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Amy:
I feel a little "101" here, but what is the bullet point implications here - I kinda assumed fused = no movement anywhere. The SIJ might not move much but lose that micromotion and some macromotions get effected. What is that lateral marco motion used for, is probably a better way to ask my question. Jerry Hesch Amy, just after I posted it I scrolled through my You tube videos and made the discovery some time ago, just did not recall! So there is another video on same topic with CT scan evidence. Yes fused left sij means no movement in the left SIJ. I do believe that every biomechanical expert would be very surprised to see that a one-sided SIJ fusion significantly restricts pelvic side-glide mobility. Pelvic side glide is not thought to be a pure motion in the sij, but rather very minuimal sij motion and more motion of the lumbar spine and of the hip joints. Place your hand on the sacrum and try to glide it left and right, tell me what you find. lie the person on their left side and compress the right ilium and spring test it. What do you feel? I will explain. Jerry Hesch The lateral micromotion is a functional motion during gait, lateral weight shift, etc. It of course becomes a macromotion during such movements. The test for this motion is very relevant as some clients have it restricted, yet it is treatable with Hesch Method and it is a preventive model. Side-glided pelvis' even if subtle alter weight bearing throughout the kinetic chain, especially the lower extremities, and of course as you know; will create a distal compensation such as at the occipitoatlantal joint, which in time becomes symptomatic and non responsive to "adjusting the upper cervical spine". Does that answer your question. Micromotion is such a fundamental property of joints like the SIJ, so very relevant to test if one is using terminology such as "joint". Otherwise one is talking about the bony pelvis as it moves on the hips, which is NOT sij motion, despite the popularity thereof. I believed such for many years, but could not ignore the burgeoning research. After the seminar we filmed a PT who has a pathological fusion of one sacroiliac joints. I was amazed to see how significantly this restricted pelvic side-glide tested passively. The SIJ might not move much but lose that micromotion and some macromotions get effected. There are 2 videos, part 1, 2.
Please copy and paste in browser. Part 1. Part 2. http://www.youtube.com/watch?v=tKYjwilI7Dk jerry hesch •
Tom, Great demo on the distinction! I also enjoy treating the first rib. The literature does not give a lot of direction, beyond elevated rib. I screen and treat for the following: 1. lateral elevation 2. posterior elevation with anterior depression 3. anterior elevation with posterior depression 4. anterior and medial rotation 5. posterior and medial rotation 6. inferior posterior portion elevated anterior 7. compressed medially at both ends. As the first rib is covered by the clavicle, the anterior portion can only be evaluated through the medial clavicle, and just beneath it. I agree with you re the relevance of treating the first rib, given the direct attachment of the top of the sympathetic chain. Keep up the good work, a client has found your posts. Best Regards, Jerry Hesch HESCH INSTITUTE Received March 2012. I am pleased to receive this from Scott Burch, PT. Especially so because I respect his manual skills and clinical skills in general. He teaches and has taught a lumbopelvic course for many years, and I am pleased that this approach is meaningful to him, additive. I gave him my Power Point program and permission to use whatever he wants to from workbook etc. He helped me understand the value of very specific hip capsule testing beyond the usual hip scour test. I kind of envy his clinical situation as he is part of a team, multiple specialties in the same building. I am limited in my clinical hours, so best option is the specialty consults via home office and writing, teaching. Two surgeries are in the wings, one a hard mass under forarm impinges ulnar nerve. Please forward a triplicate complaint form! OK back on topic.
Jerry, Thank you for your letter. I am sorry for the delay, in replying to you. I wanted to wait and see how your methods work, and how i could add it to what i already do. I have found that your techniques are very beneficial. The more chronic the condition, the more benefit has seem to benefit the pt, and is a good adjunct to what i do. I have been able to make some progress with a few folks that i had been stuck with. I have not gotten together with my teaching partner, so we have not decided upon anything. I will let you know. Thanks, Scott In response to an inquiry re pelvic/sij alignment.
