due to persistent

strong, yet function

tensor fascia lata over the

inhibited glutei muscles need to be selectively trained to contract optimally

achieve this. The patient is placed in the

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Remedial exercises position to

424

PELVIC LOCOMOTOR DYSFUNCTION

contractions and movement from the weak muscle. Gravity atone resistance to work against. Sometimes patients with

supplies

the leg.

weak abductors need assistance in just

in­

put from the periphery can be used to facilitate the "learning" process. For pinching,

or

the muscle involved recruits

awareness and facilitates contractions. The patient needs to be aware of how the muscle is the

movements it

and how

move-

poor abduction due to

ments come into play. Again in our example

weak, inhibited glutei minimus and medius muscles will cause the patient posterior when in the

to recruit the tensor fascia lata by rolling the

position. The patient needs to know that the to

rolling is

hip abductor function. The

be rolled

more anterior than the neutral side-lying posture and stabilized abducts the

while the

and thigh. In addition, peripheral procontraction.

the

to

will aid in normal movements. muscle contract and

the correct movement This is performed by

the patient over several days or weeks until his or her nervous system "remembers" how to connect with a Four

action,

of exercises and stretches are discussed next:

stretching,

dynamic

tion

and

(1)

(DROM), (3) stabilizaexercises. Their

(4)

effective lengthening

is to aid in the

muscles and the strengthening

weak ones,

PASSIVE STRETCHING

can be used

Passive or static muscle on stretch or until the

home exercises to lengthen

static stretches

tight, shortened muscles. The a sustained

place the

usually 15 to30 seconds

of

senses a release in tension,

on breathing is

important so that muscle relaxation is maximized on exhalation. No bouncing or ballistic movements should be involved. However, and Dawson3 found that when ballistic

followed static stretch-

related to the muscle in

the creased more than with static

was de-

alone. Murphy4 makes a good arof dynamic static

taken not to take the joint too far

np"nn,(l

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its normal range of motion.

Stretching and Exercise

425

Three-Point Stretch

This is the most important versatile passive stretch for the pelvic and hip regions. It stretches the sacroiliac and hip joints and piriformis and gluteus medius muscles. It entails holding the hip joint in three positions (Figure 11-1). While sitting, the patient first pulls the knee up toward the same shoulder and holds it for 30 seconds. Next, a sitting Patrick-Fabere test position is asswned, and the knee is pressed toward the floor for 30 sec­ onds. Finally, the hip is flexed and adducted strongly toward the opposite shoulder while the ankle remains crossed on the other knee. The three stretches are repeated on the other side and are performed once a day. If a

A

continues Figure 11-1 (A, B, C) Three-Point Stretch

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 11-1 continued

B

continues

person fails the chair test described in Chapter 10, improvement is usually seen after performing the three-point stretch if sacroiliac and hip joint stiff­ ness are present. This clearly demonstrates to the patient the influence that stretching can have on good function. Oriental Squat

This stretch is also good for the sacroiliac and hip joints. The person simply squats fully, with the shoulders sinking in between the knees, keeping the feet flat on the floor (Figure 11-2). Patients with stiff pelvic and hip joints will have difficulty performing this maneuver without hold­ ing a doorknob or other suitable support to steady themselves. It stretches

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Figure 11-1 continued c

the lower part of the pelvis, lumbosacral spine, hamstrings, and gluteus maximus. 1t is a good stretch for women to perform during pregnancy and facilitates stretching the bottom of the pelvis for labor. It also aids venous return from the lower extremities back into the systemic circulation. It is a difficult stretch to perform for older patients and those with knee prob­ lems. In these instances it should be avoided. Morning Star This stretch imparts torque to the low back and pelvis and affects many structures. The limbs are placed so that the patient can stretch into four different quadrants. Too much torsional strain felt by the patient can be

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Figure 11-2

Oriental Squat

minimized by bending the crossed-over leg at the knee. The structures stretched on the uppermost side include the sacroiliac and hip joints, illp abductors, piriformis, and quadratus lumborum. Also affected are the lumbosacral and thoracolumbar regions. To facilitate stretching and relax­ ation, the patient inhales deeply and holds the breath for 10 seconds. While exhaling slowly, the patient relaxes and allows the uppermost leg and arm to stretch floorward (Figure 11-3). Additionally, the patient can try stretching each limb into the direction it points. William's Flexion Exercises

These classic exercises are a good general stretch for the lumbar spine, pelvis, and hip. While the patient is supine, the knees are flexed onto the chest separately and held for 30 seconds each. Afterward they are flexed upon the chest simultaneously and held again for 30 seconds while a strong pelvic tilt is performed. Tills imparts a stretch to the lumbosacral joint and erector spinae group. McKenzie Extension Exercises

These stretches assist in improving lumbar and hip extension. Patients can start off simply lying prone while supporting their upper bodies with

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Figure 11-3 Morning Star

their elbows (Figure 11--4A). After 1 to 3 minutes of this, the hands are placed on the floor and a push-up is attempted from the waist up until the arms can lock at the elbows (Figure 11--4B). The buttocks, thighs, and legs remain relaxed. The patient exhales and relaxes the spine and hips, allow­ ing them to sag off the extended arms. Once the spine is felt to sag fully, or near fully, the person returns the upper body to the floor and repeats the stretch. A goal of 10 push-ups at least twice a day is set. This is a good stretch to recommend to patients who sit extensively during the day. If leg pain or pain radiating from the back into the leg is experienced during this exercise, then it is to be stopped. The reader is referred to McKenzie's work for further elaboration.5 Adductors

The small adductors are stretched while the patient lies supine, knees bent and abducted outward, with the soles of the feet touching (Figure l1-SA). To sh-etch the long adductors passively, the patient lies supine with the buttocks and straight legs resting against a wall. Using gravity as an assist, the patient allows the straight legs to spread by sliding along the wall to impart a comfortable stretch. The hip adductors can also be stretched standing. With the feet wide apart, the patient sways to one side,

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LOCOMOTOR DYSFUNCTION

A

B

Figure 11-4 (A) Mild extension stretch. (B) Full extension stretch.

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A

Figure 11-5 (A) Passive stretch for the short hip adductors. (B) Passive stretch for long hip adductors.

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PELVIC LOCOMOTOR DYSFUNCTION

keeping the pelvis level. A stretch is imparted on the side away from which the pelvic sway occurs (Figure l1-SB). Iliopsoas

While supine, the patient flexes one thigh against the chest while the other leg is lowered off the foot-end of a bed (Figure 11-6). This essentially is the modified Thomas test reproduced. In the illustration provided, the person is lowering his leg off the side of the couch, which tends to place the person off balance. Lying squarely on the bed while lowering the leg off the foot-end feels more secure. Another way to stretch the iliopsoas muscle passively is to place a foot up on a high stool while the weight­ bearing thigh and leg remain extended backward (Figure 11-7). The iliop­ soas can also be stretched by assuming a "squat-thrust" or lunge position (Figure 11-8). The side being stretched is extended backward. Quadratus Lumborum

This muscle can be passively stretched by having the patient prop the torso up on a bent elbow or straight arm while side lying (Figure 11-9).

Figure 11-6

Supine Hip Flexor

Stretch

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Figure 11-7

433

Standing Hip Flexor Stretch

The uppermost leg rests on the floor in front of the lowermost leg. The pelvis can be rotated forward or backward to localize the stretch to differ­ ent parts of the quadratus lumborum. Another stretch can be performed by standing and side-bending away from the tight quadratus lumborum muscle (Figure 11-10). This position can be held statically, or post­ isometric relaxation can be used, as discussed in Chapter 9 in the section "Quadratus Lwnborum." Hip Abductors

These muscles are stretched passively in the side-lying posture by hav­ ing patients lower the uppermost leg and thigh behind them off a couch or

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Figure 11-8

Lunge Stretch for Hip Flexors

Figure 11-9

Passive Side-Lying Stretch for Quadratus Lumborum

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435

Figure 11-10 Standing Postisometric Relaxation Stretch for Quadratus Lum­ borum

bed (Figure 11-11). This can be repeated with the leg lowered off the couch in front of the body. Quadriceps

While standing, the patient brings the heel up to the buttock and ex­ tends the thigh straight back, not out to the side (Figure 11-12). Thigh ex­ tension should be provided mostly by gluteus maximus contraction. The other hand should hold onto a suitable support for stability. This stretch can also be performed while side lying, with the upper leg being the one stretched as in the standing stretch.

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Figure 11-11 Hip Abductor Stretch

Gastrocnemius and Soleus Muscles

The gastrocnemius and soleus muscles are important to consider be­ cause of the effect of their shortening on gait and joint dynamics of the lower extremity and pelvis. To stretch the gastrocnemius, the patient leans against a wall and extends the straight leg backward while pressing the heel onto the floor (Figure 11- 13A). To stretch the soleus muscle, the same position is assumed but the backward placed knee is bent to relax the gas­ trocnemius muscle (Figure 11-13B). The bent knee is pressed floorward . while the heel remains on the floor. Iliotibial Band

To stretch the iliotibial band, the patient first stands about 2 ft away from a wall (Figure 11-14). The side to be stretched is nearest the wall. The other leg is crossed over in front of the leg to be stretched, and the patient sways the pelvis toward the wall, keeping it level. The trunk should re­ main vertical, yet a strong adduction force is applied to the hip region, thus stretching the iliotibial band.

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Figure 11-12 Quadriceps Stretch

DYNAMIC RANGE-Of-MOTION STRETCHING

Active facilitative or dynamic range-of-motion

(DROM)

stretching in­

volves contracting a muscle's antagonist while the associated jOint is moved through its full functional range of motion.4,6

DROM

emphasizes

slow, controlled movements, allowing the muscle being stretched to be lengthened physiologically. This type of stretching accomplishes two things. First, the antagonist's active contraction supplies a mechanical force that stretches the agonist muscle. Second, the antagonist, via its own contraction, reflexly inhibits and further relaxes the agonist through the process of reciprocal inhibition. The beauty of

DROM is that the patient is

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PELVIC LOCOMOTOR DYSFUNCTION

able to lengthen the muscle while it is simultaneously being reciprocally inhibited. In addition, the joint motion induced is maintained within a physiologic range. In comparison, static or passive stretching has the po­ tential for stretching joints and muscles beyond their physiologic range of motion, thus inviting injury. Also, reciprocal inhibition is not operant dur­ ing passive stretching. The following stretch is an example of a

DROM exercise.

To stretch the

hamstrings effectively, the person should lie supine with the hip and knee flexed while both hands support the knee from behind (Figure 11-15A). The quadriceps muscle is contracted and the leg is straightened until the knee locks into extension (Figure 11-15B). If the knee cannot lock into exA

continues Figure 11-13 (A) Gastrocnemius stretch. (B) Soleus stretch.

