Ilial Anterior Rotation Hypermobility
Letter to the Editor of Physical Therapy Journal
Published Letter to the Editor Physical Therapy Journal
On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590. 23 February 2009 Jerry Hesch,PT,MHS, is Manager
Hesch Seminars and Physical Therapy, LLC, 1609 Silver Slipper Ave, Henderson, NV 89002-9334 Send rapid response to journal:
Re: On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590.
Email Jerry Hesch
This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic. In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint dysfunction (SIJD). This is very appropriate, as research and opinion have been presented indicating that asymmetrical pelvic position and movement, and its testing and treatment, do not necessarily imply actual position and movement dysfunction (PMD) intrinsic to the sacroiliac joint (SIJ).2-4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors1 clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (ie, ilium moving on sacrum) also implies the alternate possibility of PMD of the pelvis (entire pelvis moves as a unit). The clinical reality perhaps is that at times these may be mutually exclusive entities and at other times they may be a combination of both.
The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and lateral (external) rotation of the hip, as described by DonTigny.6 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would occur primarily in the sagittal plane, less so in the frontal plane, and only slightly in the transverse plane.
In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named “upslip.”7,8 I suggest that in the prone position, the client could be screened for upslip PMD. A superior spring to the ischial tuberosity and an inferior spring to the posterior iliac shelf would both be blocked with upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as the authors noted with passive testing.
Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD than I do clients with symptomatic SIJ/pelvic dysfunction.9,10 In my opinion, treating clients who have asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention and reducing the suboptimal biomechanical influence on proximal and distal structures.
The Ostgaard test is a special test (provocative), which was described in the article.1 The test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported by Ostgaard11 and the authors1 to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, I believe that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide.
I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions, and empiricism on the subject.
References
1. Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.
2. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368.
3. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165.
4. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129.
5. Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997.
6. DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44.
7. Nyberg R. Pelvic girdle. In: Payton O, Di Fabio RP, Paris SV, et al. Manual of Physical Therapy. New York, NY: Churchill Livingstone Inc; 1989:378–380.
8. Greenman P. Principles of diagnosis and treatment of pelvic girdle dysfunction. In: Greenman P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:257.
9. Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California.
10. Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7.
11. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19:894–900.
Author Response 27 March 2009 H Todd Vaughn,
PT, DPT, OCS, MTC, is Senior Lecturer,
Physical Therapist Assistant Program, Southern Illinois University at Carbondale, Carbondale, IL Send rapid response to journal:
Re: Author Response
Email H Todd Vaughn
I would like to thank Poulter,1 Cibulka,2 and Hesch3 for their responses to the case report titled “Ilial Anterior Rotation Hypermobility in a Female Collegiate Tennis Player.”4 I appreciate their professional input regarding the case report and admire their commitment to holding the physical therapy profession accountable for fostering evidence-based practice. Several criticisms were made; some I feel are justifiable, whereas others warrant a response. I will address each of the responders separately. Poulter states, “The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm. This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, TENS, ice, ultrasound, massage and taping.”
A treatment-based classification system identifies a heterogenous group of patients and places them into subgroups based on the examination data. The classification of the patient in each subgroup guides the treatment plan.5 The assumption of this type of classification system is that all patients will fall into a particular subgroup. Each patient is unique and may have multiple impairments that require a multi-treatment approach. Based on examination data, my patient would need to be classified in both the mobilization and immobilization treatment subgroups, as proposed by Fritz and George.5 Currently, there is only a treatment-based classification system for classifying patients with acute low back pain to treatment subgroups.5 I propose that a treatment-based classification system be developed for patients with sacroiliac joint dysfunction (SIJD). I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.6
I certainly could have classified my patient as having general low back pain and ignored the patient’s mechanism of injury and the impairments identified in the examination. This approach was used by the athletic trainer for 2 weeks after the patient’s first onset of pain. The athletic trainer had the patient continue this active treatment paradigm until she no longer could play tennis, walk with a normal gait pattern, and sit with normal posture.