Derek, I have seen x-rays of "aligned" clients who had surgery and they were not aligned at the symphysis pubis joint and not aligned in the transverse plane. Tops of iliac crests appear to be symmetrical. a huge problem is the fact that the body can cause asymmetry of the pelvis from joints in the spine, hip, knee, the 26 bones in foot and ankle, all the musculature, even asymmetry of shoulders can pulll on a muscle that connects the shoulder to the ilium; latissimus dorsi. Research on x-rays covered in my torsion chapter briefly, positional artifact can affect some of the alignment. Some clients have a developmental asymmetry of the hemipelvis and this can be readily discerned. I am much more concerned about maximizing joint function than "alignment". Asymmetry, visual malalignment guides me to do passive joint testing to confirm or negate possibilities. Several pelvic asymmetries look very similar, so the passive mobility testing and ligament testing is crucial to discern. Further there are advanced patterns that are not taught to Physical Therapists, that PT's cannot find with the traditional testing. It is what it is. It is far more comnplex than what is being propounded, but fortunately for the majority, the presentation is fairly typical such as the Most Common Pattern. If interested in more you can find more at the Hesch Institute web site. Snake oil or purple kool aide $$$ dunno but we can be much more thorough in testing and treating and much more honest in the information we give to desperate clients. It is a choice we (as clinicians) can make. (18/2/06 3:59 am)
Jerry's Reply Cuboid Good answers re the topic of cuboid syndrome. I have treated this for 2 decades, so I have some thoughts. I intended to submit a letter to the editor after the article cited earlier in JOSPT in 2005, but never did. In my opinion, there are essentially 2 basic types of cuboid syndrome. I do not believe that this has been adequately addressed in the literature. For convenience I am going to name one type a TYPE I CUBOID SYNDROME and the other a TYPE II CUBOID SYNDROME. Type I can be symptomatic or asymptomatic. It responds beautifully to a manipulation of the cuboid, and the cuboid alone. If painful, the pain resolves very quickly and the treatment is repeated if necessary, 1 or 2 times. Client and clinician are both happy. Recovery is quick. Basically the cuboid fixation is the key lesion in the foot and ankle complex and restoring mobility directly to the cuboid makes for significant improvement. Sometimes there is a pattern that appears to involve several other structures in the foot and ankle, yet the manipulation performed only at the cuboid, is almost magical. Retesting the other motion fixations reveals that they are also remarkably improved and they do not require treatment. I affectionately and metaphoriclly refer to the cuboid as "1/2 of a keystone." It has no lateral structure to articulate with, as it is the most lateral of that row of mid foot bones. When it subluxes laterally with foot and ankle in inversion, there is much to hold it out there, the articulating lateral cunieform and the articulating calcaneus. The navicular also articulates with the cuboid, and the 4th and 5th metatarsals proably play a rather minor role. It is very helpful to have a foot and ankle model that includes the whole foot and a short portion of the distal tibia and fibula, of course talus and calcaneus included. Take apart the joint leaving the forefoot, the cuneoforms, the navicular and the cuboid as one and the talus and calcaneus are seperate (as is their attachment to the distal tibia and fibula. It is so helpful to learning, to have this semi-disarticulated model in hand. You can put the pieces together and observe how the bones interact. It should be easy to perceive how the cuboid is "out there by itself" being most lateral and it is easy to see how it could be elevated (vertical axis) and laterally rotated about an A-P axis, remaining stuck in an inversion injury. The cuboid can be palpated and compared to the unaffected side. Typically it is more prominent on the painful side and inferior glide spring testing and "pronatory" spring testing reveal fixation (and discomfort). I do not believe that one can NOT accurately perform a superior glide spring test due to thickness of the soft tissue on the plantar surface of the foot. The typical manipulation is opposite to the way I prefer to mobilize it. The typical manipulation involves a superior thrust from the plantar surface of the foot, see details in other post, below. The typical manipulation appears to enhance the lesion - yet gap the joint and I believe that it recoils back to normal position. I prefer to mobilize it with progressive inferior glide (dorsal to plantar direction)and add medial rotation mobilization, while I attempt to "create space" and coax it back by taking the navicular and the cuboids into medial glide and medial rotation. Now a description of what I conveniently refer to as TYPE II CUBOID SYNDROME. This can be symptomatic or asymptomatic, with all grades in between from acute to chronic. The difference is that a supinatory pattern of the foot and ankle complex has set in and efforts to mobilize only the cuboid will fail miserably, will not provide that quick fix, described earlier. Instead, you have to treat all major articulations and this is where we get into some controversy. This same pattern is commonly encountered in recurrent ankle sprains. I find restrictions (in the oppsite directions) and restore mobility in the following directions: MAJOR MOTIONS OF THE FOOT AND ANKLE:
Sometimes just before the final mob to the calcaneus I will evaluate and treat if needed, medial glide to the talus working through the distal fibula and just below it as well. After all of the above I go into a weight-bearing context and adress those motions that I can - if I find them to be restricted in weight bearing, such as distal tibia rotation, calcaneal valgus, etc. I teach the client to internally rotate from hip down to distal tibia and gently, repeatedly self-mobilize into pronation 30-100 reps, daily for a week and then as needed. There are other flavors in which there is enough laxity in the ligaments that the above is not effective, fortunatley these are in the minority and I am not referrring to this sub-population is this commentary. There is a great need for more research on the above topic and I think that our profession does not typically look at structures as patterns of motion dysfunction. The Cuboid Syndrome a perfect example in which only one dysfunctional structure (the cuboid) is mentioned and only mobilization to that singular structure is described. I have made a case for Type II Cuboid Syndrome being a much more complex pattern that requires a dozen or more sequential mobility screens and treatment with mobilization. Terms like hypermobility and hypomobility get tossed around in the literature without adequate clarification, without explaining in detail, the tests are used with the cuboid. I am delighted to announce a significant enhancement to the graphics in the 190 page Hesch Method lumbopelvic workshop. It will go to print tomorrow but will continue the grueling process to make many enhancements.
