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I A Clinical
�LU�"T'"·.o
'Proach
G. DeFranca, DC
Director Boylston Chiropractic Office Boylst...
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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
Copyrighted Material
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 . .. . . . .. .. . .. .. . .. ..... .. ..
44
Topographical
. ...........
46
Anomalies and Variants ...............
50
2-Func tion
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59
PubicSymphysis ... . .... . . . .. . . . ...... .. . . . ....
67
HipJoint . ... . ....... ..... . . . .... . ... . .........
69
Standing Posture and
..... ........ .
71
Motions During Gait .. .. . .. . .... . . . ...... .......
75
Sacroiliac Joint .. . ... ..... ...
Sacral Motion with Respiration ...................
76
. .. ....
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 ....
.
l;;:irl('\""
in Mind
To
Clues in the
to the
.
,
.
"
of Tissues .. ,.
Diagnosis. Conclusion .,.. ,
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,
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'
,
,
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"
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"
"
"
"
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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
. .. . ... . .... . .
.
.
..
Irritability. .. . .... . ..... ...... ... ... ... .
.
.
of Motion ............................... ....................
PlayfJoint Signs .....
,
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.. . ... .
.
...... ... . ..........
"
,
Join t Compression with Passive Testing . . . .. . .. .
Selective Tissue Tension "
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.. . ,
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, . .. .
andSkin Length-Strength and Movement Patterns .....
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Inequality............... . . ... . . ... ,
Chapter
.
5-Examination ...................................
Standing .........
Prone ....... .
,
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,
,
..... .. .. ... . ... .. .. .
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...... . . ... ...
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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 .................................
.
291
What Happens When a
292
Is
Grade VI Mobilization ..... .... . ............. .
296
What About the Audible "Crack"? .. ......... . .
297
Slack Removal .................................
298
Contraindications ............ .................
300
.
.
.........
SacroiliacJoint Manipulative
.
Joint Manipulation......................... .
8-Inflammation, the Soft
302 313
and General
Treatment Considerations ...................
Inflammation and
.
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
.
.
Chapter IO-Clinical Considerations ........................
.
. . . ... . .... . .. . . .. . .
Treatment
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Abnormal Movement Patterns and Treatment ..... .
395 396 402
(Chains) ................
404
Lesions ........... ...
406 409 409 411
Somatovisceral Reactions ....................... .
415
.
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
..
. .. .. .. .
..
Exercises ..... ..... ............. Frrw'\T'lro('t>r,tnrp
Exercises. . ... . ... ..
447
. .... .. .... ..
MiscellaneousStretches ........................ Appendix A-Case Follow-Ups ............. ................ Index
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437
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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":>""
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;,-"elnnp;"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'
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
Copyrighted Material
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.
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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.
Copyrighted Material
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.
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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-
Copyrighted Material
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
Copyrighted Material
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,
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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-''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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OJA. JU�'i"�f1llluu�
of the h uman l umbar spine.
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Shellshear JL, Macintosh NWG, eds. Surve1Js
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4. Kapandji l A o The
York, NY: C hurchil l Livingstone; 1974. 5. Luk KOK, Ho HC,
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200. J O.
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1981;6:620-628,
Copyrighted Material
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PELVIC LOCOMOTOR DYSFU NCTION
articulations
7,
pregnancy, labour and puerperium: an x-ray
Obste/, 1 920;30:575, N , P a r k W , Rooney PJ, What d o we know about the
8,
Semin Arthri-
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1 0 , A lbee FH, A study o f the anatomy and the clinical ' ffinfl,rtC1,ncp of the sacroiliac joint. IAMA , 1 909;53:1 273-1 276, 1 1 . Brooke R. The sacroi l i a c
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1 2 , Sashin D, A critical
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1 4 , l I l i F W , The Vertebral Column: mr,roc+i,-· 1951 .
1 5 , Weisl H , The articular surfaces o f the �"LI Vl.ll"'"
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and their relation to the movements
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1 7, Delmas A. Jonction
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1 8 , Sandoz RW, Structural and fWKtional
ring. Ann Swiss Chiro
Assac. 1981;7:101-160. 19, Freeman MD, Fox D, Richards T The joint:
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A , Poll-Goudzwaard A L , Stoeckart R, van
CJ, The J P, of the thoracolmnbar fascia: i ts function i n load transfer from spine to
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23. optimal system to control
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S, F a r fa n H F, Lamy C . The mec h a n i s m o f the lumbar
25,
using an
Clil! North A m , 1977;8:135-153.