Poulter suggests that a body chart and valid outcome measures should have been utilized in the case report. I agree that a body chart would have increased clarity of the location of the patient’s pain. The patient reported right low back pain as a general descriptor; her pain was palpated inferior to the posterior-superior iliac spine (long dorsal sacroiliac ligament). I also agree that the Oswestry Disability Index7 could have been used with this patient. However, it was apparent, based on the patient’s goals, that returning to competitive tennis was the true measure of attaining her functional outcome.
Poulter asked, “Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode?” Based on the history, examination, and mechanism of injury, I believed the patient developed right ilial anterior rotation hypermobility secondary to excessive stress to her long dorsal sacroiliac ligament (LDL). The LDL restrains anterior ilial rotation and was susceptible to sprain secondary to performing repetitive 2-hand backhands. The literature suggests that ligaments can regain 50% of their normal tensile strength by 6 months after injury, 80% after 1 year, and 100% after 1 to 3 years.8-10 The subsequent treatment program was designed to stress the LDL gradually over time, being careful not to exceed its tensile strength during the remodeling phase. The sacroiliac belt and taping technique were necessary at 6 months during tennis play secondary to the high pelvic rotational forces and the LDL only having approximately 50% of its tensile strength. The patient was reexamined 1 year later and was found to have no impairments or functional limitations. We hypothesized at 1 year that the ligament had regained its tensile strength and, therefore, the sacroiliac belt and taping technique no longer were necessary for tennis.
I do not understand the basis for Poulter’s comment suggesting that I contributed to the patient’s 6-month chronic episode. Furthermore, I believe that I was able to offer the patient a solution to her complex problem.
Cibulka states, “How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity?” I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD, where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.9
I apologize to Cibulka for not citing his article titled “Unilateral Hip Rotation Range of Motion Asymmetry in Patients With Sacroiliac Joint Regional Pain”11 in my literature review. Its omission was not intentional, and the article should have been included.
I also agree that the terms used to describe the sacroiliac joint need to be operationally defined. There is too much “jargon” that leads to confusion when discussing the sacroiliac joint.
Hesch discussed several interesting points in his response. I agree that the corrective exercise for the right ilial anterior rotation hypermobility could have been enhanced by adding abduction and lateral (external) rotation of the hip. The “upslip” of the innominate should have been examined with passive mobility testing in the prone position, as Hesch suggested. Hesch also brings up an interesting point that the Ostgaard test theoretically could induce anterior rotation of the ilium. Extensive research is needed to validate tests related to the diagnosis of SIJD.
H Todd Vaughn
HT Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, 374 E Grand Ave, Mail Code 6740, Carbondale, IL 62901 (USA), and Senior Physical Therapist, Select Medical Corporation, NovaCare Rehabilitation, Benton, Illinois.
References
1 Poulter DC. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx.
2 Cibulka M. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx.
3 Hesch J. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx.
4 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.
5 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000:25;106–114.
6 Brolinson PG, Kozar AJ, Cibor G. Sacroiliac dysfunction in athletes. Curr Sports Med Rep. 2003;2:47–56.
7 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940–2952.
8 Vailas AC, Tipton CM, Mathes RD, et al. Physical activity and its influence on the repair process of medial collateral ligaments. Connect Tissue Res. 1981;9:25–31.
9 Tipton CM, Matthes RD, Maynard JA, et al. The influence of physical activity on ligaments and tendons. Med Sci Sports Exerc. 1975;7:165–175.
10 Tipton CM, James SL, Mergner W, et al. Influence of exercise in strength of medial collateral knee ligaments of dogs. Am J Physiol. 1970;218:894–902.
11 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009–1015.
Here is a nice email from the author.
Sent: Thursday, April 02, 2009 11:14 AM
Subject: Re:+Author+Response
Hi Jerry,
Thank you for your email. I must admit I was a little
discouraged from the first two responders comments. I really
appreciate your input and professionalism. I shared your kind
comments with Wanda Nitsch (co-author).
I am always interested in research ideas. I have not
encountered, or at least recognized, a patient with a posterior
glide of the sacrum. It sounds like you would have a very
interesting case report that would add to the literature.
Other topics that interest me includes: management of lumbar
disc herniations; cervical dysfunctions and lordosis; and true
leg length discrepency and its implications on lumbar and LE
function/pain.
Thank you again for your professional feedback and
encouragement. It is really appreciated!
