Pelvic Locomotor Dysfunction: A Clinical Approach

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Copyrighted Material

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


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


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 .


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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f or

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.. .... . . . . .. . .. .

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57

... . ... . .

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


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 .,.. ,

.

,

.

'

,

,

.

"

.

. .. ,.

"

"

"

"

.. . . ,.. . .

119 129

.

.

,

.

Chapter 4--Clinical Assessment: General Considerations ....

.

................. .

VertebralSubluxation The "Five Nevers" .. . . .

Lumbar Versus Pelvis

. .. . ... . .... . .

.

.

..

Irritability. .. . .... . ..... ...... ... ... ... .

.

.

of Motion ............................... ....................

PlayfJoint Signs .....

,

.

.. . ... .

.

...... ... . ..........

"

,

Join t Compression with Passive Testing . . . .. . .. .

Selective Tissue Tension "

.

. ... . .

.

.

.

.

,

.. . ,

.

.

,

, . .. .

andSkin Length-Strength and Movement Patterns .....

.

.

.

.

Inequality............... . . ... . . ... ,

Chapter

.

5-Examination ...................................

Standing .........

Prone ....... .

,

.

,

,

..... .. .. ... . ... .. .. .

.

.

...... . . ... ...

.

.

.

.

.

.

.

. ... . . .

Radiographs ... . .......... ... . .. . . . .... .

.

.

,

.

.

.

ErythrocyteSedimentation Rate ......... .. ..... . Chapter

6-Mobilization .................. ................

General Considerations ...... . ,

Mobilization Facilitation Mobilization


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 .

.

.

.

Treatment of

.

.

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.

.

PainSyndromes.........

Treatment of Tendon and

.

.

344 344

Lesions........

376

Shortened Muscles ............

380

Miscellaneous Conditions .......................

387

Conclusion ........ ... .... ... ..............

393

Treatment of

.

.

Chapter IO-Clinical Considerations ........................

.

. . . ... . .... . .. . . .. . .

Treatment

.

.

.

.

.

.

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. . . . ... .

.

.


.

.

.

.

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.


Ann Swiss Chiro

xxiv


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


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.


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


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


28


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


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.


30


\ 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.


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


32


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


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.


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-


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


36


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


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


38


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,


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


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


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


42


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


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.


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


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

REFERENCES 1 . Warwick

R, W i l l iams p,

2,

OJA. JU�'i"�f1llluu�

of the h uman l umbar spine.

J Anal, 1978;125:1 27. 3. Shellshear jL, Macintosh NWG. The transverse

of the fifth lumbar vertebra. In:

Shellshear JL, Macintosh NWG, eds. Surve1Js

Austra l ia :

Grahame; 1949:21-32. Joints, Vol 3. The Trunk and the Vertebral Column, New

4. Kapandji l A o The

York, NY: C hurchil l Livingstone; 1974. 5. Luk KOK, Ho HC,

JCY. The iliolumbar

J Bone Joint Surg, 1 986;68B:197-

200. J O.

and microscopic anatomy of the sacroiliac joint from decade.

1981;6:620-628,


54

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-

lis Rheum, 1983;1 2 : 282-3 1 3. 9, Von Luschka H, Die a n a to m i e des Menschen in Rucksicht a u f die bedurfnisse def heilk lmde, N Laupp

1 863;2:89,

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

I Arwl. 1 924;58:299-305, of

1 2 , Sashin D, A critical

o f the sacroiliac

a n d the

joint, I Bone loint Surg, 1930; 12:891-910, 13, Schunke GB, The anatomy and development of the sacroiliac joint in man, Anal Rec, 1938;72:31 3-331 . Body, Lombard, I l l : National

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"'"

o f Chi-

and their relation to the movements

of the sacrum, Acta Anal, 1954;22:1-14, 1 6 . Solonen KA, The sacroiliac

in

of anatomical, roE,ntl�erl011Jgical and clinical

studies, Acta Orthop Scand. 1957;27: 1-127. et statique du corps. Rev Rhumatisme. 1 950;9:475-5 8 1 .

1 7, Delmas A. Jonction

o f the

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:

evidence for confirmation o f IIIi's ligament. J

Ther. 1990;13:384-390, 20. Cola chis Sc, Warden RE, Becthal CO, et aL Movement of the sacroiliac joint in the adult male. A rch 21.

Med Rehabil. 1 9 63;44:490-498.

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

1 995;20:753-758, The

22.

ana tomy o f the thoracol u m b a r fascia. C. A mathematical model of the lumbar

23. optimal system to control

and

S, Farfan HF, HeHeur C . The abdominal mechanism.

24,

1985;10:31 7-324.

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.

Spine.

1981;6:249-262, 26, H u kins DW, A spden RM, Hickey DS. Thoracolumbar fascia can i ncrease the erector

LT Clinical A natomy

27. 28. Macintosh JE,

pffid,mcv of

muscles. Clin Biomech, 1990;5:30-34, Lumbar

New York, NY: Churchill

N , The biomechanics of the thoracolumbar fascia. Clin Biamech,

1987;2:78-83. 29.