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439

Figure 11-13 continued

B

tension because of very tight hamstrings, the thigh should be lowered just until this can occur. The straight-leg position is held for 4 to

5 seconds and

then relaxed by flexing the knee. The thigh is then raised slightly more, and active extension of the knee is attempted again to stretch the ham­ strings. This is performed three to five times. Hip Muscle Exercises

Patients with hip and sacroiliac joint dysfunction often exhibit weakness in the muscles about the hip joint, especially the abductors, adductors, and gluteus maximus. The following exercises should be routinely given for

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PEL VTC LOCOMOTOR DYSFUNCT10N

Figure 11-14 Tensor Fascia Lata and Iliotibial Band Stretch

these patients. The hip abductors and gluteus maximus muscles are often inhibited, and their tight, overactive antagonists must be stretched first. Quite often, just the weight of the lower extremity provides enough resis­ tance to exercise with. However, ankle weights can be used for added re­ sistance. Slow, steady contractions should be performed. With a

DROM

procedure, the contracting muscle is strengthened while its antagonist is stretched. Initially, the patient must be taught proper technique of contrac­ tion with close supervision. Afterward, the patient is made aware of his or her responsibility to continue the exercise at home on a regular basis. Hip Rotation

While supine, the patient raises the straight leg off the floor about

6

inches, strongly internally rotates the entire leg at the hip, and holds it for

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441

A

B

Figure 11-15 (A) Hamstring dynamic range-of-motion stretch, starting position.

(B) Stretched position.

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442

4

to

5

seconds (Figure

11-16).

This induces a strong active contraction of

the internal hip rotators, thus facilitating them, and it reciprocally inhibits the external rotators, thus lengthening them. Afterward, the entire leg is externally rotated, and the process is reversed (Figure 11-17). This exercise can also be performed supine, with the hip and knee flexed to 90 degrees while the hip is rotated internally and externally. This also serves as a self­ mobilization technique for hip rotation. Hip Abduction

While the patient is side lying, the uppermost leg and thigh are kept straight in line with the trunk and raised about

45

degrees, held for

Figure 11-16 Internal Hip Rotation Using DROM, Legs Extended

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443

Figure 11-17 External Hip Rotation Using DROM, Legs Extended

seconds, and lowered slowly (Figure

11-18).

This exercise places the ad­

ductors on active stretch while reciprocally inhibiting them. The bottom leg is flexed at the knee to provide support. The leg should be raised smoothly and in a straight line of abduction. "Cheating" occurs if the leg externally rotates at the hip and the pelvis rolls posteriorly, allowing re­ cruitment of the tensor fascia lata. This also occurs if the leg is raised too high. It is amazing how weak these muscles can be. At times, just the weight of the leg and thigh lifted against gravity entails much effort. Proper movement must be performed. This exercise can also be performed standing by supporting the upright posture when abducting the straight leg.

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 11-18 Hip Abduction Using DROM

Hip Adduction

While lying on the same side as above, the patient flexes the uppermost leg to place the foot in front of the lowermost knee. The lowermost leg is kept straight and raised as far as it can be (Figure

11-19).

mally only be several inches. The end position is held for

This will nor­

4

to

5

seconds

and slowly lowered. This is performed three to five times. This exercise simultaneously stretches the abductors slightly. A padded surface should be used to lie on to eliminate painful weight bearing at the greater tro­ chanter. The person then lies on the other side and repeats the above two exercises. Hip Extension

The gluteus maximus is exercised in the prone position, with the knee flexed, foot dorsiflex ed, and thigh slightly externally rotated. The thigh is lifted off the floor, not the pelvis, and it is held for

4 to 5 seconds

in maxi­

mal hip extension (Figure 11-20). This is performed three to five times. The hamstring muscle may cramp due to its being held in a shortened position. Hamstring stretching just prior to this exercise helps alleviate this. If not,

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Stretching and Exercise

Figure 11-19 Hip Adduction Using DROM

Figure 11-20 Hip Extension Using DROM

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PELVlC

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the amount of knee flexion held should be reduced. This exercise simulta­ neously actively stretches the quadriceps and psoas muscles. Abdominal Crunches

To tone the abdominal muscles, one should place the hip flexors at a disadvantage by flexing the thigh. Any tightness in the psoas and erector spinae muscles must first be addressed. In addition, the feet should not be hooked under any support surface, or the hip flexors will tated. With the patient supine, the legs are bent and spread apart at the knees, with the soles of the feet touching (Figure 11-21). The hands are placed at the sides without touching the floor or being crossed in front of the chest. A chin tuck and pelvic tilt are performed, and the neck and tho­ rax are rolled up until the scapulae come off the floor. The position is held for 4 to 5 seconds and slowly released by unrolling the torso and neck. Thjs maneuver exercises the rectus abdominis and stretches the erector spinae. To exercise the obHques, the patient is instructed to do as above except that upon raising the torso, one raises the left shoulder toward the right knee and vice versa. At all times, the legs should remain relaxed and

Figure 11-21 Abdominal Crunch, Rectus Abdominis

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447

spread apart. To contract the lower abdomina Is, one flexes both knees onto the chest and performs a strong pelvic tilt to lift the pelvis off the floor (Figure

11-22).

This position is held for

4 to 5 seconds and repeated.

STABILIZATION EXERCISES

Stabilization exercise regimens involve teaching patients the impor­ tance of using what is called the "functional range."7-9 This is the pain-free and biomechanically correct "neutral" position that the lumbopelvic re­ gion should assume when performing exercises so as to lessen injury po­ tential. The functional range may be different depending on the task the patient is asked to perform or the position in which it is to be performed. Identifying the hmctional range is important and depends on ascertaining which movements or positions provoke or relieve symptoms. Evidence for this will usually be found in the history as well as the examination. Static and dynamic loading intolerances as well as weight-bearing and non­ weight-bearing difficulties should be assessed. The functional range concept applies particularly to the lumbopelvic region, allowing the lumbar spine and pelvis to be exercised in a position

Figure 11-22 Abdominal Crunch, Lower Abdominals

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448

of

stability. Positions that

load the joints and muscles to articulations taken to

at end range are to be avoided. End range

the capsuloligamentous struc-

thus

their end range of tures. The

tilt offers an excellent

the

for Exercises done while a

a

level of safety for the

in the neutral zone or functional loading is LU

IJ'" "UVUF."U H\CH 'LVU''''

along with any strain to the associ-

structures. Patients can then be taught to use this activities of daily living, such as vacu­ and

maintaining their neutral zone or fLmctional certain

cises or movements or

ence and know when and how to use their functional This is as they use a active in their own care. to use a functional

is a psychomotor skill that requires

developing a kinesthetic awareness of the

and

of its

application. The goals of stabilization exercises are for patients to become and to exercise to muscle

aware of their functional

should be

effect.

of the exercise. Ex-

versus

upon

amples of this type of training are variations of the pelvic tilt and bridges. Posterior Pelvic Tilt pelvic tilt (PPT) is used as a foundation to which trunk the exercise's diffi-

movements can be added for

and

abdominal

culty. The PPT aids in

and control. The PPT and no pain

the lumbar

back pain

should be or after the exercise is

with the knees bent and feet flat on the floor. This is the original or placed at the

is instructed to

sides. The

domina I muscles and flatten the lower back against the floor or against the clinician's tation can be

hand

underneath the lumbar lordosis. Facili-

by the clinician in the

dominal muscles, verbally

of

the ab-

the proper motion ("Flatten your

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449

Figure 11-23 Posterior Pelvic Tilt Starting Position

lower back against my hand," or "Roll your tailbone off the floor"), or making the patient aware of the mOnitoring hand under the lumbar spine by moving the fingers slightly. The clinician may even have to pre-posi­ tion the pelvis in a PPT position to make the patient more aware of the desired movement. Once the PPT is attained, the patient is instructed to hold this position for as long as he or she can, with 90 seconds being the target maximum. Lumbar jOint mobilization and erector spinae lengthening may have to be done first to allow ease in performing the PPT. Once the patient can hold a strong and sustained PPT, variations of it are added to make it more diffi­ cult to hold. All the while, the patient is asked to maintain a strong PPT. For instance, the patient can lie supine with the legs fully extended while trying to hold a PPT for 90 seconds (Figure 11-24). The next level of diffi­ culty would be to ask the patient to raise one arm overhead (Figure 11-25A). Both arms are then tried (Figure 11-25B). To further increase the level of difficulty, while performing a PPT, the patient is asked to raise one knee to the chest without using the arms to pull it up (Figure 11-26). The foot is then slowly lowered to the table, as in

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 11-24

Posterior Pelvic Tilt with Legs Fully Extended

the original starting tilt position above. The other knee is raised, and the process is continued for as long as the patient can hold the PPT. The next level of difficulty involves raising the knee as above while rais­ ing the opposite arm overhead (Figure 11-27). More difficult than this would be lowering the leg to a straightened position without resting it on the floor (Figure 11-28). The combination of simultaneously lowering the leg and raising the opposite arm is even more difficult. Arm and ankle weights can be used to enhance difficulty further. Each level of difficulty is progressed through to see at which one the patient is unable to perform and hold a good PPT. The critical thing to ensure is that the PPT is held throughout the exercise. The patient should then use the next difficulty level that is before this break point. The idea is to bring the patient to the level of difficulty of pelvic tilting at which the muscles are brought to fatigue. The goal is to hold the tilt for up to 90 seconds. Repetitions can be used to aid in training and allow a progression to the next level of difficulty. Each repetition can be held for 5 seconds and repeated 10 to 12 times. Postexercise soreness in the abdominal region should be experienced the following day, but not lower back pain. If low back pain is felt, most likely the PPT is being done incorrectly, or the PPT position is probably being lost during the exercise and the patient is not

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451

A

B

Figure 11-25 (A) Posterior pelvic tilt with one arm overhead. (B) Two arms over­ head.

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Figure 11-26

Posterior Pelvic Tilt with Hip Flexion

Figure 11-27

Posterior Pelvic Tilt with Hip Flexion and Opposite-Arm Raising

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Figure 11-28 Posterior Pelvic Tilt with Straight Leg Held off the Floor

aware of it. Patients should be monitored periodically to ensure proper technique. Bridge A bridge exercise is performed while supine by doing a PPT and lifting the buttocks off the floor with gluteal contractions (Figure 11-29). The spine is lifted off the floor one segment at a time from below upward. It is maintained as long as the patient can maintain it, and it can be made pro­ gressively more difficult with variations added to it. At no time should pain be experienced. If it is, poor technique is indicated. This exercise is good for training hip extension strength and control. The first variation involves maintaining a bridged position while raising each heel alternately but leaving the forefoot on the floor (Figure 11-30). This facilitates gluteus maximus contraction. The next level of difficulty entails doing a one-legged bridge, thus making the support-side gluteus medius work more (Figure 11-31A). During one-legged support, the pel­ vis should remain level. Typically, the pelvis will drop on the unsup­ ported side, indicating weakness in the hip abductors on the weight-bear­ ing side (Figure 11-318). This should be corrected by bringing it to the patient's awareness and facilitating proper form with positioning or tactile stimulation. One can make the one-legged bridge even more difficult by slowly lowering and raising the legs alternately. Abducting the straight leg while holding a level pelvis will add further difficulty (Figure 11-32).

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Figure 11-29 Bridge

Figure 11-30 Bridge with Left Heel Raised

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A

B

Figure 11-31 (A) One-legged bridge. (B) Note pelvis dropping on the left.