Todd
Todd Vaughn PT,DPT,MS,OCS,MTC
Senior Lecturer
Physical Therapist Assistant Program
Southern Illinois University Carbondale
This longer version was not accepted for publication.
Letter to the Editor
On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590.
This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic.
In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint (SIJ) dysfunction (SIJD). This is very appropriate, as research and opinion have been presented, indicating that asymmetrical pelvic position and movement, and its testing and treatment, does not necessarily imply actual position and movement dysfunction (PMD/PMDs) intrinsic to the SIJ.2-4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (i.e. ilium moving on sacrum) also implies the alternate possibility of PMD dysfunction of the pelvis (entire pelvis moves as a unit). Clinical reality perhaps being, that at times these may be mutually exclusive entities, and other times may be a combination of both.
Palpation of the pubic tubercles was performed as part of a screen to the symphysis pubis, though findings were not detailed. Screening of the symphysis pubis can be very useful in screening for a unilateral SIJD such as RAIRH. As the ilium, ischium and pubic bone are fused in the adult, unilateral movement of the ilium on the sacrum i.e. RAIRH, induces mandatory motion of the ipsilateral pubic bone, along with palpable fibrocartilage disc deformation. If there is asymmetry when palpating across the pubic bone onto the fibrocartilage and onto the opposite pubic bone, and it returns to symmetry after resolving RAIRH, it is reasonable to assume a true Anterior Ilium with intrinsic SIJ movement of ilium on sacrum, rather than extrinsic pelvic PMD.
The traditional model utilizes the pubic tubercles and pubic crests for palpation. To that I add palpation at four different locations going from the face of the right pubic bone onto the fibrocartilagenous disc and onto the left pubic bone. This is relevant as the pubic bones are elongated structures of approximately 5cm. I also palpate from the right pubic crest onto the top of the fibrocartilage and then onto the opposite pubic crest. A mutable step up or step down at either location that reverts to symmetry with treatment of RAIRH, is indicative of a true intrinsic SIJD.
One can have asymmetry of one pubic bone in relation to the opposite, however if they lie in the same para-frontal plane without step off and fibrocartilage disc deformation, this is simply a positional asymmetry of the pelvis, not an intrinsic SIJD. This asymmetry is easily demonstrated by taking a person with frontal plane symmetry, and asking them to step back with the left leg. The left pubic bone will be posterior in relation to the right, without any intrinsic SIJ or symphyseal PMD. To date, this concept has not been encountered in the literature and is ripe for research as are all other empirical observations mentioned herein. However, other possible scenarios are worthy of consideration. It seems probable that absent motion occurring within the symphysis pubis, a combination of RAIRH and a Left Posterior Ilium could occur simultaneously with motion occurring only in the left and right SIJ. Alternately, the entire pelvis could move in tri-dimensional space such as moving on the femoral heads without intrinsic SIJ or pubic symphysis motion. Finally, a combination of intrinsic and extrinsic PMD could exist. Additional landmark palpation as described above can be very informative. Very gentle passive accessory motion testing (spring testing) can also be utilized at the symphysis pubis.
SIJD has many evaluation and treatment approaches, as noted in the literature, continuing education courses, and conferences. The pelvis and lumbar spine are inextricably linked. It is not unusual to find lumbar movement dysfunction that remains after resolving SIJ/pelvic PMD. The lumbar PMD may or may not be symptomatic, and it can be subtle in a neutral posture. Typically, it will become exaggerated in flexion, and less frequently, it enhances in extension. It is also observed that RAIRH often coexists with a Left Posterior Ilium. However, the latter may not always be apparent per initial palpation and spring testing until after the RAIRH is resolved. A permutation can then occur, and Left Posterior Ilium is then encountered in prone and supine (stable) positions. Addressing both sides makes for a fairly quick and lasting gain. Often the presence of RAIRH is actually a part of a greater pattern of up to seven distinct PMDs of the SIJ/pelvis, which I refer to as “The Most Common Pattern”, as it is ubiquitous. Sequential treatment of each component is necessary in order to achieve symmetrical tri-plane position, mobility and stability.6-8 One component of this pattern is what I refer to as a Type 1 Right Inflare and a Type 1 Left Outflare PMD, which requires separate treatment after addressing Right Anterior Ilium and Left Posterior Ilium. Type 1 Inflare/Outflare PMD is much more common than the subtle Type 2 (Osteopathic) Inflare/Outflare. Type I Inflare/Outflare has a much greater anterior/posterior component, whereas Type 2 has a much greater medial/lateral component. Spring testing for Type 1 is 45 degrees away from that of Type 2, with no overlap of spring test findings. The most distal compensation for Type I Inflare and Outflare is a counter rotation at C1, which can spontaneously resolve after successful treatment of the SIJ/pelvis.