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1981;6:249-262, 26, H u kins DW, A spden RM, Hickey DS. Thoracolumbar fascia can i ncrease the erector
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J Ana/. 1985;142:218. 32. Macintosh J E, Bogduk N. The detailed biomechanics o f the l u mba.r m u l tifidus. 1986;1 :20S.�21 3. 33.
W. The h u m a n dorsal rami. J Anal. 1982;1 34:383-397.
N, Wilson AS,
34. Macintosh JE, Valencia F,
N, M u nr o RR. The morphology o f the lumbar m u l tifi�
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Clin
North Am. 1977;8:193-199. 39.
ME. Exercises for lower motor neuron lesioll.",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)
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
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,.'YO"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 ;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/ll11an,.,."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
vr'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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142
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
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
146
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
Copyrighted Material
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
Copyrighted Material
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
Copyrighted Material
152
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 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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156
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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Insti-
tute; 1981. of disease processes: some
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Boston,
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PELYlC LOCOMOTOR DYSFUNCTION
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.
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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
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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-' (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
Copyrighted Material
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.
Copyrighted Material
>-' (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
Copyrighted Material
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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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225
A
B
Figure
sion.
5-51 Joint
play
of sacroiuac joint. (A) Posterior torsion. (B) Anterior tor
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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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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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PELVIC LOCOMOTOR DYSFUNCTION
A
B
Figure 5-55 Hip rotation .
(A)
Interna l.
(B) Externa l .
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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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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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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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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.
Copyrighted Material
Examination
and
3. Ducroquet R, Ducroquet J, Ducroquet P. Philadelphia, Pa: JB
Pathological
245
A S tudy of Normal and
Co; 1968.
4. Robinson RO,
variables
the effects
IVlUnWlllW'WP Physio/ Ther. 1987;10:1 721 76. BM, Read
5.
LJ,
Senior BPE.
the effects of
patients with low back pain. J Manipulative Physiol Ther. 1988;1 1 : 1 51W, Read lJ,
6.
to
PJW, et a l . Reliability of motion palpation
detect sacroiHac joint fixations.
Physiol Ther. 1 989;12:86-92.
in Primary Care. Baltimore, Md: Wi!1iams & Wilkins; 1979.
7. Ramamurti CPo 8. Kessler RM,
E. Management
Musculoskeletal Disorders. Philadelphia,
Pa: Harper & Row; 1983. 9. Mennel l J M . Back Pain:
Boston,
and Treatment Using Manipulative
l i ttle, Brown & Co; 1960. EA. Spinal Manipula tion. 4th ed. Norwalk, Conn: Appleton &
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-
Institute; 1989.
hip
Chiro
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Med. 1988;2:8-1 1 .
246
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
to simple therapy. Pos/grad
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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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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270
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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272
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
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
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
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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.
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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
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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.
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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'rhp�
response.
Gerontal. 1968;3:289-301.
Peat M. The effect of immobilization on the ultrastructure and mechanical of the rat medial collateral
c/in Orthop. 1987;203:301-308.
6. Finsterbush A, Friedman B.
rabbits. Clin 7. Noyes E FLmctional
lion. Clin 8.
produced
immobilization in
1975;11l:29()'-298.
of knee
and alterations induced by immobiliza-
1977;123:210-242.
SA Rehabilitation of muscle
9. Katz DR, Kumar VN. Effects of
iVkdSci
Exer. 1990;22:453-456.
bed rest on cardio-pulmonary conditioning.
Rev. 1982;11:89-93. 10. Nelson D L.
of passive and active care.
Ciill Chir.
1994;1 :2()'-29. 1L
HS, Fraser [H, Peek WD. Manual Methods.
Tissues: Treatment by
Md: Aspen Publishers, Inc; 1991.
