Download SYMPHYSIS PUBIS DYSFUNCTION

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