We are in the planning stages of a tutorial of hands-on learning in Las Vegas last week in April. Two day 6 hours each, covering all major articulations toes to nose, TMJ so "top of nose". TBA. Will limit enrollment to 6.
Hi Jerry,
Thanks for your final article. We will need to make it a two part article. Do you have a preference where it should be split in two? Just some feedback I received about your work via one of our Australian members via our Facebook page: "Hi - I have had PGP for four years. I am slowly making sense of it as I navigate through life, two toddlers and a two storey house. I have just spoken to my specialist about Jerry Hesch and she said that she has a patient who went to the US to see him and was happy with the results. My specialist has referred me to another specialist who knows of Jerry's work and if anyone in Australia practises his method." I know how lovely it is to get feedback sometimes! I works as a primary care nurse (Family & Child Health & General Practice) and my husband is a doctor (Family Medicine). Thanks for being a member of our association. Kind regards, Jess Pelvic Instability Association Inc (PIA) PO BOX 449 Bentleigh, VIC 3204 PH: (61-3) 9539 3217 (Message-bank) www.pelvicinstability.org.au "Nice compliment.
After having some big setbacks and flare-ups in the last month I decided to go see Jerry Hesch near Las Vegas. I saw him over three days and he was full of information for me. My sacrum was completely stuck out of place by the time I got there which was good because he could see my full dysfunction; he saw me at my worst! He evaluated me from foot to head and corrected my pelvis/sacrum. I finally have a name for my dysfunction: “bi lateral inflare of the illia” and “ posterior glide fixation of the sacrum”. He corrected it very gently and showed my husband how to do the correction. Jerry’s initial correction lasted five days, including one day of air travel, it has relapsed since, but because of the training we received we have been able to do the correction ourselves at home. On our first attempt, we weren’t quite getting it so Jerry walked my husband thru it on the phone. I can’t even tell you the relief I feel of knowing what is wrong and being able to correct it. None of those self corrections were ever totally working before. Even though I have had some good local people help me before, my main problem was never thoroughly diagnosed or addressed. Unfortunately, like a lot of you in the group I am hyper mobile all over so need to be careful. Jerry also addressed some stuck joints in my foot, shoulder and neck/sternum. He also did a lot of problem solving around a strange twist in my torso that I get when I lean forward. The first day he just said “I don’t know” and the second day he had me do all kinds of things to figure out where the heck it was coming from. It turns out my right hip joint is much looser than the left and this is causing the twist and is also making my right leg appear longer and my right illium higher in standing. (Jerry, correct me if i am not explaining right.) Jerry suggested I see a hip specialist but in the meantime gave me an exercise that may help it along with some other simple strengthening exercises and tips in doing daily activities. He also suggested trying a heel lift in the left shoe. He has a wealth of knowledge, but what is also impressive is that he has a lot of intellectual curiosity and great problem-solving skills. Instead of fitting my condition into his existing bag of tricks, he took the time to analyze a problem when he hits an unknown area or a sticking point. I would highly recommend him to anyone who doesn’t understand their dysfunction and wants a thorough evaluation from a thoughtful and analytical practitioner. The best part was that we never felt rushed like you do at a regular PT or doctor’s appointment. He is not a radiologist but also goes over your x-rays and MRI’s with you and examines them before you arrive. I am very glad I went and feel hopeful." |
Dr. Jerry Hesch, DPT, MHS, PTMarried with 4 grown kids. Earned my Doctorate at A.T. Still University in Tempe, AZ, MHS at the University of Indianapolis and my BS PT at University of New Mexico. I enjoy working with my hands and particularly making glass objet d'art. Powered by Calendar Labs Archives
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