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PELVIC LOCOMOTOR DYSFUNCTION

Figure 11-32 One-legged bridge with leg abducted. Due to the angle of the photo­ graph, the left pelvis appears to be inappropriately dropping down.

Again, each level is performed while holding a good bridge position, which includes a PPT. The level at which the patient cannot hold a good position is noted, and the patient is exercised at the next lower level. Con­ traction times should approach Ph to 2 minutes. The muscles should be­ come fatigued. Repetitions can be used, with each bridge position held for 5 seconds. Cramping of the hamstrings may occur and indicates the need for their stretching or for positioning the heels further away from the but­ tocks. Difficulty in performing bridges indicates the need to search for tight tensor fascia lata, quadratus lumborum, piriformis, or hip abductor muscles and dysfunctional hip, lumbar, and sacroiliac joints. Dead Bug

The dead bug position is held to train abdominal strength and control. A PPT is held as the hips and knees are flexed to 90 degrees and both arms are held upright (Figure 11-33). Difficulty holding this position can be eased by flexing both hips slightly more. To increase the difficulty of this exercise, one can raise the arms alternately overhead (Figure 11-34) or si-

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Stretching and Exercise

Figure 11-33 Dead Bug Position

Figure 11-34 Dead Bug Position with Arm Raising Added

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multaneously (Figure 11-35) while maintaining the pelvic tilt and leg posi­ tions. Further progression would entail lowering the legs alternately (Fig­ ure 11-36) by themselves or in combination with raising the arms over­ head (Figure 11-37). Again, throughout the exercise, the PPT must be maintained. The leg and arm positions can be held statically or moved rhythmically into and out of their positions. Gym Balls A large gym ball can be used to exercise and challenge the neuromuscu­ lar system. Exercises such as the pelvic tilt, abdominal crunches, bridges, and spinal stretches can be employed with the ball. The patient is taught to maintain balance on the ball while performing the exercises smoothly. Fig­ ures 11-38 through 11-43 demonstrate some exercise positions that can be used effectively. These positions can be statically held or used with repeti­ tions. Again, the goal is to fatigue the muscle to a "burn" without causing pain and all the while maintaining a functional range and proper tech­ nique.

Figure 11-35

Dead Bug Position with Two Arms Overhead

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Figure 11-36

Dead Bug Position with Leg Lowering Added

Figure 11-37

Simultaneous Arm Raising and Leg Lowering

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Figure 11-38

Ball Exercises with Pelvic Tilting and Abdominal Crunches

A

continues

Figure 11-39 (A)

Squat position, getting ready for transition to (8) bridged posi­ tion. Pelvic tilt is held throughout.

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Figure 11-39

continued

B

Figure 11-40

Spinal Extension Stretch

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A

B

Figure 11-41 (A) Spinal flexion stretch. (B) Extension exercises. Feet should be placed against a wall for stability.

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Figure 11-42 Side Stretch

Figure 11-43 Hamstring bridge. Ball can be rolled toward patient.

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PROPRIOCEPTIVE EXERCISES and muscles can be en-

input from the peripheral to train central

and improve activation times and coordithat reflex activation of the

nation.lO Bullock-Saxton et apo muscles was achieved nr"A'"t>nl-m-a

"balance shoes" that stimulated the pro-

mechanisms

strategies can

walking. Simple

patients to facilitate the cerebellovestibular muscle activation and coordination. This can lead to im­ and better neuromuscular controL Freemanll used a similar approach in the rehabilitation of sprained ankJes. Labile surfaces like balance boards or wobble boards, balance shoes, and cises can be used to train

stance exer-

the

coordination of

postural muscles through sensorimotor stimulation. It is easy and can be fun for the patient to perform balance board or other labile surface exercises for 15 minutes a day. Patients are instructed to use

ankle and leg mo-

tions to maintain their balance and not trunk motions

at the waist.

Rocker boards or wobble boards can be purchased at various suppliers. Rocker boards allow tilting to occur in one plane and are therefore called uniplanar labile surfaces. With a little time and minimal investment, homemade devices can be made and used as labile surfaces.

A broomstick

cut to 18 inches or some other similar dowel-like item can be

under

an 18 x 18-inch board. The board should be grooved to hold the dowel in place. This allows tilting to be can alter their

in one

of motion. Patients

on the board to challenge different axes of bal-

ancing

anteroposterior

lateral tilting, and

ing. Tilting exercises can be

with eyes open or

tiltEye clo-

sure removes visual balancing cues and places more of a burden on vestibular and proprioceptive

For multiplanar to a wooden board.

spherical structure can be

a hemi-

A

wooden bocci

ball can be cut in half and screwed to the bottom of a board. This affords of tilting motion in which the

",,.'''',,,,,,r,,-or,h

is

stance can also be used to train coordination and balance (Figure 1

The

should look

ahead and not down. The

eyes can be open or closed. The patient should attempt to stand as stable as possible for

20 to 30 seconds without

too much or

balance.

MISCELLANEOUS S TRETCHES

The

maximus for

!--,V.""C'VH

relaxes the levator ani and

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Figure 11-44 One-Legged Stance

ated with a painful coccyx. The stretch can be taught to the patient for use at home and is explained and illustrated in Chapter 6, Figure 6-34B. Pelvic Floor Muscles

Active isometric contraction of the pelvic floor muscles can be per­ formed to increase tone, especially in women after childbirth. They are called Kegel exercises and entail active contraction of the pelvic floor muscles as if urination or defecation were to be stopped and held back. Women with stress incontinence should perform three sets of 10 to 12 con­ tractions three times a day. Each contraction is held strongly for 3 seconds. Younger women fare much better with these exercises, demonstrating im-

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control after a minimal benefit.

usu-

of several weeks. Older

Chapter Review •

Why is joint manipulation not enough in the care of musculoskeletal conditions?

•

What are remedial exercises? What is passive

•

What is dynamic

•

• • • •

stretching? What is the difference between DROM and What is a criticism of What are stabilization exercises? What is the "functional range"?

REFERENCES 1.

L,

Exercise and spinal

in the treatment of low back pain.

Spine. 1995;20:615-619. 2. Lewit K. Manipulative

in Relulbilitalion of the Locomotor

2nd ed. London:

Butterworths; 1991. 3. Vujnovich AL, Dawson NJ. The effect of J Orthop

muscle stretch on neural processing.

Ther. 1994;20:145-153.

4. Murphy D ,

range of motion training: a n alternative to static stretching.

Sports Med. 1994;8:59-66.

5. McKenzie RA The Lumbar Spine: Mechanical Diagnosis and

Waikane, New

Zealand: Spinal Publications; 1981.

Ft. Total

RH,

6.

New York, NY: Warner Books; 1982.

7. Saal JA, Saal IS, Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome 8. Saal JA

1989;14:431-437,

muscular stabilization in the nonoperative treatment of lumbar

syndromes, Ortho Rev. 1990;19:691-700. 9,

D. Concepts in functional

and postural stabilization for the low-back-

Top Acute Care Trauma Rehabil, 1988;2:8-17. 10. Bullock-Saxton JE, Janda V, Bulock MI. Reflex activation of gluteal muscles in 1993;18:704-708. 11. Freeman MAR. Co-ordination exercises in the treatment of functional instability of the foot. Phys Ther, 1964;44:393-395.

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Appendix A

Case Follow-Ups

CASES

Case 1: Sacroiliac Pain Case 2: "Bladder Infection" and Groin Pain in a Hockey Case 3:

and Groin Pain

Case 4: Painful Tailbone Case 5: Low Back Pain in a Weight Lifter and Buttock Pain in an 11-Year-Old

Case 6:

Case 7: Low Back Pain After a Tennis Serve Case 8: A Golfer with Thigh Pain Case 9: A Rollerblading Executive with Hip Pain Case 10: "Growing Pains" in a 7-Year-Old Dancer Case 11: A "Turned-Out Foot" in a 12-Year-Old

CASE 1: SACROILIAC PAIN

A

with severe

woman, 3 months

"hip" and leg

of 3 weeks' duration after she attempted to move a she

in order to sweep behind it. She said that in so

twisted her trunk and felt a "catch" (here she pointed to her sacroiliac joint region). The

was

localized to the left sacroiliac

and but­

tock with occasional radiation into the proximal posterior thigh Trunk bending and twisting to the left hurt her. Walldng and climbing stairs were difficult, since any The act of

caused jabs of pain to be

from a chair was most difficult,

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468

PELVIC LOCOMOTOR DYSFUNCTION

Figure A-I Case 1: Sacroiliac Pain

itself was not. She was able to at night, but at times she would her left knee upon over in bed. her pain upon her chest seemed to alleviate the for a short period of time. She limited in her ability to do normal housework without In the last few days before clinical she had noticed her entire left and her calf region sore. She denied any bowel or bladder problems, she admitted to moderate exacerbation her pain upon Examination

in flexion and left bend.. Trunk range of motion was full but ing. line were tender. .. Left PSIS and SI .. There were left medius and minimus trigger .. Left Yeoman's and Gaenslen's tests were .. Sacral apex test was painful and showed lateralizing to the left

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""''''ULC

•

Gillet's test showed restricted ion and extension.

and lower

•

Lumbar joint play and range of motion were normal.

•

Motor and sensory reflexes were normal.

•

X-ray was normal.

in

A

469

flex-

with gluteal

Left Treatment

to Visit 1: Ice to painful both upper and lower aspects, using flexion and extension Visit 2: Patient felt 70% better. Still achy into leg. Myofascial postisometric relaxation (PR) and ischemic of manipulation. Visit 3: Patient felt much improved. SIJ manipulation. Three-point and hip exercises given. Daily walking program. Case

........lAW"". ..

problem. Provocative testing was positive and manipulation to the joint greatly improved her conon Gluteal trigger points were found; in the dition, thus these are very common with especially in the gluteus minimus. CASE 2: "BLADDER INFECTION" AND GROIN PAIN IN A HOCKEY PLAYER History

A his

to block a puck with He felt in what making him think he an He found it difficult to walk one shoe on at a time and lie on his abdomen. VV<'H",J. hurt him. on his back and

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470

PELVIC LOCOMOTOR DYSFUNCTION

Figure A-2 Case 2: "Bladder Infection" and Groin Pain in a Hockey Player

his thighs adducted afforded him relief. Urination was unaffected, and no fever was admitted to. Examination •

Adductor longus muscles were painful and tight to palpation, passive stretch, and active contraction, especially the right.

•

Pubic symphysis was painful to direct pressures.

•

Rectus abdominis insertions were tense and tight.

•

Gaenslen's test was positive bilaterally.

•

There was SIJ dysfunction at the right upper and lower poles.

•

X-ray was normal.

Diagnosis

Pubic symphysis joint dysfunction and adductor muscle strain.

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Appendix A

471

Treatment symphysis and right adductor tendon until by 5 minutes of walking. Repeated every 2 hours.

