Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
SYMPHYSIS PUBIS DYSFUNCTION Beyond Category 2 Antwerp 19th-21st September 2008 Dr Eric Pierotti DC. DO. Ch.D (Adel) DIBAK Introduction • Increasing number of patients presenting with pain to lower back and or sacroiliac joint area • No obvious pattern of pain or aetiological incidence • Many also had pain of left or right lower abdominal quadrant (s) and or groin pain Introduction • Therapy localisation and challenge of lumbars, pelvic bones and joints all negative • No visceral fixations or malpositioning • Postural analysis essentially normal except for; Introduction • Minor loss of lumbar lordosis with associated posterior pelvic tilt • Standard quadriceps and rectus femoris test negative • Beardall’s test showed marked inhibition of quadriceps group • Occasionally functionally inhibited abdominals, adductors and piriformis muscles unilaterally or bilaterally Introduction • Therapy localisation to all factors of the IVF failed to isolate one common reflex which facilitated the inhibition • Possible association with pubic symphysis dysfunction was recognised after examining a patient postpartum Case history • 32 year old female 8 weeks postpartum second child • Presenting symptoms of general lumbar spine pain and acute bilateral groin and pubic pain • Particularly difficult pregnancy and instrument assisted delivery • Difficult walking and erecting after sitting or lying • No previous history of spinal related problems Case history • Examination elicited normal ranges of motion of the lumbar spine and sacroiliac joints • Exquisite tenderness at the pubic tubercles, medial joint and inferior ramus bilaterally • Palpatory widening of symphysis • Bilateral weakness of quadriceps (Beardall’s) and rectus abdominus • Negative TL and challenge to all lumbars, SIJ’s and innominates Case history • TL to pubis negated muscle weakness • Diagnosis; symphysis pubis diastasis associated with ligamentous compromise Case history • Correction of pubic subluxation using activator and blocking techniques • 95% reduction of lumbar and pubic pain immediately after first correction • Correction and remedial exercises over 2 weeks completely resolved all symptoms and findings Normal Anatomy • A fibrocartilaginous joint with a cleft at the confluence of the two pubic bones • A thick intra pubic fibrocartilaginous disc is sandwiched between thin layers of hyaline cartilage Normal Anatomy • Major stability is • provided by the inferior pubic (arcuate) ligament The superior pubic ligament connects the bones from above and provides superior support and stability Normal Anatomy • Further support is provided by an aponeurosis created by the tendons of the rectus abdominis above and the gracilis and adductor longus below giving anterior and inferior support where they merge with the acuate ligament Biomechanics • Little in literature regarding biomechanics of the symphysis pubis • Gray’s Anatomy states – “angulation, rotation and displacement are possible but slight, and are likely in activities at the sacroiliac joints. Some separation is held to occur late in gestation and child birth” Biomechanics • More recent authors in keeping with early research(1937) have stated quite categorically that; – “Pelvic biomechanics should be viewed from the perspective of the symphysis pubis” P.E. Greenman • Movement at the symphysis pubis consists of two movements Biomechanics • No.1 – A superior to inferior translatory movement that occurs during one legged standing (Chamberlain) – On prolonged one legged standing, the ipsilateral pubes moves cephalad – This should return to normal on standing on the opposite leg or on prolonged twolegged standing Biomechanics • No.2 – As an axis of rotation for the alternating anterior to posterior rotation of the right and left innominate bones during gait (Pitkin and Pheasant et al) Patho-mechanics • Habitual one legged stances may result in muscle imbalances between the abdominals and the adductors with the resultant restriction of the pubic bone in aberrant relationship with its partner • A leg length discrepancy of 1cm or more causes torsion to occur in the pelvic girdle resulting in changes in the sacrum and pubis which frequently results in sacroiliac pain (Bellamy et al) Biomechanics • “the most reliable clinical sign of instability of the sacroiliac joints is disruption of normal function at the symphysis pubis resulting in increased mobility when alternate weight bearing on either leg” P.E.Greenman Biomechanics • It appears that the symphysis; – Provides an axis of rotation during normal gait patterns via both interosseous and reciprocal flexing around the joint without actual separation or translatory shear – As long as this bound but flexible union is maintained, normal biomechanics of the innominates and sacrum can occur without undue strain placed upon their joints Biomechanics • When this firmly bound union fails or becomes hypermobile; – It allows the normal synchronous forward and backward motion of the innominates and combined lumbar side bending and rotation during gait, to move beyond their normal range (usually unilateral) – Causing undue and repetitive strain on the