Download Pelvic OMT Skills and Techniques, Andrew Porter, D.O., Via Christi

Pelvic OMT Skills
Andrew S. T. Porter, DO, FAAFP
Via Christi Sports Medicine & Family Medicine
DMU-COM Graduate 2004
KAOM Mid-Year Conference – Wichita, KS
11-11-2016
Osteopathic Medicine
“Osteopathic medicine is a complete
& distinctive primary care centered
approach to medical, surgical, &
other health services founded on a
philosophy embracing the
importance of hands-on evaluation &
treatment of the total person &
dedicated to the furtherance of
healthcare for all Americans”
– DMU-COM 2000
Osteopathic Medicine
A system of diagnosis & treatment
that recognizes the role of the
musculoskeletal system in the
healthy functioning of the human
body
The DO is a fully licensed physician
with the additional training in
osteopathic palpatory diagnosis
& manipulative treatment
Osteopathic Medicine
Osteopathic physicians emphasize that all
body systems operate in unison, & that
disturbance in one system can alter the
function of the other system in the body
The osteopathic physician uses
manipulative techniques, as well as
traditional diagnostic & therapeutic
procedures to diagnose and treat
dysfunction in the body
– DMU–COM 2000
OMT
OMM = Osteopathic Manipulative
Medicine
– The practice of OMM that utilizes OMT
OMT = Osteopathic Manipulative
Treatment
– The treatment that you perform on your
patients
OMT
Used as primary treatment and used
as an adjunct in medical care
– Primarily musculoskeletal
– Many other settings as well
Helpful in acute setting & chronic
setting
OMT
Used to help re-align the body to
help promote healing & function
Most helpful if used in conjunction
with Home Exercise Program (HEP) &
interim muscle strengthening &
stretching
– Formal Physical Therapy (PT)
– Athletic Training Rehabilitation
Wichita State University
Newman University
OMT
Most effective if we allow the body
time to heal & repair
– Days to weeks
– Each condition is different & each
patient is different
Challenging to tell how much OMT a patient
will require
– How many OMT treatments?
– Exceptions
OMT
Depending on clinical picture you
want to make sure red flags are not
present before OMT (Relative &
Absolute Contraindications)
– Bone pain
– History of surgery in affected area
– Potential stress fracture or fracture
– Severe muscle spasm
– History of or current cancer
– Infection
Important Anatomy
Adequate anatomy knowledge is
critical to diagnosis & treatment
Pelvis Anatomy
Pelvis Anatomy
Pelvis Anatomy
Innominate Bone is made up of
Ilium, Ischium, & pubic bone
Pelvis Anatomy
Pelvis Anatomy
Inferior Lateral Angle
Inferior Lateral Angle
Pelvis Anatomy
Approach to OMT
Somatic Dysfunction
– Impaired or altered function of related
components of the somatic (body
framework) system: skeletal, joint, &
myofascial structures, & related to
vascular, lymphatic, & neural elements
Approach to OMT
The positional & motion aspects of
somatic dysfunction my be described
using 3 parameters
– Position of the element as determined
by palpation
– Direction in which motion is freer
– Direction in which motion is restricted
Approach to OMT
Diagnosis of somatic dysfunction
TART
– Tissue Texture Changes
– Asymmetry
– Restricted Range of Motion
– Tenderness to palpation
Right Innominate of pelvis is anterior
inferior & inflared with TART
OMT of Pelvis
Helpful for many conditions that I
see in my practice
– Low back pain
– SI joint inflammation & dysfunction
– SI joint pain
– Piriformis syndrome
– Sciatica