Visit 1:

Visit 2: Patient felt 50% better. PR using general followed by grade IV mobilizations with this Visit 3: Patient

tech-

by 80%. PR to

muscles. Visit 4: Patient felt same. PR using this gave most relief. SIJ manipulation felt much improved. Case example of a patient's describing one "Bladder infection" to this pubic was most referral to the bladder area. The mechanism of injury is consistent with a pubic symphysis Provocative maneuvers since tests the joint were painful. The muscle strain was the adductor's contractile elements were positive. Interestingly, an ish the case. CASE 3: HIP AND GROIN PAIN History and stiffness of A 53-year-old housewife 5 months' duration after for hours in a crouched position on her hands and knees She found it to stand erect and walk the next morning. She could flex her to put on socks, but it hurt her and she could not fully it when flat. The front of Her her thigh ached and felt was described as and her knee did not hurt her achy. She also noted a diffuse knee did. No back pain but when she used it. Sitting did not bother was present. Examination •

and restricted in flexion, internal and exHip joint play was ternal rotation, and extension.

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472

PELVIC LOCOMOTOR DYSFUNCTION

Figure A-3 Case 3: Hip and Groin Pain

•

Patrick-Fabere test was painfully restricted.

•

Right adductor longus was painful and tense, with trigger points present.

•

Right iliopsoas muscles were tense and tender.

•

There was joint dysfunction in anterior and posterior glides, flexion, and lateral glide.

•

Gluteus medius trigger points were present.

•

Lumbar spine examination was normal.

•

There was SIJ dysfunction bilaterally, with painful right posterior Sij ligaments.

•

X-ray showed mild degenerative changes in hip joint.

•

Knee joint examination was normal.

Diagnosis

Osteoarthritis of right hip with hip joint dysfunction and gluteal and adductor myofascitis.

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Appendix A

473

Treatment

and right adductor tendon until Visit 1: Ice to pubic 5 minutes of walking. Repeated every 2 numb, followed hours. I and II medial rotations, followed Visit 1: Gentle extension mobilizations. PR of adductor and iliopsoas 2:

Grade I and II medial rotato all

muscles. Long-axis extension manipulation. Visit 3: Patient felt 50% better. followed by grade VI in long axis. Gluteus medius myofascial stretching with PR and ischemic comPR mobilization into full extension. Visit 4: Patient felt the same. long-axis and extension; (AP) and posterior-to-anterior IV n,::"·�".·rn.::.r! Visits 5-10: Patient felt 75% better. Repeated and findings. Psoas muscle and mobilizations as and hip stretches implemented. Much improved. walking started. Case Commentary

Hip joint problems, especially in "UY,"",,,,This woman's knee and anterior with groin ally from her hip joint. Mobilizations in the initial phases of care help tremendously in painful hip conditions. SIJ and needs to be treated. tion is often associated with hlp joint conditions. limited in hip Extension is CASE 4: PAINFUL TAILBONE

Three months previously, a 42-year-old man had rug and slid down three stairs on his buttocks.

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474

PELVIC LOCOMOTOR DYSFUNCTION

Figure A-4 Case 4: Painful Tailbone

his "tailbone" that was severe and prevented him arising (Figure He had been taken to the local hospital where examination findings, for fracture but he had been told he X-rays, had been had a bent coccyx. His subsided slightly since its onset, but he still found it difficult to sit lip straight, especially on hard surfaces. He said he was aware of a constant tension around his anus and defecation was at times. Examination • • • • •

Trunk range of motion was normal. was tender,

on PA

and lateral tilts.

was painful with Yeoman's and Patrick tests on the left. Levator ani was tender and tense. sacrotuberous

was painful and firm.

and 51} dysfunctions.

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nnf'na;[yA

475

Treatment

Visit 1. Gluteus maximus PR to relax levator ani. Lateral and PA I and II mobilizations to coccyx. Visit 2: Patient felt sore but slightly lateral, and PA mobilizations tions.

Gluteus maxirnus PR, IVs, SIJ manipula-

Visit 3: Patient felt 80% improved. Sacrotuberous ligament pressure mobilizations. technique, grade IV gluteus maximus technique.

Visit 4: Patient felt much better. sacrotuberous Case Commentary

Typical coccygeal pain involves direct trauma. X-rays are often noncon­ even if they show a bent coccyx. Many coccygeal X-rays show Treatment to the sa,:roiCOCC11\!E?a malaligned segments in normal SIJ, and neighboring soft tissues aids healing greatly. embarrassment were also much and understanding for this preciated. CASE 5: LOW BACK PAIN IN A WEIGHT LIFTER History

A male lifter with bilateral sacroiliac and lower back stiffness of 2 weeks' duration (Figure The was constant but was worse up and standing, and pressing in on his lower abdoarching his spine, on men. The pain was alleviated with ice packs, flexing the he and A dvils. It had his side in a fetal weights using a sitting began lifting extremely noticed his lower back was sore and sensitive to touch where the workout in on machine's seat met his back. He could reproduce his and along his lower left abdomen, it to hurt across his lower each sacroiliac concerned about this and suspectcare physician ing visceral work and a CT scan of his Results were normal. Examination •

Sacroiliac and thoracolumbar

were stiff and

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476

PELVIC LOCOMOTOR DYSFUNCTION

Figure A-5 Case 5: Low Back Pain in a

Lifter

trigger were bilaterally. muscle belly was very tender and pHJU.'..'-......... much of his in the back even upon light lumbar were very and thickened was found over the spinous processes.

.. ..

..

Diagnosis

Iliopsoas myofascial

syndrome, thoracolumbar

dysfunction.

Treatment

Visit

1:

of sacrospinalis and sacroiliac joint mapoint Gave moderate but only temporary relief. work and myofascial Much

u.�uuu,,,.

Visit 2:

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Appendix A

477

Visit 3: Condition still painful but better. Thoracolumbar with more myofascial stretching muscles Visit 4: Patient felt much better and continued to feel better. Further stretching was performed, with thoracolumbar Patient was shown stretches and told to decrease to a more reasonable amount. Case

It is to note that very light muscle was to elicit his pain needed to be ruled out in such a case, as it was Thoracolumbar joint dysfunction often and treatment needs to be directed at

muscle

CASE 6: RIGHT HIP AND BUTTOCK PAIN IN AN 11-YEAR-OLD BOY History

of 2 An I1-year-old boy presented with tion after he had turned a sharp corner while ing so, he had twisted his trunk and heard a loud that resulted in buttock The pain was sharp, localized to the left lateral hip and sacroiliac joint regions (Figure and twisting his trunk to the left were painful. He walked with a lunging his left leg forward, since weight over in bed and getting The felt better while were the most up from a an achy pain in he was supine with both knees flexed to his left groin and was worried he had a hernia. He was unable to play any due to his He denied any bowel or bladder Examination

.. Trunk flexion was limited to 90

and left rotation was limited.

.. Left PSIS and 51 joint line were .. Left gluteus medius hip region. .. Left Yeoman's test was at 60

tender to palpation. was found that referred pain to his and left straight-leg raise was positive

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478

PELVIC LOCOMOTOR

A-6 Case 6:

• •

•

DYSFUNCTION

Hip and Buttock Pain in an 11-Year-Old Boy

Gillet's SIJ palpation demonstrated restricted motion in left SIJ. Motor and reflexes were no nerve tension were present. were normal. X-rays of the

Left sacroiliac joint dysfunction and

myofascitis.

Treatment

Visit 1:

and SI} mobilization grades I through III; cryokinetics at home recommended, consisting of ice applica­ tions until followed by 15 minutes of 2 hours. Visit 2: Patient felt 50% better. stretching of gluteus medius and SI} were performed.

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Appendix A

479

Visit 3: Patient felt much better. Wanted to participate in sports exercises for manipulation repeated. Patient was SIJ, and tensor fascia lata. Visit 4: Patient felt no Myofascial of tensor fascia lata and Patient was instructed in Pf()Pl'lO(:ep,n exercises and balance board use, Case Commentary

It is important to rule out a slipped femoral epiphysis with this history of a limp, hip, and groin his examinawell to treatment. tion directed attention to CASE 7: LOW BACK PAIN AFTER A TENNIS SERVE

A 47-year-old tennis player with low back pain after serving tennis balls for an hour 1 The pain had come on over the course of that The was located over the flank (Figure A-7), and left and SIJ area and was worse with and sudden trunk Sitting erect or lying supine lessened his movements created stabbing pain in the back His right buttock also ached. No bowel or bladder dysfunction was Examination • •

•

•

•

Trunk flexion and left lateral flexion were limited and painfuL were found that reproduced his pains. Additional trigger were found in the gluteus minimus and tensor fascia lata. Hip abduction showed an abnormal movement hikwith ing initiating the movement. Thoracolumbar dysfunction was palpated,

Diagnosis

lumborum myofascitis with tion.

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joint

480

PELVIC LOCOMOTOR DYSFUNCTION

A-7 Case 7: Low Back Pain After a Tennis Serve

Treatment

Visit 1: Stretch and spray of quadratus lumborum with heat applica­ tions. but stiff in with no radiation into Visit 2: Patient felt less lower back. Thoracolumbar region manipulated, and stretch of quadratus lumborum and nr{,"�,,; and was home stretches for Visit 3: Patient was much lumborum. Case Commentary

lumborum (QL) muscle is often overlooked in lower back patients. Flank pain and coughing are not unusual symptoms with QL points but also signal other The abnormal of hip movement us a clue that during hip abduction the QL is overactive and vulnerable to developing trigger points. Thorapoints. columbar dysfunctions are also linked with QL

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A

481

CASE 8: A GOLFER WITH THIGH PAIN History

A

player

of 2 weeks' duration. The

came on

It was described as a

nine holes

headache in the

the upper anterolateral thigh to the distal lateral thigh

that spread

The pain was worse with walking, that side. The pain was on his side and

eased with warm

his

leg and thigh

him. He also mentioned that he had had lower back was alleviated by yoga stretches.

A-8

Case 8: A Golfer with

Pain

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and and off the bed

482

PELVIC LOCOMOTOR DYSFUNCTION

Examination ..

..

.. .. .. ..

hip abduction was and exhibited a poor movement with the tensor fascia lata "'.",."."" •• ,., well before the to roll the pelvis n;.,{'",,,,,;.,y'll medius while the Modified Thomas test demonstrated testing for a tensor fascia with slight and abduction noted in the dependent band. was observed along the thigh. A notable Tensor fascia lata was tight and with very painful the in it that adductor shortness was noted. with pain Yeoman's, Patrick-Fabere tests were localized to SIJ. SIJ was for joint

Diagnosis

Tensor fascia lata myofascitis with sacroiliac Treatment

lata was done. Visit 1: Postisometric relaxation of the tensor of the right Postfacilitation formed. Visit 2: radiation down thigh. last treatment. S]J function present on and manipulation was Tensor fascia lata and adductor stretching also done. lower back pain same. Visit 3: Patient felt 75% improved. quadratus lumborum point on assessment. Stretch and spray to quadratus lumborum and manipula­ tion performed. He was given stretches for SIL tenVisit 4: Patient felt much sor fascia lata, and adductors. Case Commentary

The tensor fascia lata often causes anterolateral or lateral pain. It commonly in a chain reaction of dysfunction involving the quadratus lumborum, minimus, joint, and as we see also in the next case.