N. A

of the anatomy of the human lumbar erector

1980;131 :525-540,


I Anat.

Anatomy

30"

55

N . The myotomes of the h u m an m u l tifidus" J Anal. 1983;136:148-149.

3 1 . Macintosh J E,

N" The qual itative biomechanics of the l umbar back m uscles.

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�

dus muscles. Clin Biomech. 1986; 1 : 196-204. 35. Donisch EW, Basmajian JV.

back muscles in man. Am J Anal.

of

1 972;133:25-36" Pain and

36. Travel! JG, Simons DC.

Point Manual. Vol 2.

The

Baltimore, Md: WiUiams & W i lkins; 1992. 37. Kendall FP,

and Fundion. 3rd ed. Baltimore, M d : Williams

EK. Muscles:

& Wilkins; 1983. 38. Rab GT, Chao EYS, Stauffer RN. Muscle force analysis o f the lumbar spine.

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)


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


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


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.


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


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.


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


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


and resting

116


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.


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


142


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


are evident


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


144


o

Figure

4-5

When Contractile Tissue Is Involved

o

Figure 4-6 Involved

Pain

When Passive or Inert Tissues Are



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


146


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



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


148


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



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


150


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


In


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


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


muscular re-

153


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.


155


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


156


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



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


158


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"


159


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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1.

of the Spine.

[urltiI1lgt(Jn Beach, Calif: Motion

Insti-

tute; 1981. of disease processes: some

2. Karr 1M. The spinal cord as

perspec-

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cord as

of sympa1979;4:57-62.

thetie innervation as a common

4.

New York, NY: Plenum L.TllfUIJlut,"L

5. Gillet H, Liekens M.

Research Notes. Huntington Beach, Calif: Motion

Institute; 1984. 6. Mennell

JM.

Back Pain:

un'VfI,,,,,>

Boston,

Mass: Little, Brown & Co; 1960. 7. Jirout]. Studies on the dynamics of the spine. Acta Radiol. 1956;46:55-60. 8. Travel! jG, Rinzler SH. The rrn.r"t"�r,,,, 9. Korr 1M. PT()nr·,nc·pnto 10. Janda

V. Muscles, central nervous

In: Korr 1M, ed. The

Ne,lIfobioloilic Mechanisms in Manipulative

New York, NY: Plenum Publishing

Corp; 1978:27-41.

11. Cotran RS, Kumar V, Robbins SL

Pnlh,,/,wlr

Pa:WB

Saunders; 1989. 12. Salter RB, Simmonds DF, Malcolm BW, et at. The UIL"V),'L'" effect of continuous passive

in

motion on healing of full-thickness defects in the rabbit. J Bone Joint 13. Selye H. The Stress

1980;62A:1232-1251.

New York, NY: McGraw-Hill

Co; 1956.

14. Levi L. Stress: Sources, Management, and Prevention. New York, NY: 15. Zohn DA, Mennell ]M. Musculoskeletal Pain:

1967.

and Physical Treatment. Boston,

Mass: Little, Brown & Co; 1976. 16. Mennell JM. The Musculoskeletal System:

Gaithersburg, Md:

Publishers, Inc; 1992.


and Physical

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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.

Spine. 1993;18:704--708.



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

o f lower extremity

J

Rad

Ther, 1 946;56:616-623, Pain and

Travell jG, Simons DC.


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


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


and

assessment

the normal. It is well to

164


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


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


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.


>-' (Y) '-1

188



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.


190


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


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


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


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-


194


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.


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


196

PELVIC


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,


Examination

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



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


Examination

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


200


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


Examination

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.


202


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


203

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


on the

204


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.


Examination

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


206

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


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


208


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


Examination

A

B

Figure

5-39

Hip rotation.

(A)

Externa l .

(B)

Interna l .


209

10

Figure


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).


Examination

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.


212


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.


Examination

213

Figure H2 continued C

D

contin ues


214


Figure 5-42 continued E

F


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


216


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.


Examination

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


at its

218


A

B

Figure 5-45 (A, B) Quadratus lumborum muscle trigger point examination. Twelfth rib is marked.


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


220


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


Examination

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


222


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.


Examination

Figure

5-49 Horizontal-Plane Gapping of Sacroiliac Joint

Figure 5--50 Sagittal-Plane Shearing of Sacroiliac Joint


223

224


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


Examination

225

A

B

Figure

sion.

5-51 Joint

play

of sacroiuac joint. (A) Posterior torsion. (B) Anterior tor


226


Figure 5-52 Prone Measurement of Posterior Superior Iliac Spine Distance

Figure 5-53 Hip Extension Movement Pattern


Examination

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


228


A

B

Figure 5-55 Hip rotation .

(A)

Interna l.

(B) Externa l .


Examination

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


230

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


Examination

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


232


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


Examination

A

B

Figure 5--60 Hip joint play. (A)

In extension.

(B) In anterior glide.


233

234


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.


