Download Somatic Dysfunction

Sacroiliac Joint Dysfunction
• Anatomy and Biomechanics
• Epidemiology
• Diagnosis
– Clinical Presentation
– Evaluation
• Treatment
– Standard
– New treatments
Anatomy
• Diarthrodial joint
– Width 1-2 mm
– Lined with hyaline cartilage, fibrocartilage
– Rough irregular surface, wedge shape of
sacrum forms interlocking mechanism
w/ ilium
• S1 segment: post width greater
• S3 segment: ant width greater
• High variability
• Jt space decreases w/ age
Anatomy
• Ligaments
– Posterior
• Superior (short)
• Inferior (long)
– Connects sacrum to PSIS
– Close relations w/ erector spinae, TL fascia, sacrotuberous
ligament
– Anterior
– Interosseous
• Innervation
– L4-S1 nerve roots
– Superior gluteal nerve
– Lateral branches S1-3 dorsal roots
Sacroiliac Joint
Biomechanics
• Absorbs vertical forces b/t spine and pelvis/LEs
• No muscles acting directly across SIJ
• Stable, complex dynamic motion
– 2-3 deg in transverse or longitudinal planes
• Axis passing obliquely across pelvis
– Hip flexion – ipsi ilium glides post/inf
– Hip extension – ant and away from sacrum
– ? Can motion be clinically detected
• Transverses abdominus ctx: dec laxity of SIJ
• Delayed activation of multifidus, internal oblique
and glut max w/ SIJ pain
• Netter mm attachments slide
Piriformis
Intimate Association
• Piriformis syndrome
Epidemiology
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LBP affects 70% of people
Pain generator can be identified in 75% cases
SIJ is source in 13-30% of chonic LBP
Underappreciated cause of LB or buttck pain
History of trauma in about 50% pts
Athletes at risk
– Unilateral loading: soccer, baseball, figure skating
– Overuse: running, xcountry skiing, rowing
• Pregnancy
Differential Diagnosis
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Piriformis sydrome
Hip joint pathology
Discogenic pain
Facet arthropathy
Rheumatoid arthritis
Ankylosing
spondylitis
• Trochanter pain
syndrome
• Visceral referral pain
• Malignancy
• Stress fracture
• Radiculopathy
Evaluation
• Pain below the beltline
– LBP, sacral, pelvic, gluteal
• Less often numbness, popping, clicking, groin
pain
• Pain w/ transitional movements
• Unilateral 4:1
• Pelvic obliquity: torsion/shear
• SIJ provocative maneuvers
• Normal neuro exam
SIJ Provocative Maneuvers
• Patrick’s Test
– FABER
– Flexion, Abd, ER
– Positive: Pain contra SI
• Gaenslen’s Test
– Patient flexes hip and knee, holds
– Examiner hyperextends contra hip
– Positive: Pain HF side
SIJ Provocative Maneuvers
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Sacral sulcus tenderness
Distraction/compression test
Seated flexion test
Standing Gillet’s
Femoral shear test
• Yoeman’s (Modified Gaenslen’s)
Diagnostic Imaging
• Generally not helpful
• R/O other sources of pain
– MRI
– Bone scan
– Plain radiographs
• Intrarticular Diagnostics
– Many consider guided injection
gold standard
– Clinical inj in office intraarticular in
only 22%
– More often periligamentous
Treatment
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Activity modification
Ice, NSAIDs acutely
Therapeutic Exercise
SI Compression Belt
Manual Therapy
Therapeutic Cortisone Injection
Regenerative Injection Therapy
– Platelet Rich Plasma
– Prolotherapy
Somatic Dysfunction
• Impaired or altered function
of related components of
the somatic system
– skeletal, arthroidial, myofascial
structures, related vascular,
lymphatic, neural elements
• Parameters
-- Anatomic position determined by palpation,
referenced to adjacent defined structure
--Eval direction motion is restricted
Restrictive (Pathologic) Barriers
Limit of passive motion
Anatomic barrier
Limit of active motion
Physiologic barrier
Neutral
Motion loss due to
somatic dysfunction
Pathologic (Restrictive) barrier
OMT Techniques
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Thrust (HVLA)
Articulatory (LVHA)
Counterstrain
Facilitated Positional Release
Muscle Energy
Myofascial Release
Lymphatic Technique
Visceral Manipulation
Restrictive Barrier
Soft - The elastic barrier; usually due
to hypertonic muscles
ƒ Responds well to MET, myofascial,
counterstrain
Hard - Firm barrier
ƒ Responds well to HVLA, articulatory
technique
SIJ Dysfunction
• Articulatory Treatment (ART):
– Direct, passive technique
– Low velocity / high amplitude
– Dysfunctional joint is carried through its full
ROM with an activating force of either
springing or repetitive circular movement
through the restrictive barrier
SIJ Articulatory Technique
Techniques
• Muscle Energy
– Direct, active technique
– Patient activates muscle group
against isometric resistance
controlled position at restrictive
barrier.