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Appendix A

483

CASE 9: A ROLLERBLADING EXECUTIVE WITH HIP PAIN History

A

male executive

with hlp

tion after 2 hours of RoHerblading. The ened as the day went on. The

of 2

dura-

came on gradually and wors-

was

and

It was localized in

the left lateral hip region with no radiations (Figure hurt him, and he said he noticed a

movements

in the area. Ice

on the area hurt, as did any hip movements, climbing

and and

in and out of his car. Examination

.. Active and .. A

movements were

in any range .

swelling was detected over the left painful and slightly reddened.

A-9

Case 9: A

Executive with Hip Pain

Copyrighted Material

trochanter that

484

PELVIC LOCOMOTOR DYSFUNCTION

Diagnosis

Left trochanteric bursitis

to overuse.

Treatment

were applied to the bursa. Visit 1: Ice and interferential current The was instructed to continue every 2 hours until Visit 2:

Further examination was IJV''''H''-''C TFL and minimus The hip was mobilized and

reduced and bursa palVisit 3: Patient felt much pated as painless. Postisometric relaxation to TFL and minimus mobilized. to stretch hip and SI Visit 4:

Case Commentary

A The of bursitis is often handed out too is that the pain must be in a known anatomical site of a bursa. This case af­ fords us that, as well as painful movements in all ranges, whether active or This patient was too uncomfortable to continue with an further examination examination on the first visit. After his pain revealed other dysfunctions that were treated. This case to overuse in the of reseems to a bursitis lated and muscle dysfunction. However, it should be remembered disease. of a that bursitis may be a CASE 10: "GROWING PAINS" IN A 7*YEAR*OLD DANCER' History

A 7-year-old girl classes. The and lower

leg pains after 3 weeks of dance and located in the lateral A-lO).

Copyrighted Material

Appendix A

A-IO Case 10:

485

Pains" in a 7-Year-Old Dancer

- .--.----.---

Examination • •

Trunk

of motion was normaL

There was

SlJ dysfunction and restricted hip extension joint

play. •

Right SI joint line and PSIS were tender.

•

Gluteal and hip adductor

•

abduction movement tion and tensor

lata and

her

pains.

were poor, with weakness of mo­ lwnborwn substitutions.

Sacroiliac joint dysfunction with gluteal and adductor ger

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PEL VIC LOCOMOTOR DYSFUNCTION

486

Treatment relaxation of the adductors

manipulation and muscles.

Visit I:

and

Visit 2: Patient slept better, but her

still ached.

hip mobilization, and tensor fascia lata stretching. Visit 3: Patient felt much better. She had no ter, felt minimal discomfort. Hip to her dance teacher. Patient

vice

Case Commentary that are commonly

Children very The clinician

nosed as growing ment of the locomotor

is versed in functional assess-

will find relevant

in a large

majority of the cases. Children too can benefit greatly from this type of often dramatically so, Pelvic joint and muscle commonly at fault in a iliac and

Young

joints and gluteal and hip adductor

as well as older ones, often do not have the coordination and strength for so with hip abduction move-

certain dance routines. This is and

movement

can result if a child is

or her CASE 11; A "TURNED-OUT FOOT" IN A 12-YEAR-OLD BOY

with the concern that for the past 3 years

boy

had flared out as he walked. His mother commented that he C:PP'TYl"'(1

clumsy but thought it was normal

his age. She also

foot turning outward when he walked. He admitoccasional soccer or

and lower back achiness after playing

also

headaches at a frequency of one trauma was

per week. No history of advised them to do

as it would

An orthopedic out with

time.

Examination •

Postural examination revealed an anterior tilt to the with a pronounced slouch. He

"Y"llnp,,.,p';

in his movements.

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Patient sat

Appendix A

487

.. Gait examination revealed an externally rotated and foot. .. Tnmk flexion was limited due to hamstring tightness and discomfort. .. Modified Thomas test showed substantially short psoas muscles bi­ especially on the .. Sacroiliac and hip joint dysfunction was found on the right, in extension. The right SlJ line was tender to palpation, and Yeoman's on the right.

and Patrick-Fabere tests were ..

with adduction was very limited and painful bilaterally, on the shortness.

and limited due to

..

.. Hip adductors were shortened and tight. and poor cervical movement pat-

.. Craniocervical joint terns were exhibited.

Diagnosis SIJ and

dysfunction with

and

myofascial shorten-

Treatment neuromuscular facilita-

Visit 1: Visit 2: Patient felt looser. Still "stiff" in PNF. Hip mobilization, adductor stretches were

Visit 3: Patient felt difference in hips while running; not as achy. Felt as if foot did not flare out as much. On observation of gait, foot PNF per-

still externally rotated. formed. Hip and

manipulated.

Visit 4: Felt a big difference. However, headaches seemed worse. On less of an external

foot

rotation. Craniocervical manipulation performed.

ad-

ductor, hamstring PNF. Visit 5: Patient felt much better with headaches, and major difference with walking. No achiness in lower back with running. Felt much looser overall. Foot only slightly almost not noticeable.

manipulation

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rotated with Pa-

488

PELVIC LOCOMOTOR DYSFUNCTION

tient taught psoas, hamstring, adductor stretches. Pelvic tilting exercises were

Wobble board exercise for proprioceptive

input was given. No headaches since last time, and walking

Visit 6: 1 month

with no external rotation of right foot. Psoas and hamstring PNF and

manipulation performed. Exercises re­

and

viewed. Discharged.

Case Commentary who seem to be neuromuscu-

It is not uncommon to find young

and display jerky movements.

lar "illiterates." They seem have a difficult time

and fully

go when they are exand

amined and treated. Movements joint/muscle dysfunctions are

case is a good ex-

ample of this. Although the patient presented with no real painful comhis concern of an

joint

led to the

to his major concern. As with most His major

were tight

seemed to be ex-

hamstring, and adductor muscles. This is a com-

mon pattern seen in young patients who are Their coordination is faulty, and they exhibit it hard to relax in response to examination SIJ

were also

his craniocervical

seemed to be linked to his

problem, since his headaches worsened

as work on his pelvis was undertaken. He experienced a noticeable overall difference after the

cervical

Pelvic and craniocervical

are often linked, and the cians to look for the other. It would have been would have happened if

the craniocervical

first.

Copyrighted Material

of one should alert clinito see what

Index and exhibits;

numbers in italics denote those followed

"t" denote tables.

Articular fixations, 408

A

Assessment of patient differential

Abdominal aortic aneurysm, 127

119-129

Abdominal crunches,446-447, 446-447 Abnormal illness behavior, 399, 401 UJl,.uU'lI�.l63, 404--406, 406

Acetabulum, 2, 5, 6,18

380-381

Active care, 396 f\curt'-DI:la�ie treatment,396-399 factors in, 397 and duration of, 397

B

scope of, 398 UVII"U'''':�

test,193-195,195

of, 397

Baer's point, 49, 109-111

response to, 399 soft tissues, 336-339 "'n�mlV"

Balance shoes, 403,464 Barlow's test, 415

processes, 103-104

Aerobic exercise, 423

Berhterew's test, 129

Anatomy, 1-53

Biochemical response, 134-135 Bladder infection, 127

articular innervation, 44-46 8-21

Bone, 115-116

congenital anomalies and variants, 50-53

Bone cancer, 103, 126 I-Olt-pllao,, " theories, 247

muscular, 21--44 osseous, 1--8

exercises, 453--456, 454-456 Bursa,

20

Bursitis,115,116--117 ischial, 115 Angle

trochanteric, 115

of anteversion of femur,19, 170--172, 171 of inclination of femur, 19

case history of, 483-484 "Butt lift," 191, 192

inferior lateral, of sacrum, 4 Q,I72 Ankylosing

viii,124-125

c

Aponeurosis, 327 erector spinae, 29, 30

Canal anal,45

Arthritis,124-125

sacral,4

septic,414 Articular facets, 3--4, 4

Case histories, 467--488

489

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PELVIC LOCOMOTOR DYSFUNCTION

490

in

"bladder infection" and

hockey player,92-94, 93-94, 469-471 pain,481, 481-482

pains" in

dancer,

in, 413, 484-486

knee pain in,95 n""'o, ,"',,..,,

of low back pain in, 412

response to treatment, 413

484-486,485 hip and

412-413,484-486 "growing

bone cancer, 126 with

disorders related to dance classes,

arthritis in, 414

pain,94-96,95-96,

transient synovitis of hip in, 414-415

471-473,472 low back pain after tennis serve, 479-480,

480

treatment techniques for, 413 Chondroitin sulfate, 329 treatment, 399-402

low back pain and headaches in

for acute exacerbation of chronic

413-414

old

in

low

lifter, 475-477,

condition, 402 characteristics of abnormal illness

476 tailbone,96-98, 97, 473-475, 474 groin muscle" in 6-year-old

behavior, 399,401 five "D's" of chronic pain

and duration of, 399, 401

rectal cancer,100-101 hip and buttock

in

r.hi,orh,,,'�

executive with

Claudication,

120, 120-121

sacroiliac pain, 90-92, 91-92, 467-469 pain, 391

400

signs of chronic

pain,

483, 483-484

sacrotuberous

of,400-401

of soft tissues, 339-340

477-479,478

sacroiliac

399,

400

dancer,412

123-124

Coccydynia,124, 240-242 case history of, 96-98,97,473-475,474 due to pain referred from pelvic floor muscles, 98 98

tennis 1,

mobilization per rectum, 288 Cold-induced vasodilation, 340 294,297

Cavitation

328 reactions, 103-104, 396,401

Central stenosis, 123-124 Chair test, 410-411 Children,411-415

Connective tissue, 327-329, 328

case histories of -V""I-lJIU

(CRAC)