The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and external rotation of the hip, as described by DonTigny.9 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would primarily occur in the sagittal plane, less so in the frontal, and only slightly in the transverse plane.
In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named Upslip. The presence of an Upslip PMD could be validated or negated with the client in prone. A superior spring to the ischial tuberosity and inferior spring to the posterior iliac shelf would both be blocked with Upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As Upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as Vaughn and Nitsch1 noted with passive testing.
Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD, than I do clients with symptomatic SIJ/pelvic dysfunction.10,11 Treating the clients who present with asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention, and reducing the suboptimal biomechanical influence on proximal and distal structures.
The Ostgaard test is a special test (provocative), which was described in the article.1 the test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, it seems that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide.
I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions and empiricism on the subject.
Jerry Hesch
J Hesch, PT, MHS, Manager
Hesch Seminars and Physical Therapy, LLC
Address all correspondence to Mr Hesch at: [email protected].
References
1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.
2 Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test.Spine. 2000;25:364–368.
3 Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165.
4 Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129.
5 Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997.
6 Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Vleeming A, Mooney V, Dorman T, et al, eds. Movement, Stability and Low Back Pain: The Essential Role of the Pelvis. London, United Kingdom: Churchill Livingstone; 1997: chap 42.
7 Hesch J. Course Workbook: The Hesch Method of Treating Sacroiliac Joint Dysfunction: Integrating the SI, Symphysis Pubis, Hip and Lumbar Spine. Henderson, NV: Hesch Seminars; 2009.
8 Hesch J. Manual therapy evaluation of the pelvic joints using palpatory and articular spring tests. Presented at the First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint; November 6, 1992; San Diego, California.
9 DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44.
10 Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California.
11 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7.
On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590. 23 February 2009 Jerry Hesch,PT,MHS, is Manager
Hesch Seminars and Physical Therapy, LLC, 1609 Silver Slipper Ave, Henderson, NV 89002-9334 Send rapid response to journal:
Re: On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590.
Email Jerry Hesch
This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic. In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint dysfunction (SIJD). This is very appropriate, as research and opinion have been presented indicating that asymmetrical pelvic position and movement, and its testing and treatment, do not necessarily imply actual position and movement dysfunction (PMD) intrinsic to the sacroiliac joint (SIJ).2-4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors1 clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (ie, ilium moving on sacrum) also implies the alternate possibility of PMD of the pelvis (entire pelvis moves as a unit). The clinical reality perhaps is that at times these may be mutually exclusive entities and at other times they may be a combination of both.
The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and lateral (external) rotation of the hip, as described by DonTigny.6 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would occur primarily in the sagittal plane, less so in the frontal plane, and only slightly in the transverse plane.
In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named “upslip.”7,8 I suggest that in the prone position, the client could be screened for upslip PMD. A superior spring to the ischial tuberosity and an inferior spring to the posterior iliac shelf would both be blocked with upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as the authors noted with passive testing.
Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD than I do clients with symptomatic SIJ/pelvic dysfunction.9,10 In my opinion, treating clients who have asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention and reducing the suboptimal biomechanical influence on proximal and distal structures.
The Ostgaard test is a special test (provocative), which was described in the article.1 The test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported by Ostgaard11 and the authors1 to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, I believe that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide.
I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions, and empiricism on the subject.
References
1. Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.
2. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368.
3. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165.
4. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129.
5. Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997.
6. DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44.
7. Nyberg R. Pelvic girdle. In: Payton O, Di Fabio RP, Paris SV, et al. Manual of Physical Therapy. New York, NY: Churchill Livingstone Inc; 1989:378–380.
8. Greenman P. Principles of diagnosis and treatment of pelvic girdle dysfunction. In: Greenman P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:257.
9. Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California.
10. Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7.
11. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19:894–900.
Author Response 27 March 2009 H Todd Vaughn,
PT, DPT, OCS, MTC, is Senior Lecturer,
Physical Therapist Assistant Program, Southern Illinois University at Carbondale, Carbondale, IL Send rapid response to journal:
Re: Author Response
Email H Todd Vaughn
I would like to thank Poulter,1 Cibulka,2 and Hesch3 for their responses to the case report titled “Ilial Anterior Rotation Hypermobility in a Female Collegiate Tennis Player.”4 I appreciate their professional input regarding the case report and admire their commitment to holding the physical therapy profession accountable for fostering evidence-based practice. Several criticisms were made; some I feel are justifiable, whereas others warrant a response. I will address each of the responders separately. Poulter states, “The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm. This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, TENS, ice, ultrasound, massage and taping.”
A treatment-based classification system identifies a heterogenous group of patients and places them into subgroups based on the examination data. The classification of the patient in each subgroup guides the treatment plan.5 The assumption of this type of classification system is that all patients will fall into a particular subgroup. Each patient is unique and may have multiple impairments that require a multi-treatment approach. Based on examination data, my patient would need to be classified in both the mobilization and immobilization treatment subgroups, as proposed by Fritz and George.5 Currently, there is only a treatment-based classification system for classifying patients with acute low back pain to treatment subgroups.5 I propose that a treatment-based classification system be developed for patients with sacroiliac joint dysfunction (SIJD). I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.6
I certainly could have classified my patient as having general low back pain and ignored the patient’s mechanism of injury and the impairments identified in the examination. This approach was used by the athletic trainer for 2 weeks after the patient’s first onset of pain. The athletic trainer had the patient continue this active treatment paradigm until she no longer could play tennis, walk with a normal gait pattern, and sit with normal posture.
Poulter suggests that a body chart and valid outcome measures should have been utilized in the case report. I agree that a body chart would have increased clarity of the location of the patient’s pain. The patient reported right low back pain as a general descriptor; her pain was palpated inferior to the posterior-superior iliac spine (long dorsal sacroiliac ligament). I also agree that the Oswestry Disability Index7 could have been used with this patient. However, it was apparent, based on the patient’s goals, that returning to competitive tennis was the true measure of attaining her functional outcome.
Poulter asked, “Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode?” Based on the history, examination, and mechanism of injury, I believed the patient developed right ilial anterior rotation hypermobility secondary to excessive stress to her long dorsal sacroiliac ligament (LDL). The LDL restrains anterior ilial rotation and was susceptible to sprain secondary to performing repetitive 2-hand backhands. The literature suggests that ligaments can regain 50% of their normal tensile strength by 6 months after injury, 80% after 1 year, and 100% after 1 to 3 years.8-10 The subsequent treatment program was designed to stress the LDL gradually over time, being careful not to exceed its tensile strength during the remodeling phase. The sacroiliac belt and taping technique were necessary at 6 months during tennis play secondary to the high pelvic rotational forces and the LDL only having approximately 50% of its tensile strength. The patient was reexamined 1 year later and was found to have no impairments or functional limitations. We hypothesized at 1 year that the ligament had regained its tensile strength and, therefore, the sacroiliac belt and taping technique no longer were necessary for tennis.
I do not understand the basis for Poulter’s comment suggesting that I contributed to the patient’s 6-month chronic episode. Furthermore, I believe that I was able to offer the patient a solution to her complex problem.
Cibulka states, “How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity?” I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD, where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.9
I apologize to Cibulka for not citing his article titled “Unilateral Hip Rotation Range of Motion Asymmetry in Patients With Sacroiliac Joint Regional Pain”11 in my literature review. Its omission was not intentional, and the article should have been included.
I also agree that the terms used to describe the sacroiliac joint need to be operationally defined. There is too much “jargon” that leads to confusion when discussing the sacroiliac joint.
Hesch discussed several interesting points in his response. I agree that the corrective exercise for the right ilial anterior rotation hypermobility could have been enhanced by adding abduction and lateral (external) rotation of the hip. The “upslip” of the innominate should have been examined with passive mobility testing in the prone position, as Hesch suggested. Hesch also brings up an interesting point that the Ostgaard test theoretically could induce anterior rotation of the ilium. Extensive research is needed to validate tests related to the diagnosis of SIJD.