– Post-isometric relaxation utilized
to correct somatic dysfunction.
Repeat into new barrier.
Techniques
• Counterstrain:
– Indirect, passive technique
– Local tenderpoint(s), inappropriate
stretch reflex.
– Reflex inhibited by placing body segment
in position exactly opposite to strain,
extinguish the tenderpoint.
– Inappropriate afferent signaling from the
intrafusal muscle fibers (induced by the
stretch reflex) reset to baseline, leading
to normalized ROM and function.
New Treatment Concepts
• Enthesis Organ
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Collection of related tissues at or near
the enthesis
For example, achilles
– Osteotendinous junction
– A sesamoid fibrocartilage
– Periosteal fibrocartilage
– Retrocalcaneal bursa
– Sensory nerve endings
EF=tendon insertion
Benjamin et.al. J Anat. 2006
SF and P=fibrocartilage
What is Regenerative
Injection Therapy?
• Prolotherapy, Platelet Rich Plasma
• Injection therapy used to treat chronic
ligament, joint capsule, fascial and
tendinous injuries
• Technique for healing ligament, tendon, and
cartilage injury by stimulating the growth of
normal cells and tissue in a specific location
Klein RG. Patterson J. Eek and Zeiger D. Prolotherapy for
The Treatment of Back Pain. AAOM Postion Statement
Prolotherapy Injection
Theoretical Basis
• Proliferants cause local tissue injury at enthesis,
release of inflammatory mediators.
• Recruitment of granulocytes and macrophages
• Fibroblasts deposit
collagen at the site.
• Collagen remodels
ligament / tendon
• Promotes healing cascade
Proliferant Solutions
• Osmotic shock agents – Hyperosmolar
dextrose/glucose and glycerin
• Irritants – Phenol
• Chemotactic agents – Sodium morrhuate
• Particulates – Pumice flour
Research
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Liu YK: An in situ study of the influence of a sclerosing solution in rabbit medial
collateral ligaments and its junction strength. Connect Tissue Res; Jan 01, 1983,
11(2-3): 95-102
Hoksrud, A., L. Ohberg, H. Alfredson, et al. Ultrasound-guided sclerosis of
neovessels in painful chronic patellar tendinopathy: a randomized
controlled trial. Am. J. Sports Med. 34:1738Y1746, 2006
Ongley MJ: A new approach to the treatment of chronic low back pain. Lancet; Jul
18, 1987, 2(8551): 143-6
Reeves KD: Randomized prospective double-blind placebo-controlled study of
dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alter Ther
Health Med; Mar 2000, 6(2): 68-74, 77-80
Yelland MJ, Glasziou PP, Bogduk N, Schluter PJ, McKernon M. Prolotherapy
injections, saline injections, and exercises for chronic low back pain: a randomized
trial. Spine. 2004 Jan 1;29(1):9-16
YellandMJ, Mar C, Pirozzo S, Schoene ML, Vercoe P. Prolotherapy injections for
chronic low back pain. Cochrane Database Syst Rev. 2004;(2): CD004059
PRP INJECTION
• Platelet-Rich Plasma (PRP) injection therapy:
– Injection of autologous plasma rich in platelets
and growth factors into dysfunctional tissues
Research
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Holloway et al. Wounds 1993
R. Gfatter, et al; The mitosis of fibroblasts in cell cell culture is enhanced by
Binding GP IIb-IIa of activated platelets on fibrinogen Platelets, Vol 1, 2000.
Furerst et al. Oral Maxillofac. Implants. 2003
Anitua et al. New Insights into and novel applications for platelet rich fibrin
therapies. Trends in Biotechnology 2006; 5:227-234
Sanchez et al. Comparison of surgically repaired Achilles tendon tears using
platelet rich fibrin matrices. Am J Sports Med 2007;2:245-251
Mishra and Pavelko. Treatment of Chronic Elbow Tendinosis With
Buffered Platelet-Rich Plasma. AJSM. 2006
Murray M, et al. J Ortho Res 2006
Sampson et al. Platelet rich plasma injection grafts for musculoskeletal
injuries: a review. Curr Rev Musculoskelet Med 2008.
K. Ali, C. Pocock, et al. Ultrasound guided dry needling and autologous blood
injection for patellar tendinosis. Br. J. Sports Med. 41:51, 2007
Cochrane Database of Systematic
Reviews 2006
• Treatments for Lower Back Pain
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TENS
Traction
Heat or Cold
NSAID
Massage
Lumbar supports
Epidural, facet and local injections
Exercise therapy
Acupuncture
¾ Convincing evidence lacking
THANK YOU!!
Should all asymmetries
be fixed?