Many others
OMT of Pelvis
PRACTICAL
– Find your eye dominance
– Dominant eye is over medial side of
table
OMT of Pelvis
Standing, Supine, & Prone Exams
Standing
– Observe: tilting (static vs gait)
– PSIS
– Flexion tests (FT) - standing & seated
Put thumbs inferior to PSIS & have patient
bend forward
Which thumb moves more superior
Iliosacral Dysfunction = +Standing FT
& -Seated FT
SI Dysfunction = +Standing FT & +Seated FT
OMT of Pelvis
Iliosacral dysfunction
– Lower extremity, hamstrings, long
restrictors of the hip, innominate
somatic dysfunction
SI Dysfunction
– SI Joint
OMT of Pelvis
Supine Exam
– Reseat pelvis
– Leg lengths
– Long restrictors
Hip Flexion
– Iliopsoas
– Rectus Femoris (also extends knee)
Knee Extension
– Rectus
– Vastus
– Vastus
– Vastus
Femoris
Medialis
Intermedius
Lateralis
OMT of Pelvis
Hip Long Restrictors
Hip Extension
– Gluteus Maximus
– Hamstrings
Biceps Femoris
Semimembranosus
Semitendinosus
Hip External Rotation
– Piriformis (primary)
– Gluteus Maximus
– Obterator Internus
– Obterator Externus
– Gemellus Superior
– Gemellus Inferior
– Quadratus Femoris
OMT of Pelvis
Hip Long Restrictors
Abductors/Internal Rotation of Hip
– Tensor Fascia Latae
– Gluteus Medius
– Gluteus Minimus
Adductors of Hip
– Pectineus
– Adductor Longus/Brevis/Magnus
– Gracilis
OMT of Pelvis
Hip Long Restrictors
Dx:
– Check for tightness in hip long restrictors by doing their
opposite function
Rectus Femoris (Primary Hip Flexor)
– Patient prone, extend hip to a barrier & note ROM
& compare to other side, noting which side is
restricted
Tx:
– Use muscle energy technique for muscles main function
Rectus Femoris
– Patient prone, extend hip to a barrier & then have
patient flex hip isometrically for muscle energy
technique
OMT of Pelvis
Supine Exam
FABER test
– + in SI Joint with SI joint problem
Pelvic Roll
Iliac Crest Heights
Iliac Compression Test
ASIS Level
Pubic Symphysis Levels
FABER Test
OMT of Pelvis
Prone Exam
Long Restrictors
Crest Heights
PSIS Level
Sacral Sulcus
Sacral Inferior Lateral Angle
Ischial Tuberosities
OMT of Pelvis
Pubic Symphysis
Diagnosis
– Reseat Pelvis
– Superior or inferior
Treatment
– Muscle Energy
– Isolytic
OMT of Pelvis
Pubic Symphysis
Muscle Energy
– Superior Pubic Tubercle
Supine with ipsilateral leg off table
Stabilize opposite ASIS & press down on
knee to barrier & have patient lift knee to
ceiling isometrically for 3 seconds
Relax
Bring leg to new barrier & repeat muscle
energy technique for total of 3 times
Re-check
Muscle Energy
Superior Pubic Tubercle
OMT of Pelvis
Pubic Symphysis
Muscle Energy
– Inferior Pubic Tubercle
Supine with ipsilateral thigh at 90° & knee bent so
leg rests on your shoulder
One hand on ischial tuberosity while stabilizing the
ipsilateral ASIS with other hand
Bring thigh to a barrier while applying cephalad
pressure to ischial tuberosity
Patient extends hip isometrically for 3 seconds & then
relaxes
When patient relaxes, take up the slack in the hip &
push the ischial tuberosity further superiorly
Repeat muscle energy technique for total of 3 times
Re-check
Muscle Energy
Inferior Pubic Tubercle
OMT of Pelvis
Popping the pubic tubercles (Isolytics)
– Muscle energy into Isolytic technique
– Reseats the sacrum between the
innominates & treats both pubic tubercles
at the same time
– Separates the SI Joints
– Improves lymphatic flow
Popping Pubic Tubercles
OMT of Pelvis
Lateral Sims Mobilization
– Tx restricted SI Joint
Lateral Sims position on side opposite
dysfunction