dancer, autogenic and nhpn()m,>n�

inhibition in, 380-381

hip adductors, 383, 383 "turned-out foot" in

Contusion, muscle, 331 Cornua

486-488 dislocation of hip in,415 craniocervical joint 413-414

in, Counternutation,sacral, 60

Copyrighted Material

Index

End range, 448

Crest

End-feels, 143, 143, 249

iliac, 2,5,46,172

14

of sacroiliac

294,297-298 Craniocervical joint dysfunction, 413-414

491

Endocrine disorders, 128 Endometriosis, 104

tenderness at, 116

329

6 sacral, 3,4

Endosteal pain, 115-116

trochanteric, 19

arthritis, 124,125

Crahn's disease, 125

Enuresis, 417

Cross-fiber massage, 376-380, 379

Erythrocyte sedimentation rate, 243-244,

Crush injuries, 331

244t

ryoldnetics, 338-339, 340

of pain, 122-129

Cryotherapy, 338, 398

infection, 125 mechanical, 100-101, 122-124

D

metabolic/ endocrine, 128 neoplasia, 126

Dead

position, 456-458, 457-459

ycholo,gic, 128-129

Dennatomes, 105, 108, 109

""')lV),I�,

Differential

124-125

vascular, 127

Diabetes meLUtus, 128 119-129

visceral disease, 104,127-128

case histories

Examination, 133-159, 162-244

bone cancer, 126

163, 404-406,

associated

12 0,

sacroiliac joint

406 in history, 133

120-121 of

of, 134

122-129

infection, 125 mechanical, 122-124

244t

metabolic/endocrine, 128

"five nevers" of, 136

nee'plasla, 126 LlllHu,elL

for, 133-134, 162-163 with

128-129

testing,

rheumatologic, 124-125 vascular, 127

joint irritability, 136-138

visceral disease, 127-128 rule out

disease, 122

139-140

joint joint

inequality, 153-158, 154t, 155

rule out severe disease, 121-122 rectal examination, 242

length-strength and movement patterns, 147-153

Disc, interpubic, 16 Distraction tests, 129

145-146 pathology, 135-136 in prone position, 224-242

Dynamic rarl�e-ot"-m()tl()n

coccyx, 240-242 heel-to-buttock test, 224,227, 22 7

stretching, 437-447 Dysmenorrhea, 104, 128,392,416

extension movement pattern, 224,

226

242

hip

E

227-229,228-229 measurement of

Ehlers-Danlos

409

iliac

Elastin, 328

floor, 242

Copyrighted Material

superior

distance, 224, 226

492

PELVIC LOCOMOTOR DYSFUNCTlO:'>J

sacral accessory movements!sacral

hip joint accessory movements, 210,

shear,232, 235-237,

212-214

236-239 sacro-ilio cross, 237,239 sacrotuberous

231-232,

234--235

Patrick-Fabere test, 205,206 197-200,199

pubic 240

static

sacroiliac joint distraction,iliopsoas 200-201,200-201

extension differential test,240, 241

test,201-203,202

Yeoman's!gluteus maximus muscle play,230-231,230-233

134-135

vertebral subluxation Exercises

radiographs,242-243,243 138-139,139

range-of-motion

trunk curl-up test, 196--197,198

aerobic, 423

out lumbar spine involvement,

play

restored,293-294

benefits of,422-423

136,137 ruling out thoracolumbar joint 136,137

465-466 muscle response to

330-331

selective tissue tension, 143-144,143-145

to prevent injury,418-419

in

Dr()Dr:IOC'�Dtlve,403,424,464,465

position,217-224

423

tensor fascia lata,and points,219,

stabilization,447-458 453-456,454--456

219-220,221 hip abduction movement pattern, 217 and provocation

dead

456-458,457-459 458,460-463

gym

posterior pelvic tilt, 448-453,449-453

221-222, 223

423 stretching, 422-447, See also

iliotibial band, 220-221, 222 UatHdLU;:'

lumborum trigger point,

217-219,218

F

sacroiliac joint play in torsion, 224, 225 in sitting position,190-196 lumbosacral

vs, sacroiliac

192-195,194-196

251

Fascia 195-196

190-192,191-193 soft tissue and skin

in

Facilitation

14&-147,147

thoracolumbar,25-26,26--27 transversalis,26 Fascicles,329, 330 Femur

163-190 gait,163-172,165--167,169-171 posture,172-178,173, 175-178 sacroiliac palpation: Gillet's test,

head of, 18-19 pain at,116 neck of

184-185,184-190,187-188,190

of anteversion, 19,170-172,171 of inclination, 19

of motion, 178-183,

femoral trochanters of

in supine position, 196--217 raise and lumbosacral tilt,

greater, 19,48,116 lesser,19

215-217 Gaenslen's test, 203-205, 205

Fever, 104

hip adductor

Fibroblasts,327

205-206,207-208

flexor length,203,204

327

Copyrighted Material

414

493

Index

Fibrosis, 325 "Five nevers," 136 toe-in, 19,

"Flat-back" syndrome, 417

toe-out, 19, 171

Fluod-Methane stretch and spray

Gastrointestinal disorders, 127

346

Genu valgus, 171,172 Foramen

Genu varus, 172

obturator, 6,7 sacral, 3,

Gillet's test, 184-185,184-190 329

4 Gout, 115

sciatic, 16 Fossa acetabular, 18

center of, 71

iliac, 7

effects on pelvis

popliteal, 36

standing, 71-75,

73-76 " viii, 413, 484-486

Fovea, 18-19 Functional mechanics, 57--86 closed kinematic chain, 58 of hip

69-71,70, 72

H

of lifting, 79-80, 81 literature review of pelvic joint motion, Head's zones, 111

81--86

336,337 157-158 Heel-to-buttock test, 224,227,227

75-76,77-78

motions pelvis as

complex,

57,58

Hemarthrosis, 115

symphysis, 67-fJ9, 69

of

zoster, 125

sacral motion with respiration, 76

Hiatus, sacral, 4, 4, 18

of sacroiliac joint, 59-fJ7

"Hip

posture and gravity, 71-75,

"168

joint, 18-21,20-21 abduction of, 217, 403--404

72-76

abductors of

Functional range, 447

exercises for, 423--424, 442-443,444

G

<:;trf>trhin" of, 433, 435,436 of, 220,221

Gaenslen-Lewin test, 203

strength of, 220 weakness of, 164, 167,423--424

Gaenslen's test, 203-205, 205,230,311

accessory movements of, 210, 212--214

Gait, 163-172

adductors of, 40-42

164

exercises for, 444, 445

effect of

of, 429,431,432

femoral version

of, 385-387,

gluteus maxim us 168-169, 170

and tightness of, 174, 175,

medius lurch, 167,168 "hip

203

168

joints involved in, 164 muscles involved in, 164

383,

limp, 168 pelvic motions 167

383 75-76,77-78, 164,

testing length of, 205-206,207-208 testing

Copyrighted Material

of, 220

494

PELVIC LOCOMOTOR DYSFUNCTION

points in, 374-376,375-378

Hip joint mobilization, 268-281

8n!:prr)Oostprior shear of,206-208, 210

accessory movement,277-281

anteverted, 19, 170-171,171

caudal glide in flexion,279-281,282

of, 19

lateral glide with flexion, 281,283

case history of dysfunction of, 94-96,

extension in neutral,

95-96,471-473,472

277-279,280

dislocation of, 415

r"'''>"�'n;t�1

281, 284

anterior

281,283

extension of,224, 226, 403

pnYSI'OIOI;IC movements,268-277

exercises for, 444-446, 445

abduction, 271,274, 274

extension, 231,233 flexion/adduction

combined flexion/adduction,268-271,

test of,

270, 272-273

208,211 flexors of

extension,277,279 medial and lateral rotation, 274-277,

of, 432,432-434

passive

of, 168-169,169

275-276,278

length of, 203, 204 functional mechanics of, 69-71, 70,72 gait,164,167-169,169

adduction, 444,445 extension,444-446, 445

innervation of,46 i"" ",,,",C

of,19-21

rotation, 440-442, 442-443 107,107

Hip osteoarthritic,95 pain due to disorders of, 123 referred pain from, 95, 96, 123 retroverted, 19, 171, 171 rotation of, 206,209, 227-229, 228 rotators of exercises for, 440-442,442-443

case histories, 90-98, 467-488. See also Case histories

lateral, 38-40 119,186,387

clues to types of tissues injured,114-119 bone,periosteum, 115-116 bursae, 115,116-117

71,72 transient

of, in children,

menisci,

414-415

membrane, 114-115 joint

joint extension, 314-315,317

muscle,117-119, 118 nerve root,119

lateral rotation,315, 318

examination based on, 133

extension,315,318 in

117

joints,119

in prone

position,313-314

"'>l.eiUClII'.

extension,313-314,316 317-321

to patients,98-99 proper

questions to

in mind

flexion,319,

continued symptoms and

320,320

fever and/or weight loss, 104

compensatory reactions, 103-104 at90

mechanical vs. organic lesion,100-101, 320-321, 321

101 morning stiffness, 103

Copyrighted Material

Index

night

103

495

Inflammation,103, 135,324-326,326

occupation and posture,104

acute inflammatory response,325

onset

chronic, 324, 325

101-102,102

pain location and character,104-107,

of, 324

106-107

disease, 103,125

radicular pain,112-113, 113 referred pain, 107-112,109-110,112 visceral disease,104 effect,340

of muscles,331-332

114

of tendons,332

329

Innominate bone,1,4-7,6-7 Insertional sites,334-336, 336 Intertrochanteric line,19 136-138

Irritability

Ischemic compression of

points,250,

347-348,410 Ischemic muscle Ice application, 340, 398

uU."'''!'>'',

331-332

6, 6-7

Ischial

Iliac arteries,52

Ischial tuberosity,6,6

Iliac horns,52

Ischium, 5, 6, 6

Iliac spine anterior inferior, 5,6 anterior superior,2, 5,6-7,48-50,49,178

J

posterior inferior,5,6, 48 xiii,2,5,6,46-48,116

posterior

during forward flexion,179

117,327

Joint play, 139-140

test,186

during

Joint p""rr,,�m"7

lateral flexion, 182,182-183 of,172,184,185

136-145

Joint

prone measurement of distance

before restoration of, 293-294

Joint Signs,140-141, 248 irritability,136-138

between,224,226

joint

measurement of distance

with

141-142,142

between,192,193

play fjoint

Iliac tuberosity, 7

joint

139-140

140-141

Iliotibial band,36,37-38,39,42, 177,178 range of motion,138-139,139. See also

passive stretching of,436,440 shortening and

of,172,221,387,

387

selective tissue tension,143-144,143-145

treatment of, 387-390,388-390 testing

of, 220-221, 222

Joints ankle mortise, 164

Iliotibial tract,49

"rr"rk,lO"" of,294,297-298

Ilium,5-6, 6

femoroacetabular,18

movements of,59�1, 61

18-21,20-21. See also

Ulness behavior, abnormal, 399, 401 242-243,243 Immobilization, 324 lySIOlo;gIC
joint

of,119,409-411 innervation of,44-46 knee,164,170-171,171 h\fT'I'r.�"t.'n�i"n

tissues and,326-327,327 infection,125

Copyrighted Material

of, 176, 177

496

PELVIC LOCOMOTOR DYSFUNCTION

I.
127

Leriche

midtarsal, 405

Lifting mechanics,79-80,81

movement of,247

117,240

gender

in, 16

of head of femur (ligamentum teres), 20-21

iliofemoral (Y

of Bigelow),19,

20-21 joint

iliolumbar, 8-9,10,17,

sacroiliac,9-15,13. See a/50 Sacroiliac

46

calcification of, 52

joint

5,22,42,49,49 injuries of, 333-334

subtalar, 167,405 thoracolumbar,111, 123,136,137

transverse friction massage of, 376-380,379 interosseous, 4,7,12, 13, 47 ischiofemoral,19-20,21