H Todd Vaughn
HT Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, 374 E Grand Ave, Mail Code 6740, Carbondale, IL 62901 (USA), and Senior Physical Therapist, Select Medical Corporation, NovaCare Rehabilitation, Benton, Illinois.
References
1 Poulter DC. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx.
2 Cibulka M. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx.
3 Hesch J. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx.
4 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.
5 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000:25;106–114.
6 Brolinson PG, Kozar AJ, Cibor G. Sacroiliac dysfunction in athletes. Curr Sports Med Rep. 2003;2:47–56.
7 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940–2952.
8 Vailas AC, Tipton CM, Mathes RD, et al. Physical activity and its influence on the repair process of medial collateral ligaments. Connect Tissue Res. 1981;9:25–31.
9 Tipton CM, Matthes RD, Maynard JA, et al. The influence of physical activity on ligaments and tendons. Med Sci Sports Exerc. 1975;7:165–175.
10 Tipton CM, James SL, Mergner W, et al. Influence of exercise in strength of medial collateral knee ligaments of dogs. Am J Physiol. 1970;218:894–902.
11 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009–1015.
Here is a nice email from the author.
Sent: Thursday, April 02, 2009 11:14 AM
Subject: Re:+Author+Response
Hi Jerry,
Thank you for your email. I must admit I was a little
discouraged from the first two responders comments. I really
appreciate your input and professionalism. I shared your kind
comments with Wanda Nitsch (co-author).
I am always interested in research ideas. I have not
encountered, or at least recognized, a patient with a posterior
glide of the sacrum. It sounds like you would have a very
interesting case report that would add to the literature.
Other topics that interest me includes: management of lumbar
disc herniations; cervical dysfunctions and lordosis; and true
leg length discrepency and its implications on lumbar and LE
function/pain.
Thank you again for your professional feedback and
encouragement. It is really appreciated!
Todd
Todd Vaughn PT,DPT,MS,OCS,MTC
Senior Lecturer
Physical Therapist Assistant Program
Southern Illinois University Carbondale
This longer version was not accepted for publication.
Letter to the Editor
On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590.
This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic.
In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint (SIJ) dysfunction (SIJD). This is very appropriate, as research and opinion have been presented, indicating that asymmetrical pelvic position and movement, and its testing and treatment, does not necessarily imply actual position and movement dysfunction (PMD/PMDs) intrinsic to the SIJ.2-4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (i.e. ilium moving on sacrum) also implies the alternate possibility of PMD dysfunction of the pelvis (entire pelvis moves as a unit). Clinical reality perhaps being, that at times these may be mutually exclusive entities, and other times may be a combination of both.
Palpation of the pubic tubercles was performed as part of a screen to the symphysis pubis, though findings were not detailed. Screening of the symphysis pubis can be very useful in screening for a unilateral SIJD such as RAIRH. As the ilium, ischium and pubic bone are fused in the adult, unilateral movement of the ilium on the sacrum i.e. RAIRH, induces mandatory motion of the ipsilateral pubic bone, along with palpable fibrocartilage disc deformation. If there is asymmetry when palpating across the pubic bone onto the fibrocartilage and onto the opposite pubic bone, and it returns to symmetry after resolving RAIRH, it is reasonable to assume a true Anterior Ilium with intrinsic SIJ movement of ilium on sacrum, rather than extrinsic pelvic PMD.
The traditional model utilizes the pubic tubercles and pubic crests for palpation. To that I add palpation at four different locations going from the face of the right pubic bone onto the fibrocartilagenous disc and onto the left pubic bone. This is relevant as the pubic bones are elongated structures of approximately 5cm. I also palpate from the right pubic crest onto the top of the fibrocartilage and then onto the opposite pubic crest. A mutable step up or step down at either location that reverts to symmetry with treatment of RAIRH, is indicative of a true intrinsic SIJD.