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PELVIC LOCOMOTOR DYSFUNCTION
12. Caplan A, Carlson B, Faulkner J, Fischman D, Garret W. Skeletal muscle. In: Woo SL-Y, Buckwalter J A, eds. Injun) and Repair of the Musculoskeletal Soft Tissues. Park Ridge, III: American Academy of Orthopedic Surgeons; 1987:213-291. 13. Jerusalem F. The microcirculation of muscle. In: Engel AG, Banker BQ, eds. Myology. New York, NY: McGraw-Hili Book Co; 1986:343-356. 14. Janda V. Muscle Function Testing. Boston, Mass: Butterworths; 1983. 15. Faulkner JA. New perspectives in training for maximum performance. JAMA. 1986;205:741-746. 16. Saltin B, Gollnick P. Skeletal muscle adaptability: significance for metabolism and performance. In: Peachey LD, Adrian RH, Geiger SR, eds. Handbook of Physiology. Bethesda, Md: American Physiology Society; 1983:555--631. 17. Friden J, Sjostrom M, Ekblom B. Myofibrillar damage following intense eccentric exercise in man. Int J Sports Med. 1983;4:170--176. 18. Hoppeler H. Exercise-induced ultrastructural changes in skeletal muscle. Int J Sports Med.1986;7:187-204. 19. Garrett W, Tidball J. Myotendinous junction: structure, function, and failure. In: Woo SL-Y, Buckwalter JA, eds. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, ll!: American Academy of Orthopedic Surgeons; 1987: 171-207. 20. Jarvinen M. Healing of a crush injury in rat striated muscle. Acta Pathol Microbiol Scand. 1976;142:47-56. 21. Lundborg G, Myrhage R, Rydevik B.: The vascularization of human flexor tendons within the digital synovial sheath region: structural and functional aspects. J Hand Surg. 1977;2:417-427. 22. Gelberman RH, Woo SL-Y, Lothringer K, et al. Effects of early intermittent passive mobi lization on healing canine flexor tendons. J Hand Surg. 1982;7:170-175. 23. Salter RB. The biologiC concept of continuous passive motion of synovial joints: the first 18 years of basic research and its clinical application. Clin Orthop. 1989;242:12-24. 24. Kennedy JC, Hawkins RJ, Willis RB, Danylchuk KD. Tension studies of human knee liga ments, yield point, ultimate failure, and disruption of the cruciate and tibial collateral ligaments. J Bone Joint Surg. 1976;58A:350-355. 25. Frank C, Amiel D, Woo SL-Y, Akeson WHo Normal ligament properties and ligament healing. Clin Orthop. 1985;196:15-25. 26. Frank C, Woo SL-Y, Andriacchi T, et al. Normal ligament: structure, function, and com position. In: Woo SL-Y, Buckwalter JA, eds. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, Ill: American Academy of Orthopedic Surgeons; 1987:45-101. 27. Andriacchi T, Sabiston p, DeHaven L, et al. Ligament injury and repair. In: Woo SL-Y, Buckwalter JA, eds. Injury and Repair of the Musculoskeletal Soft Tissues. Park Ridge, III: American Academy of Orthopedic Surgeons; 1987:103-128. 28. Dahners LE. Ligament contraction: a correlation with cellularity and actin staining. Trans Orthop Res Soc. 1987;11 :56. 29. Woo S, Maynard J, Butler D, et al. Ligament, tendon, and jOint capsule insertions to bone. In: Woo SL-Y, Buckwalter JA, eds.Injury and Repair of the Muswloskeletal Soft Tissues. Park Ridge, Ill: American Academy of Orthopedic Surgeons; 1987:133-166. 30. Mennell JM. The Musculoskeletal System: Diff erential Diagnosis from Symptoms and Physical Signs. Gaithersburg, Md: Aspen Publishers, Inc; 1992.
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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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u,",,,mJb'"
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
Tissue Structures
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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and
346
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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350
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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352
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
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this
and palpa-
w Ul Q\ ""d
tTl r
:5 n r
' /
'
';�:
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
361
,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
363
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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364
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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366
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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368
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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370
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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Treatment of Myofascial and
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. ,-
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.
"'.'''"''
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,
rHAlnl-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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re-
reduces tension in it associ-
Stretching and Exercise
465
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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466
PELVlC LOCOMOTOR DYSFUNCTION
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'',
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;gICU,,:>, 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
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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
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Yeoman's test, 230, 23()-231,3 1 1