ligamentous supports of the spine and SIJ’s Aetiology of Dysfunction • There appears many and diverse reasons • for dysfunction of pubic symphysis 1. Pregnancy – Normal widening of the symphysis due to laxity of connective tissue under hormonal (relaxin, oestrogen) control which peaks at around 38 weeks – Separation usually occurs around 20 weeks with gradual progression to its maximum at around 30-35 weeks gestation (Pierotti) Aetiology of Dysfunction • The normal spacing 0.5-5 mm • Pregnancy: 9.012mm • Abnormal : 1 cm and above Aetiology of Dysfunction – If widening is excessive or too rapid, instability results with increased ranges of motion at one or both SIJ’s causing a repetitive type strain with resultant pain and usually inflammation Male Soccer Player Aetiology of Dysfunction • Post partum 28 year old female, 3rd child Aetiology of Dysfunction – According to the Office of National Statistics: • In 2002 there were 594,634 pregnancies in the UK • Figures from Manchester University and Leeds Royal Infirmatory showed that 1:36 of those women did or would suffer pelvic dysfunction Aetiology of Dysfunction • 2. Failure of symphysis to close after delivery – During delivery as the baby’s head breaches the pelvic rim, a further slight separation occurs at the symphysis – Which in some sort of body logic effects a “rebound” type motion closing the symphysis over the next 24-26 hours Aetiology of Dysfunction • 2. Failure of symphysis to close after delivery – Within 24 hours of parturition blood levels of relaxin markedly reduce and ligaments begin to tighten regardless of joint position – Failure to elicit this “rebound” in the presence of reducing relaxin levels contribute to maintaining the joint in a separated or dysfunctional position Aetiology of Dysfunction • Failure to separate can be as counterproductive as excessive widening as; – Separation provides extra space in the birth canal for the baby’s head to breach the bony pelvic rim – Failure of separation requires the sacroiliac joints to compensate to a greater degree than normal – Causing both instability and pain especially during the last trimester Aetiology of Dysfunction • This condition is responsible in part, for long and difficult labours and in many cases responsible for failure of the cervix to adequately dilate resulting in many emergency caesarean sections (Pierotti) Failure to separate Aetiology of Dysfunction • 3. Direct Trauma such as; – Falling in split leg position Sports and activities such ballet, dance or callisthenics requiring the “splits” • 4. Postural Strain – Standing stationary for extended periods of time (hairdressers, sales assistants, production workers) – Secondary to positions of coitus Aetiology of Dysfunction • During prolonged standing there is a natural tendency to gravitate to one leg to relieve the stress. Resultant muscle imbalances effect the shearing type subluxation Shearing Subluxation Aetiology of Dysfunction • This is particularly more relevant around the time of menses with resultant ligament laxity due to fluctuations in hormone levels Shearing Subluxation Aetiology of Dysfunction • 5. Repetitive Strain – Faulty gait mechanics associated with asymmetrical stride length can cause a specific torque pattern to the side of short stride not dissimilar to a dural torque pattern but resulting in a pubic subluxation Aetiology of Dysfunction • Recent spate of osteitis pubis in AFL players is as a result of strong repetitive torque of the symphysis during the follow through in the action required to kick the ball in excess of 50 metres Aetiology of Dysfunction • Traumatically induced as a result of sporting incidences Signs and Symptoms • Can range from; – Acute pain at the pubes or groin – Medial aspect of the thigh unilaterally or bilaterally – Supra pubic pain – Pain on weight bearing activities (walking, negotiating stairs) Signs and Symptoms – Parting the legs or turning over in bed – Dysfunction of the urogenital diaphragm (frequency and stress incontinence) – Dyspareunia – Exquisite palpatory tenderness around the pubis on examination Signs and Symptoms • A large percentage of patients present with this subluxation but are not aware of any symptoms other than vague or diffuse lumbar spine pain Postural Examination • Main postural feature in most but not all cases is a hypolordosis of the lumbar spine and posterior tilt of the pelvis Postural Examination • Note the subtle anterior pelvic tilt (24 year old hockey player nulliparous) Postural Examination • Pubis separation widens the pelvis causing an increase in Q angle which gives rise to knee symptoms and instability Postural Examination Pre Correction Post Correction Postural Examination Radiological • Weight bearing Xrays in a “Flamingo” stance best illustrates symphysis instability Muscle Weakness • There is a specific and recurrent bilateral muscle weakness now correlated in well over 1000 patients • That is a bilateral quadriceps muscle weakness tested as a group but only on Beardall’s test • This weakness is classically accompanied by hypertonic hamstrings Muscle Weakness • Beardall’s Test – Patient supine, flex the leg to 45˚ from the table with the knee in full extension. The opposite