K

lacunar,42 patellar,42

Kegel exercises,465-466

changes in,76,78

Kemp's test, 181

pubic,8,16

disease,104, 127

put.otemoJral 20,20

Kinematic chain, 57-58

17-18,17-18

134-135 test, 62, 64,184-190,

sacroiliac, anterior,10,12, 13,47

187-188,190

posterior,12,17

52

Knife-clasp

sacrospinous,6,16,17,38

Kyphosis,175, 177

sacrotuberous,16,17, 38 calcification of,52 of pain from, 391

L

from,232, 235 of,231-232,234 treating pain from,390-392,392-393

Labrum, 18

structure and function of, 332-334,333

Lateral canal stenosis, 124 Lateral mass,sacral, 3

12-14

150-151,152,174

Layer Leg

supraspinous, 8,17 transverse,18

disease,96,414 ,PC1-ipnC1th

inequality,153-158,178 loading due to,156--157 of,153-154, 154t

effect on lateral weight distribution, 157 gait and,157

Listening to patients, 98-99 Literature review anatomy of sacroiliac

of joint,9-11

of pelvic joint motion, 81-86 Lordosis,175,177,179

heel lifts for correction of, 157-158

Lower

measurement of, 154-156, 155

Lumbar disc conditions,122-123, 406

deviations due to, 172-174,173 il>c'r:""h,.r evaluation

of, 156

disturbances,405 122-123,406

Lumbar facet

L umbosacral tilt test, 215-217,216 �.-I",nrn"H",

as risk factor for arthritis,157

Copyrighted Material

135

Index

497

of,248-250,249,291,291

M

hip joint, 268-281. See a/so

joint

mobilization 248

Major Malingering, 128

pressure

Manipulation,290-322

of

for, 250 symphysis, 262-268. See also

Pubic symphysis mobilization

audible "crack" characteristics of

lIUI,lldUle

of

lesion,

joint, 281-288, 285-288

of sacroiliac joint,252-262. See also

291-292

Sacroiliac joint mobilization

cornDarE�d with mobilization, 248,

theory of, 248-250

290-291

star, 427--428,429

contraindications to, 300-302, 301 joints, 410

stiffness, 103 Movement patterns,150-153

definition of, 290

correlation with joint function,152-153

grade VI mobilization, 248, 291, 291,

hip abduction, 217,403-404

296--297

hip extension, 224,403

of

150-151, 152, 174

layer lack of patient control

maneuvers for assessment of, 150

290

150, 151, 175

mechanism of action of, 290 during pregnancy,301, 416--417 of sacroiliac joint, 302-313. See also manipulation

minimus and medius, 150 for,

treatment of abnormalities of, 402--404 trunk flexion, 404

slack removal for, 293,298-300,299 during, 292-296, 295 elln,,; ",\"..,,,

Muscle length-strength testing, 147-153,330 maneuvers to assess movement patterns,

409

150

disease,124-125

McKenzie extension exercise,428--429,430 Mechanical causes of

126

Multiple

1OG-101,101,

pelvic muscle imbalance patterns, 150-153,151-152 phasic muscles,151

122-124

reciprocal inhibition, 148, 149

Menisci,114 joint

Menstrual-induced changes in

stretch-weakness, 149-150 Muscle length-strength treatment,380-387

mobility, 76, 79 124, 359

Meralgia Metabolic

380-383,381

128

Minor fixations, 408--40 9

",,�I'"in,",�

rrl>mn,,,",>,;

381,382

hip adductors,383,383

Mobilization, 247-289 248,

with

postfacilitation stretching, 385-387, 386 relaxation of rectus

290-291 contraindicated for

joints,

femoris, 383-384, 384-385 Muscle relaxation

410 facilitation

251

Muscle spasm, 141, 324,

definition of, 248 251

of, 248 Vl,248,291,291,296--297

Muscles, 21--44 abdominal, 21-22, 23, 178, 178 adductor breviS,4D-41

Copyrighted Material

498

PELVIC LOCOMOTOR DYSFUNCTION

adductor longus,40-41,41,42, 50 adductor magnus,38,40,41

testing strength of,220 trigger points in,374-376,375-378

biceps femoris,36,38, 42-43

of hip and gluteal region,35-42

bulbospongiosus,242

iliacus, 24, 24-25,50

coccygeus,44,45,242

palpation of, 200-201,201, 366 i.Iiococcygeus,44,45,242

pain referred from,98 erector spinae,25,26-27,27-28,47,48 shortening and tightness of,179

iliocostalis Jumborum,28,29 iliocostalis thoracis,30,32,179 iliopsoas, 22-25, 24, 41,42

gastrocnemius,36,38 stretching of,436,438

passive stretching of,432,432-434

gemelli,38, 40

trigger pOints in,201,365-369,366-368

gluteus maximus,vii,35-37,36,38, 39, 49

injuries of,331-332

during gait,164, 168-169, 170

contusion,331

horizontal gluteal folds,174,175

ischemia,331-332

testing in prone position,230-231,232

strain, 331

trigger points in,354-355,356

lateral rotators of hip,38-40

weakness of,176

latissimus dorsi, 27 levator ani, 44,45, 242

gluteus medius,37,38, 42,49 during gait, 164,167

pain referred from,98

trigger points in, 219,219-220,345,

trigger points in,242 longissimus lumborum,28,29

353-354,354

longissimus thoracis,28,29,31

gluteus minimus,37,38, 49 trigger point referral pattern of,118, 118

of lower back region,25-35 multifidus, 31-34, 33

trigger points in, 219, 219-220,345,

oblique external,21-22, 23, 27

349-352,350-353

internal,22,23,26-27

gracilis,36, 38,41-42,42

obturator externus,40,41

hamstrings, 42-43 during gait,164

obturator internus,38,39-40

shortness and tightening of,175-176,

pectineus,41,41,42

201-202

of pelvic floor,44,45,242

stretching of,381,382, 438-439,441 hip abductors,217

stretching of,465-466 piriformis,3,38, 38-39,48

exercises for, 423-424

testing length of,229

stretching of, 433,435,436

testing strength of,195-196

testing length of, 220, 221

trigger points in,219,219-220,345, 359-365,360-361,363-364

testing strength of,220

plantaris,36

weakness of,164,167

psoas,vii,50,51

hip adductors,40-42,174, 175 passive stretching of,429,431, 432

psoas major,22,24,26

postfacilitation stretching of,385-387,

psoas minor,24,25

386

pubococcygeus,44,45,242

shortening and tightness of,174,175,

puborectalis,44,45 quadratus femoris,38,39

203 stretching with contract-relax­

quadratus lumborum,25,26,34-35,35

antagonist-contract teclmique,383,

hypertonic,182

383

passive stretching of, 432-433,

testing length of,205-206,207-208

Copyrighted Material

434-435

499

in, 2 1 7-219, 2 1 8, 345,

trigger

369, 369-374, 371-374 164

N

stretching of, 435, 437 length of, 224, 227, 227

Neoplasia, 126

rectus abdominis, 22

case histories o f

rectus femoris, 41, 42, 43

b o n e cancer, 1 26

of, 383-384, 385

rectal cancer, 100-101

points in, 384, 384 response to

due to, 103

330-331

124, 359, 363

sartorius, 36, 41, 42, 43

Nerve tension signs, 136

semimembra nosus, 36, 38, 4 1 , 43

Nerves

semitendinosus, 36, 38, 43

lateral femoral c utaneous, 124, 359

serratus posterior, 27 soleus,

of, 436, 439

structure and function of, 329-332, 330 tensor fascia lata, 36, 37, 39, 42, 176-178 stretching of, 440

sciatic, 49, 363 c l a u dication, 1 23-124 Neuropathophysiology, 134-135 Night pain, 1 03

points i n , 2 1 9, 2 19-220,

NOciception, 105-106, 106

"""-"J'7. 357-358

Notch

transversus abdominis, 22, 23, 26

acetabular, 18

27 and

sacral, 3

femoral, 128

str<'rrhino- of, 423

of,

greater sciatic, 7 N u t a tion, sacral, 59-60

vaslus intermedius,

o

vastus lateralis, 38, 4 1 , 42 vastus medialis, 41, 42 Myofascial

1 13, 1 19,

Nerve entrapment

retrom a lleolars, 167

syndromes, 1 17-1 19, 1 18,

124, 344-376. See IIlso

Ober's test, 220-221, 222, 387 104 une-j,el:n;�ed stance exercises, 464, 465 causes of pain, 100-1 0 1 , 1 0 1 , 1 22,

treatment of individ u a l muscles, 349-376 maximus, 354-355, 356 minim us, 349-352, 350-353 hip a d d uctors, 374-376, 375-378

Osteoarthritis, 103, 123, 1 4 1 , 154 case

Osteomalacia, 128

359

p i riformis, 359-365, 360-361, 363-364 llu,aarawis l u m borum, 369, 369-374, 371-374 tensor fascia lata, 355-359, 357-358

1 25 Usteot:,orc)sis 128 Overreaction, 129 Overtake phenomenon, 1 79, 180

inactivation, 346-348

p

Myofibers, 329, 330 134-135 n"sitir�nc

331

ot, 94-96, 471-473

manipula tion for, 301-302

i liopsoas, 365-369, 366-368

trigger

Oriental squat, 426-427, 428 Ortolani's test, 4 1 5

medius, 353-354, 354

meralgia

1 24-128

Pain, 141 d i fferential

Copyrighted Material

�"'''''' ' V'''

of, 1 19-129

PELVIC LOCOMOTOR DYSFUNCTION

500

due to mechanical vs. organic lesion,

Plasma cells, 328 Point

100-101, 1 0 1 location and character of, 104-107,

Baer's, 49, 109-111 McBurney'S, 49, 50, 111

1 06-107 night, 103

PostfaciJitation stretching, 385-387, 386

onset of, 101-102, 1 02

Postisometric relaxation (PR), 251, 346-347 compared with contract-relax-antagonist-

phantom limb, 105

contract technique, 381, 381

radicul ar, 112-113, 1 1.3 referred, 105, 107-112, 109- 1 1 0, 1 1 2

compared with postfacilitation stretching, 385

reproducing, 162-163

Postsurgical back pain, 417

visual analog scale for, 90, 91 Pain-sensitive structures, 105-106, 106

Posture, 104, 1 72-178 antalgic, 123

Palpation, 145-146 of iliacus muscle, 200-201, 201, 366

assessment of, 172-175

sacroiliac, 184-185

deviations due to leg-length inequality, 172-174, 1 73

of sacrotuberous ligament, 231-232, 2.34

normal alignment of, 172, 173, 174, 1 76

static, 240 topographical anatomy for, 46-50

Pregnancy, 123 changes in pelvic joint mob i l ity dming,

Pancreatitis, 127

76-79, 81

Paraglenoid sulcus, 52 Passive care, 396

gait during, 79

Patella, 170-171

low back pain and "back labor," 416

Pathology, 135-136

manipulation during, 301, 416--417

Patrick-Fabere test, 50, 141, 205, 206, 230, 311

meralgia paresthetica in, 359 pelvic arthropathy of, 79

" Peau d'orange" appearance, 147

sacroiliac joint dysfunction and, 79, 92

Pelvic crossed syndrome, 150, 1 5 1 , 175

sacroiliac joint mobilization during, 261

Pelvic step, 164

Prevention of injury, 418--419

Pelvic tilt

Primary versus secondary lesions, 406--409

anterior, 150, 175

Proprioceptive exercises, 403, 424, 464, 465

posterior, 176

Proprioceptive neuromuscular facilitation

exercises w ith, 448--453, 449-453 Pelvis

( PNF), 251 Prostate disease, 104, 127, 416 Pseudoarthrosis, 409

bony, 1-8, 2-7 changes in shape during movement, 60,

Pseudoparesis, 148 Psoriatic arthritis, 124, 125

61 as closed k inematic chain, 58

Psychologic factors, 128-129

leg-length inequality and obliquity of,

Pubic bone, 5, 6, 6, 16

153, 1 55

Pubic symphysis, 1, 2, 6, 7-8, 16

motions during gait, 75-76, 77-78, 164,

case history of dysfunction of, 92-94, 93-94, 469--471

167 testing functional efficiency of pelvic

fixation of, 262-263 functional mechanics of, 67-69, 69

ring, 410--411 as three-joint complex, 11, 57, 58

innervation of, 46

Perimysium, 329

pain referred from, 123

Perineal body, 44, 45

pregnancy-induced changes in, 76, 78

Periosteal pain points, 115-116, 334 Periosteum, .327 Piedallu's sign, 179, 180

testing for dysftmction of, 197-200, 1 99 Pubic symphysis mobilization, 262-268 abduction facilitation, 267, 267