– Flex hip until motion felt at S1-S2 (PSIS Level)
– ABduct the thigh & induce IR or ER
– Take deep breath
– While monitoring SI Joint, ABduct & extend leg off
table
OMT of Pelvis
Lateral Sims Mobilization
OMT of Pelvis
Treatment of SI joint dysfunction
– Strain/Counterstraion
Find tender point
Place in position of comfort
Hold for ~90 seconds
Slowly return to neutral
Re-check tender point
OMT of Pelvis
Counterstrain SI Joint
OMT of Pelvis
Joint Mobilization of SI Joint
Treatment of SI joint dysfunction
– Joint Mobilization of SI Joint
Place patient in prone position
Find SI Joint
Internally and externally rotate hip joint
Can incorporate muscle energy technique
OMT of Pelvis
Joint Mobilization of SI joint
OMT of Pelvis
Piriformis Syndrome
– Piriformis muscle hypertrophy &/or scar
tissue, somatic dysfunction may
compress the sciatic nerve
Sxs = piriformis muscle &/or tendon pain,
paresthesias in sciatic nerve distribution
(posterior aspect of leg)
Piriformis Syndrome
Counterstrain
– Piriformis
8 cm medial & just proximal to height of
greater trochanter
– Tx: With patient prone, flex the thigh to 120° &
fine tune with ABduction
Piriformis Syndrome
Counterstrain
OMT of Pelvis
Treat SI Joint Dysfunction
– Muscle energy
Patient supine
Muscle energy of affected leg resisting
flexion to contralateral shoulder while
monitoring SI joint
OMT of Pelvis
Muscle Energy of SI Joint
OMT of Pelvis
Counterstrain
– MidPole SI Tender Point
In gluteal musculature just lateral to
midpoint of sacrum
– Tx: With patient prone @ edge of table, flex &
slightly ABduct the thigh
OMT of Pelvis
Sacrum
Sacrum is considered the keystone of
the pelvis
Sacrum supports the entire spine &
transmits the forces of the spine to
the ilium, which in turn go to the
pubic bones, the acetabulum and the
femoral head
Sacrum
Motions of the Sacrum
Flexion/Extension
– With flexion of sacrum, base (articulates
with L5) moves anteriorly
– With extension of sacrum, base moves
posteriorly
Torsion
– All sacral dysfunctions are restrictions of
normal sacral motion
Sacral Somatic Dysfunctions
Torsions
– Torsions are named as rotation on an
oblique axis
Spring Test
– Determines whether the sacral base has moved
anterior or posterior
– Negative spring test = sacral base has moved
anteriorly
Forward sacral torsion
– Positive spring test = sacral base has moved
posteriorly
Backward sacral torsion
Sacral Somatic Dysfunction
Left on Left Sacral Torsion
– Sacrum rotated left on left oblique axis
ILA posterior inferior on left
Sacral sulcus more compressible on right
- Spring test
Left on Right Sacral Torsion
– Sacrum rotated left on right oblique axis
ILA posterior inferior on left
Sacral sulcus more compressible on right
+ Spring test
OMT of Pelvis
Left on Left Forward Sacral Torsion
Patient is in lateral sims position on
the same side as the axis
While monitoring the lumbosacral
junction, flex the patients knees until
motion is felt
Place patients thighs on your knee &
push ankles towards floor
Muscle energy technique
OMT of Pelvis
Left on Left Forward Sacral Torsion
Sacral Somatic Dysfunctions
Right on Right Sacral Torsion
– Sacrum rotated right on right oblique axis
ILA posterior inferior on right
Sacral sulcus more compressible on left
- Spring test
Right on Left Sacral Torsion
– Sacrum rotated right on left oblique axis
ILA posterior inferior on right
Sacral sulcus more compressible on left
+ Spring test
Sacral Somatic Dysfunctions
Unilateral Sacral Shears
– A non-physiologic shearing of one of the SI