(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


a localized

at

236


A

B

continues

Figure 5-63 (A) Sacral apex pressure. (B) Cranial shear. (C) Craniocaudal shear.


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.


238


A

B

continues

Figure 5-64 Direct lateral gapping. (A) With thumb contact. (B) With reinforced contact. (C) With double-thumb contact.


Examination

Figure 5-64 continued C

Figure 5-65 Sacra-Ilia Cross


239

240


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


Examination

241

A

B

Figure 5-66 Trunk extension differential test. (A) Tnmk extension without joint stabilization, (B) With joint stabilization.


242


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


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


244


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.


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


Med. 1988;2:8-1 1 .

246


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


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


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


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


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


I and II

250


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.


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.


for

252


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


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.


254


Figure 6-3 continued

B

c


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


256


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.


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.


258


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.


..

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


260


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


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


262


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


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.


264



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


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.


266


Figure &-15 General Pubic Symphysis Countertorque

Figure &-16 Countertorque Using Psoas Muscle Facilitation Stretch


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.


268


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


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


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.


(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


272


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)


-

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


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


332


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


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.


this are the repair

334


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


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


336


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-


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.


and

338


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.


342


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.


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,


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


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


and

346


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-



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


348


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.



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


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


9-3). The

anterior fibers


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


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.


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.


354

PELVIC


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-


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


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.


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


9-10).

A tight pirifor-

362


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 •



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,


364


Figure 9-12 Piriformis Stretch, Sup ine

Figure 9-13 Piriformis Stretch, Supine, Using Adduction and Internal Rotation


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


366


,

•

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



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.


368

PELV1C LOCOMOTOR DYSFUNCTION


B

c



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


370


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.


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-


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


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-


466


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.


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,


468


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


""''''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



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


Yeoman's test, 230, 23()-231,3 1 1

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Pelvic Floor Dysfunction - A Multidisciplinary Approach

Pelvic Organ Dysfunction in Neurological Disease: Clinical Management and Rehabilitation

Deep Pelvic Endometriosis: A Multidisciplinary Approach

Respiratory Physiology: A Clinical Approach

A Clinical Approach to Medicine

Management of Erectile Dysfunction in Clinical Practice

Management of Erectile Dysfunction in Clinical Practice

Contemporary Treatment of Erectile Dysfunction: A Clinical Guide (Contemporary Endocrinology)

Contemporary Treatment of Erectile Dysfunction: A Clinical Guide

Mark's Basic Medical Biochemistry A Clinical Approach

Marks Basic Medical Biochemistry A Clinical Approach

Clinical MR Imaging A Practical Approach

Cardiac Pacing and Defibrillation: A Clinical Approach

Basic Medical Biochemistry: A Clinical Approach (Books)

Clinical Ophthalmic Echography: A Case Study Approach

Clinical Electrocardiography: A Simplified Approach, 7Th Edition

Clinical Electrocardiography: A Simplified Approach, 7th Edition

Bone metastases: a translational and clinical approach

Inherited Metabolic Diseases: A Clinical Approach

Clinical Ophthalmology: A Systematic Approach (6th Edition)

Marks' Basic Medical Biochemistry: A Clinical Approach

Bone Metastases: A translational and clinical approach

Erectile Dysfunction

Chronic Prostatitis Chronic Pelvic Pain Syndrome (Current Clinical Urology)

Fang dysfunction

The Female Pelvic Floor

Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction (Wiley Series in Nursing)

Voiding dysfunction

Pelvic Locomotor Dysfunction: A Clinical Approach

Pelvic Floor Dysfunction - A Multidisciplinary Approach

Pelvic Organ Dysfunction in Neurological Disease: Clinical Management and Rehabilitation

Deep Pelvic Endometriosis: A Multidisciplinary Approach

Respiratory Physiology: A Clinical Approach

A Clinical Approach to Medicine

Management of Erectile Dysfunction in Clinical Practice

Management of Erectile Dysfunction in Clinical Practice

Contemporary Treatment of Erectile Dysfunction: A Clinical Guide (Contemporary Endocrinology)

Contemporary Treatment of Erectile Dysfunction: A Clinical Guide

Mark's Basic Medical Biochemistry A Clinical Approach

Marks Basic Medical Biochemistry A Clinical Approach

Clinical MR Imaging A Practical Approach

Cardiac Pacing and Defibrillation: A Clinical Approach

Basic Medical Biochemistry: A Clinical Approach (Books)

Clinical Ophthalmic Echography: A Case Study Approach

Clinical Electrocardiography: A Simplified Approach, 7Th Edition

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Bone metastases: a translational and clinical approach

Inherited Metabolic Diseases: A Clinical Approach

Clinical Ophthalmology: A Systematic Approach (6th Edition)

Marks' Basic Medical Biochemistry: A Clinical Approach

Bone Metastases: A translational and clinical approach

Erectile Dysfunction

Chronic Prostatitis Chronic Pelvic Pain Syndrome (Current Clinical Urology)

Fang dysfunction

The Female Pelvic Floor

Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction (Wiley Series in Nursing)

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