False Positive Pelvic Instability in Pregnancy Briefly Noted: Presented at the World Congress of Low Back Pain
Jerry Hesch, MHS, PT
This case involves a 29 year old female in the 32nd week of pregnancy referred by a friend for manual therapy. The client had progressive pelvic joint pain and perceived pelvic instability. She also had worsening of bladder control, and a diagnosis of interstitial cystitis with onset during the pregnancy. She described the feeling that her pelvis was coming apart in the front and she maintained hip adduction with all positional changes. Gait was antalgic, with a narrow base of support and shortened stride length with excessive trunk flexion. Pelvic instability in pregnancy is a well established concept due to the enhancing size of the fetus, with a background of hormonal priming; particularly Relaxin and Estrogen. Evaluation was performed in a cautious and limited manner with the expectation that pelvic instability would be encountered. Palpation and Springing with Awareness provoked significant clinical surprise, as the entire pelvic structure was stuck. This was based on 12 passive accessory spring tests to the sacrum, illia, ischia and symphysis pubis. A Posterior Glide of the Sacrum fixation was encountered along with Bilateral Type 1 Inflare of the Illia (Hesch Definition). After treating these with a gentle passive fulcrum for 5 minutes, mobility was restored and re-evaluation revealed a Bilateral Anterior Ilium (Hesch definition). This too was successfully treated, after which pelvic posture was much improved, and pain and antalgia were significantly reduced. She was taught self management. She was again symptomatic the week before her C-section, although less than previously, but declined the opportunity to return. She is now 5 weeks post and will return shortly for a checkup. She reports significant improvement in bladder control, greater than pre pregnancy. The subjective sense of instability was most likely a reflection of the visceral tension and compression and perhaps due to pelvic nerve tension and compression with the 3-dimensional non-physiological positioning of the pelvic articulations. This case report might be the first reported case of true hypo-mobility of the pelvic joints, presenting as subjective “instability”. This case underscores the value of utilizing the Springing With Awareness joint mobility evaluation tool. Video fluoroscopy has demonstrated that sacroiliac joint spring tests induce movement in and through the joints. It is encouraging to think that, in spite of the overarching paradigm of late pregnancy instability; there may a larger number of similar cases than can respond positively to Manual Therapy intervention at this late stage.