joints causing the sacrum to move more
inferior & anterior on that side
– Left unilateral sacral shear
ILA inferior on left
Sacral sulcus more compressible on left
– Right unilateral sacral shear
ILA inferior on right
Sacral sulcus more compressible on right
OMT of Pelvis
Innominates
– Outflared
– Inflared
– Upslip
– Anterior/Inferior
– Posterior/Superior
OMT of Pelvis
Outflared
– Dx: Reseat pelvis
– Patient prone & evaluate to see if one Ischial
Tuberosity (IT) is more medial
Named by motion of a point on anterior
innominate
– Tx: Supine
Sit on side to be treated
Flex knee, IR leg & place patients foot on table
Add lateral traction to PSIS & IR hip to a
barrier
ER hip isometrically x 3-4 times
Re-Check
OMT of Pelvis
Outflared Innominate
OMT of Pelvis
Inflared
– Dx: Patient prone evaluate to see if one
IT is more lateral
– Tx: Supine
Flex, Abduct, & ER thigh (Figure four
position) on side of inflare
Muscle energy via stabilizing opposite ASIS
& applying downward pressure on knee
while patient pushes up towards ceiling
Re-Check
OMT of Pelvis
Inflared Innnominate
OMT of Pelvis
Upslip
– Dx: Need 3/5 landmarks to be superior on
one innominate. HISTORY.
IT (this must be there), ASIS, PSIS, Pubic
Tubercle, Iliac Crest
– Tx: Prone.
Remember Red FLAGS
Gap SI joint
Have someone else stabilize opposite ILA
HVLA tug to leg
Muscle energy
Re-Check
OMT of Pelvis
Up-Slip
OMT of Pelvis
Anterior/Inferior & Posterior/Superior
Innominates
– Dx: Compression over ASIS & ASIS
Levels
– Tx: Supine
Anterior/Inferior
– Muscle energy with hamstrings
– HVLA via leg tugs (raise leg 30°)
Posterior/superior
– Muscle energy with iliacus & rectus femoris
– HVLA via leg tugs by gapping SI joint along plane
of table
OMT of Pelvis
Anterior/Inferior Innominate
OMT of Pelvis
Posterior/Superior Innominate
OMT of Pelvis
Counterstrain for Sacrum & Hip
Basically you find a tenderpoint &
wrap around the tenderpoint and
hold for about 90 seconds until
patient feels better & you feel a
release (increased blood flow to the
area)
Slowly return the patient back to
neutral position
Re-check the tenderpoint
OMT of Pelvis
Lumbosacral Junction
When the sacrum rotates in one
direction, L5 usually rotates in the
opposite direction
OMT of Pelvis
Lumbosacral Complex
Diagnosis:
– Supine & Re-seat pelvis
– Rotation
Pelvic Roll
– Place hands on lateral aspect of pelvis & induce
rotation to the right & left
– Note which direction the pelvis rotates easier
– Rotation is named according to the direction of
freer motion
Sidebending
– Iliac crest heights
Sidebending is named to the side of the
higher iliac crest
OMT of Pelvis
Lumbosacral Complex
Treatment
– Have patient lay on side
opposite of rotation in lateral
recumbent position
You want to try & rotate
them back to neutral
– Bring top leg up until you feel
motion at L5-S1 & place top
leg in popliteal fossa
– Stabilize upper arm/axilla &
put your forearm halfway
between crest & ischial
tuberosity
– Patient takes a deep breath &
bring their pelvis towards you
& as they exhale give an
HVLA thrust
– Can also perform muscle
energy
OMT of Pelvis
Lumbosacral Complex
OMT of Pelvis
Always reseat & re-check the pelvis
Suboccipital Tension Release
Tension Headaches
Safe
Effective
How AT Still first started thinking
about Osteopathy
Subocciptial Tension Release
Patient supine
Place fingers in
suboccipital region
– Just off base of
occiput
Start with head
raised & allow it to
passively fall into
your hands
Keep fingers
straight
QUESTIONS?
THANK YOU