Copyrighted Material

Index

adduction faci l i tation, 267, 268

501

Sacroiliac joint, 2, 9-15, 47

adduction fac i litation with thrust,

accessory, 52

267-268, 269

anomalies and variants of, 52

countertorque with facil itation, 264-265,

anteroposterior shear of, 206-208, 2 1 0

266

anatomy of, 14-15 counter torque

Hterature review of, 9-1 1

263-264, 266

distraction of, 200, 200-201

Pubic tubercle, 6, 6, 8, 41

of, 1 4

pain a t, 1 1 6

extension of, 1 88, 189 fixation of, 1 90 flexion of, 186-189, 1 88 anatomy of. 12-14, 1 3

R

and provocation

242-243, 243 and ventral prima ry, 44-46

Rami,

Range of motion, 292-293, 293

selective tissue tension

innervation o t 46

1 39 143-1 44,

143-145

with hip jOint, 71 , 72 122-23

trunk, 178-183

case

extension, 1 8 1

467-469

flexion" 179-181, 1 80-181

congenital anomalies and, 50-53

lateral flexion, 1 82, 1 82-183 Reciprocal inh i b i t ion, 148, 1 49, 380-381 Rectal cancer, 1 00-101 viii, 124, 1 25

Reiter's

hypermob i le, 4 1 0 joint

1,aI12:e'-or-m()!lC)fl "lrrptrhill1U 437-447 l{ang,:;-ot-J1lOtion testing,

221-222, 223

Relaxin, 79 sacral motion with, 76 Reticulin, 328

1 92-195,

vs. lumbosacral 194-197

v�h mctim1� and, 405-406, 406

muscle other

associated with,

404-405 refZlrlancv-lreiated. 79, 92

Retinaculum, medi a l patellar, 4 1 Reversal sign, 123, 1 7 9 Rheumatoid arthritis, 1 25, 1 41 Rheumatoid factor, 124, 125 Rheumatologic d i sorders, 1 24-125 Rocker boards, 464

trigger points associated with, 363, 405 Sacroiliac joint function, 59-{l7 motion, 61-66 motion relative to each other and to sacrum, 62-66, 64-65 sacral motion relative to ilia, 61-{l2, 63

s

axes of rOlation, 66-67, 68 palpa tion of motion, 145-146

Sacral ala,

movements, 57, 59

3

Sacral promontory, 3, 3, 50 Sacralization, 409 S"crnr{)('r,,"" "

case

joint, 1 6-18, 1 8 of pain at, 96-98, 97,

473-475, 474

symmetrical motion, 60-{l1 i liac motion, 60-61 , 6 1 sacral nutation/ counlemulation, 60 i n prone position, 3 1 1 extension, 3 1 1 , 3 1 3

mobilization of, 281-288, 285-288 of, 242

302-31 3

Sacroiliac joint

upper-pole extension, 3 1 1 , 3 1 2

Copyrighted Material

502

PELVIC LOCOMOTOR DYSFUNCTION

in

291, 292, 302-3 1 1 309-3 1 0

Sciatica, 1 54 Sclerotomes, 105, 108, 1 1 0 Scoliosis, 155, 156, 174 Selective tissue tension, 143-144, 143-145

flexion fixation, 303, 306,

Selye's general

1 34-135

Septic arthritis, 4 1 4 and clinician positioning, 309, 310

Shingles, 1 25 Sign

posttreatment soreness, 31 0-3 1 1 series o f thrusts, 3 1 0 UDDe:r-D Ole extension fixation, 303,

Ortolani's, 4 1 5 , Piedallll s, 1 79, 1 80 reversal, 1 23, 1 79 Simulation tests, 1 28

305-306 lIppe:r-pole flexion fixation, 302-303,

Skin

147, 147, 323

Slack removal, 293, Slipped

femoral

414

Slump test, 193-195, 1 95 SmaH

190-192, 1 9 1 - 1 93 1 19, 186, 387

joint mobilization, 252-262 in prone position, 252-257

Soft tissue treatment, 344-394

direct gapping, 253, 253-254

clinical considerations for, 336-340

extension mobilization, 255, 256-257

336-339

gapping, 229, 229, 253-255, 255-256 sacro-i lio cross, 237, 239, 252, 252

339-340 NU,r.I"",,' ''''C

338-339, 340

rr\l"tt'II' r,mv

338

varied sacral pressures, 255-257, 258

336, 337 339

in side-lying position, 257-261 anterior torsion, 257, 259 flexion with fac i l itation,

344-376, Sec

259-260 lower-joint gapping technique, 260-2 6 1 , 262 posterior torsion, 259, 260 sagittal shear, 260, 261

in supine position, 261-262 a n terior-to-posterior shear, 262, backward

with torsion, 261-262,

263-264

""'''«''''.'11

Sacroi liitis, 1 03, 1 25 Sacro-il io cross, 237, 239, 252, 252 Sacrum, 1-4, 2-5

nncti'",nnp'rir

relaxation, 383-384, 385

transverse friction massage of tendon and

accessory movements/sacral cranial shear, 232, 235-237,

injuries, 376-380, 379

Soft tissues, 323-341 in reaction to joint dysfunction,

agenesis of, 5 1 anomalies a n d variants of, 50-51 leg-length inequa l ity and sacral base

1 46-147, 323 definition of, 323 immobilization effects on, 326-327, 327

obl iq u i ty, 1 56 motion with respiration, 76

inflammation and repair of, 324-326, 326 hypoxic injury of, 338

nutation/ counternutation o f, 59-60 Scarring, 325

stretching, 385-387,

386

structure an d function of, 327-336

Copyrighted Material

Index

503

connective tissue, 327-329, 328

soleus, 436, 439

insertional sites, 334-336, 336

three-point stretch, 425-426, 425--427 W i l l iam's flexion exercises, 428

332-334, 333 of

muscle, 329-332, 330

floor m u scles, 465-466

334, 335

385-387, 386 Stretch-weakness, 1 49-150

tendon, 332, 333 Somatovisceral reactions 10

Stripping

treatment, 415-4 1 7

348, 4 1 0

o f iliotibial

bifida oc( u l ta, 52

388-389, 388-389

Subacu te-phase treatment, 399 of soft tissues, 339 Subjective

of

1 33

Synovi a l membrane, 1 14-1 1 5 Synovitis, 1 1 4-1 1 5

exercises, 447-458

transient, of

453--45 6, 454-456 dead

4 1 4415

position, 456-458, 457-459

gym b alls, 458, 460-463 T

po:srel'lor pelvic tilt, 448-453, 449-453 Tendons, 327

Starling's law, 380 Sti ffness, 1 4 1

lHlJ"'>U,,:>, 5 injuries of. 332

morning, 1 03 Straight-leg-raising test, 1 23, 1 29, 201 -203,

transverse friction massage of, 376-380, 379

202 Strain inj uries, 331

structure and function of, 332, 333 Thoracol u mb ar joint dysfunction, 1 1 1 , 1 23,

Stress reduction methods, 135 Stretching, 422-447

1 36, 137, 407 case histories of, 475-477, 479-480

ba llistic, 424

��"'��, 1 1 , 57, 58

for

stretch, 425-426, 425--427 anatomy, 46-50 anterior aspect, 49, 49-50 lateral aspect, 48-49 abdominal crunches, 446-447,

no,a""It"

aspect, 46-48, 4 7

Transitional segments, 409

446-447 hamstrings, 438-439, 441

Transverse friction massage, 376-380, 379

hip muscle exercises, 439-446

Trauma, 1 0 1 . See also Injuries Trea tment categories, 396-402

passive (static), 424436

acute exacerbation of chronic condition,

43 6 438 ,

hip abd uctors, 433, 435, 436

402 acute

hip a d d u c tors, 429, 431, 432

l lIOIJSOalS, 432, 432-434

subacute

band, 436, 440 McKenzie extension exercise, 428-429,

399

Treatment goals, 396 points, 103, 1 1 8-1 19, 1 24, 1 35, 1 62,

430 star, 427-428, 429 squat, 426-427, 428 quadratus l u mborum, 432-433,

See also Myofascial pain c""

rl ,'nnnpc

abnonnal movement patterns and, 402 active vs, latent, 345 a c u te-phase treatment of, 398

434-435 435, 437

d efinition of, 345

Copyrighted Material

PELVIC LOCOMOTOR DYSFUNCTION

504

maxi mus, 354-355, 356 med i u s, 219, 21 9-220, 345,

lateral flexion of, 1 82, 182-183 of, 178-183

range-of-motion

sitting rotation of,1 92-193, 194

353-354, 354 m inimu5, 219, 21 9-220, 345, 349-352, 350-353

u

hip add uctors, 374-376,375-378 iliopsoas,201, 365-369, 366-368 inactivation o f,346-348 Fluori-Methane stretch and spray

Ulcerative c o l itis, 125 Ureteral disease, ] 04, 127 Urethra, 45

'''ClHlI(llle 346 ischemic compression, 250, 347-348 postisometric relaxation, 346-347

v

massage, 348 leva tor ani,242 Vagina,45

loca lions of, 345 examina tion, 345-346 219, 219-220, 345,359-365,

Vaginal pain,242 Vascular disorders, 1 27 Vertebral subluxation cOfl1plex (VSC),

360-361, 363-364 I Ufl1b orurn,21 7 -219, 218, 345, 369, 369-374, 371 -374 rectus femoris, 384,384 referred pain from, 345, 346 sate l l i te, 345

1 34-135 Visceral d isease, 104,127-128 response to treatment for pelvic problems, 41 5-417 Visua l a n a log scale for pain, 90, 9 1

over area of,346

skin

tensor fascia lata, 219, 21 9-220, 355--359,

w

357-358 Trochanter belt,410 Walking, 423

Trochanters of femur

Joss, 104

grea ter, 19, 48

Wil liam's flexion exercises, 428

pain at, 1 1 6

Wobble boards, 464

Jesser, 1 9 Tnmk test, 196-197, 1 9 8 extension d ifferential test, 240, 241

y

extension of, 181 flexion o f, 179-181, 180-181,404

Copyrighted Material

Yeoman's test, 230, 23()-231,3 1 1