leg remains fully extended on the examination table Note inability to fully extend the legs from hypertonic hamstrings Biomechanics of Muscle Weakness • Hypothetically; contraction of say the right quadriceps in the supine position performing a resisted muscle test requires, – The left ilium to be forced posteriorly into the examination table to stabilize the pelvis and provide a fulcrum point for the muscle to maintain an isometric contraction – This torque motion is centred around an intact symphysis Biomechanics of Muscle Weakness • If the symphysis fails and the resulting translatory motion is too great, general pelvic instability occurs and inhibition of the test muscle results • This is bourn out by having the patient flex the opposite knee with the foot flat on the table • This now provides the missing stabilizer and the positive test is negated Biomechanics of Muscle Weakness • This test will show a • significant percentage of pubic symphysis subluxations When suspected but Beardall’s test is negative, incorporating 10-20˚ of external leg rotation will show the rest Therapy Localisation • TL to the pubis will • negate the weakness of the associated quadriceps TL will weaken a previous normal facilitated indicator muscle Challenge • Challenge is directed to the ramus of the pubis with a thenar contact in either caudal, medial, lateral or cephalad or combination of these • For separation dysfunction use a double hand contact to the lateral aspects of the ramus in a compressive rebound fashion Challenge • Most frequent subluxation found is the shearing or translatory type with one pubis superior and the other in an inferior configuration along the coronal plane or Y axis Respiratory Challenge • During inhalation – The innominates move anteriorly in a rotation motion around the Y axis – The bony arch separates and moves inferiorly – The opposite occurs on exhalation Respiratory Challenge • Respiratory challenge only seems valid in facilitating the inhibited quadriceps when the pubis is either separated or compressed, that is; • Strong inhalation will facilitate the inhibited quadriceps when the pubis is compressed • Strong exhalation will facilitate the quadriceps when the pubis is separated Correction • Correction is performed in the opposite direction to the positive manual challenge by either; – Using an impact instrument (activator) Correction right inferior pubis (on exhalation) Correction • Activator correction for left superior pubis (on inspiration) Correction • Manual correction • Bring patient’s right leg into flexion, abduction and external rotation with the sole of the foot to the medial thigh left leg • Right thenar contact to left pubic tubercle, left hand grasps patient’s right knee Correction • Manual correction • At point of maximal stretch apply a short sharp low amplitude thrust in an inferior lateral direction Correction for left superior pubis Correction • Manual correction • Repeat the procedure on the opposite side contacting more inferiorly on the right tubercle and thrust in a cephalad and lateral direction Correction right inferior pubis Correction • Separation • subluxations requires both manual and activator correction Patient supine place DeJarnette blocks under each hip joint at 90˚ to the spine Correction • Take a bilateral • thenar contact to the lateral aspect of pubic tubercles As patient exhales apply a compressive force in a medial direction increasing the force towards the end of the exhalation Correction separation subluxation Pre-correction Post-correction Pre and Post Correction Pre-correction Post-correction Pre and Post Correction Rehabilitation • There appears little in way of remedial • • exercise as we are essentially dealing with a ligament laxity regardless of origin One procedure has proven useful in at least creating some stability to the symphysis in these cases But, requires an assistant to gain the best benefit Rehabilitation • Patient supine, • • knees flexed to 90˚ heels together and soles of feet flat on the table Assistant contacts lateral aspect of knees and provides resistance to the patient abducting the knees to 45˚ Repeat twice First Contact Rehabilitation • With the knees in • 45˚ abduction assistant contacts the medial aspect of the knees and resists the patient’s adduction to the neutral position Repeat twice Second contact Conclusion • Corrective techniques shown have • addressed the joint predominantly, be aware that the secondary support structure of the adductors, gracilis and abdominals can in many cases be dysfunctional as a result of micro avulsion of these muscles Addressing this problem is beyond the time constraints of this presentation, just be aware that; Conclusion • This condition can and is multi factorial • Applied kinesiology teaches us the triad of • health and the importance of looking at every patient from the point of view of structure, chemical and emotional implications This technique makes the assumption that all facets of the triad have been assessed and any dysfunction corrected before embarking on this course Conclusion • Treating this condition as part of a holistic approach will ensure a positive and lasting result Thanks for your Attention