One can have asymmetry of one pubic bone in relation to the opposite, however if they lie in the same para-frontal plane without step off and fibrocartilage disc deformation, this is simply a positional asymmetry of the pelvis, not an intrinsic SIJD. This asymmetry is easily demonstrated by taking a person with frontal plane symmetry, and asking them to step back with the left leg. The left pubic bone will be posterior in relation to the right, without any intrinsic SIJ or symphyseal PMD. To date, this concept has not been encountered in the literature and is ripe for research as are all other empirical observations mentioned herein. However, other possible scenarios are worthy of consideration. It seems probable that absent motion occurring within the symphysis pubis, a combination of RAIRH and a Left Posterior Ilium could occur simultaneously with motion occurring only in the left and right SIJ. Alternately, the entire pelvis could move in tri-dimensional space such as moving on the femoral heads without intrinsic SIJ or pubic symphysis motion. Finally, a combination of intrinsic and extrinsic PMD could exist. Additional landmark palpation as described above can be very informative. Very gentle passive accessory motion testing (spring testing) can also be utilized at the symphysis pubis.
SIJD has many evaluation and treatment approaches, as noted in the literature, continuing education courses, and conferences. The pelvis and lumbar spine are inextricably linked. It is not unusual to find lumbar movement dysfunction that remains after resolving SIJ/pelvic PMD. The lumbar PMD may or may not be symptomatic, and it can be subtle in a neutral posture. Typically, it will become exaggerated in flexion, and less frequently, it enhances in extension. It is also observed that RAIRH often coexists with a Left Posterior Ilium. However, the latter may not always be apparent per initial palpation and spring testing until after the RAIRH is resolved. A permutation can then occur, and Left Posterior Ilium is then encountered in prone and supine (stable) positions. Addressing both sides makes for a fairly quick and lasting gain. Often the presence of RAIRH is actually a part of a greater pattern of up to seven distinct PMDs of the SIJ/pelvis, which I refer to as “The Most Common Pattern”, as it is ubiquitous. Sequential treatment of each component is necessary in order to achieve symmetrical tri-plane position, mobility and stability.6-8 One component of this pattern is what I refer to as a Type 1 Right Inflare and a Type 1 Left Outflare PMD, which requires separate treatment after addressing Right Anterior Ilium and Left Posterior Ilium. Type 1 Inflare/Outflare PMD is much more common than the subtle Type 2 (Osteopathic) Inflare/Outflare. Type I Inflare/Outflare has a much greater anterior/posterior component, whereas Type 2 has a much greater medial/lateral component. Spring testing for Type 1 is 45 degrees away from that of Type 2, with no overlap of spring test findings. The most distal compensation for Type I Inflare and Outflare is a counter rotation at C1, which can spontaneously resolve after successful treatment of the SIJ/pelvis.
The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and external rotation of the hip, as described by DonTigny.9 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would primarily occur in the sagittal plane, less so in the frontal, and only slightly in the transverse plane.
In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named Upslip. The presence of an Upslip PMD could be validated or negated with the client in prone. A superior spring to the ischial tuberosity and inferior spring to the posterior iliac shelf would both be blocked with Upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As Upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as Vaughn and Nitsch1 noted with passive testing.
Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD, than I do clients with symptomatic SIJ/pelvic dysfunction.10,11 Treating the clients who present with asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention, and reducing the suboptimal biomechanical influence on proximal and distal structures.
The Ostgaard test is a special test (provocative), which was described in the article.1 the test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, it seems that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide.
I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions and empiricism on the subject.
Jerry Hesch
J Hesch, PT, MHS, Manager
Hesch Seminars and Physical Therapy, LLC
Address all correspondence to Mr Hesch at: [email protected].
References
1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590.
2 Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test.Spine. 2000;25:364–368.
3 Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165.
4 Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129.
5 Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997.
6 Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Vleeming A, Mooney V, Dorman T, et al, eds. Movement, Stability and Low Back Pain: The Essential Role of the Pelvis. London, United Kingdom: Churchill Livingstone; 1997: chap 42.
7 Hesch J. Course Workbook: The Hesch Method of Treating Sacroiliac Joint Dysfunction: Integrating the SI, Symphysis Pubis, Hip and Lumbar Spine. Henderson, NV: Hesch Seminars; 2009.
8 Hesch J. Manual therapy evaluation of the pelvic joints using palpatory and articular spring tests. Presented at the First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint; November 6, 1992; San Diego, California.
9 DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44.
10 Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California.
11 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7.