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Pubic Bone DownslipTwo Part Lecture on Symphysis Pubis Diastasis |
Symphysis Pubis Discussions with Jerry Hesch, MHS, PT
Here are a few recent posts on the topic of hypermobility and diastasis (seperation) of the symphysis pubis. Also a recent x-ray study and later I will post some elaboration. Of note, the symphysis pubis is the first thing I treat, if movement dysfunction is noted. It is the first of 8 patterns of sequential movement dysfunctions in what I named The Most common Pattern of SIJ Dysfunction. The symphysis ubis and the sacrum are intimate indeed. If one is involved, the other is too. On rare occasions, the other will self-correct when you treat the primary, but most of the time both have to be treated for movement dysfunction. Dear Group,
A brutal presentation. This is in advance of reading the other replies.
Please let me know if you need any further clarification, pictures, etc. I am also available by phone.
Referral to home health care is probably a crap shoot, though a phone call to ask for a skilled therapist may be more successful. I know your phone time re care for this client already qualifies you for sainthood.
maybe reduced frequency of seeing you.
I am in complete agreement that a lower placement is much more appropriate for symphysis pubis separation than for SI, based on logic, anatomical location, etc. Surprisingly, one study negates that, but me agrees with you in this case.
I am concerned that the upslip pube may actually be a downslip pube on the opposite side, and again I advocate direct testing, gently gaining purchases above and below the pubic bone and performing the gentlest of passive motion tests, or better yet; creep. It in fact is the same as the treatment I use; creep with same purchase.
Alternately, a vertical support on the low side may be helpful.
If you get x-ray, and there is unique info re the SI joints, please let me know. I am skeptical that there will be any useful info, whether or not the SI joints are involved (they are). I summarily reject Dilman's radiographic analysis, even though it correlates with Hesch method of eval (Kramer poster presentation, elaboration upon request). I do have a copy of his out of print book on x-ray of the SI.
Please keep us posted.
Sincerely
Jerry Hesch, MHS, PT
Dear Group,
Another thought.
The pelvic belts provide circumferential support, and pressure =force/area. Thus there is a small force compressing the pubic joint medially.
the goal for healing is to compress the symphysis pubis, in addition to correcting any other dysfunction such as a vertical, A-P/P-A, rotational, while correcting dysfunction at SIJ and of course the other goals of pain, strength, proper body mechanics etc., etc. Re joint compression:
1. If a towel roll or foam roll (2-3" diameter x 8" long) is placed vertically directly on each PSIS with coverage above and below, it will encourage anterior glide and compress the ilia against the sacrum, enhancing SIJ stability. Perhaps 2 minutes or more to allow gentle creep. Client is supine. I can easily image how this could reduce the open-book phenomenon that would occurr posteriorly at the SIJ.
2. In sidelying the same towel roll or foam roller placed vertically just lateral to the ASIS with contact above and below, maintained 2 minutes or more to allow creep into medial compression of the symphysis pubis, via the weight bearing ilium, pushing the pube and ischium. Then repeat same on opposite side.
The unknown. Does significant separation cause a tendency for the pubic bones to migrate superiorly? Inferiorly? I appreciate that one may travel farther than the other. I think this is in the land of the unknown at present. How could we evaluate it on a case to case basis?
Jerry hesch
Dear Group,
I Had middle of the night additional thoughts.
The email replies seem to encourage flexion of the trunk, pelvis and hips and with some vertical force:
1. Navigating stairs in sitting, in which trunk, pelvis and hips are moderately flexed and weight bearing on the ishcial tuberosities-very close to the symphysis pubis-would impart a vertical force in flexion to the symphysis pubis.
2. Ascending stairs backwards, in standing. In addition to different use of muscle strategy, the trunk, pelvis and hips utilize flexion primarily. As I practice this, my knees do of course achieve extension to end-range, but my trunk and pelvis and hips do not.
I think this supports the belief that the pubes do migrate inferiorly, in addition to laterally with a significant separation. Additionally, the pregnancy also encourages the same with enhanced lordosis in some and anterior weight gain, etc.
This leads me to an exercise I believe to be relevant. Client supine with hips and knees flexed, feet flat. Client brings the left foot to rest just above the opposite knee where it will remain. With left hip and knee in a Patrick-Fowler position. She clasps the left knee with both hands and draws it towards the opposite shoulder and maintains that position for 2-5 minutes allowing creep. She repeats with the opposite side, repeats sequence x3. Holds times are relative to comfort. This exercise should traction the ilium at the ilio-femoral joint, and induce a vertical and medial force to the symphysis pubis. The oblique vector can be reduced to a medically directed force and a vertically directed force. I practiced and using palpation i remain quite confident that the above forces do in fact impact the symphysis pubis.
I can easily visualize how the SI joints participate in this "open book lesion". This exercise would bring the ilia away from the sacrum, in direct apposition to what the separation induced.
I have concern regarding an apparent vertical pubic bone. I am concerned that it is simply a matter of degree and that both still need to move superiorly and medially. Thus any attempt to move it inferiorly would probably be meet with more pain and greater dysfunction. A gentle superior force could be tested using contact on inferior pubic bone.
If anyone should try the above exercise with this type of presentation, please share your results. As Jill stated, there is very little research publication to guide us.
I hope this is additive.
Sincerely,
Jerry Hesch
[email protected]
Article: Single-Leg-Stance (Flamingo) Radiographs to Assess Pelvic Instability: How Much...
Garras et al. J Bone Joint Surg Am.2008; 90: 2114-2118
The following is actually the poster presentation, I do not have the above published article, but wanted to reference it. soon, the abstract will be available online.
2007 AAOS Annual Meeting Poster Presentations Single-leg stance (flamingo) radiographs to assess pelvic instability: how much motion is abnormal? Poster Presentation Number: P470
Location: San Diego Convention Center, Sails Pavilion
Trauma
Joshua Tolbert Carothers, MD Albuquerque NM (n)
Steven A Olson, MD Durham NC (n)
David N Garras, MD Philadelphia PA (n)
This study provides acceptable total translation values in healthy, non-pathologic subjects as measured on flamingo AP pelvis radiographs described by Chamberlain.
Pelvic instability is an uncommon cause of pelvic/back pain. Chamberlain advocated measuring the translation in position of the pubic bones on alternating right and left single-leg stance AP Pelvis radiographs (flamingo views) but did not describe normal values. We hypothesized that multiparous females will have greater motion than nulliparous females or males in patients without pelvic pathology.
45 patients (15 males, 15 multiparous, and 15 nulliparous females, mean age 31.8 years) were evaluated with three standing AP pelvic radiographs (two leg stance, right and left flamingo views). Patients completed a questionnaire to determine appropriateness of participation and an examination to exclude certain physical anomalies (limb-length discrepancy, gait abnormality). Total translation (TT) was measured by 3 blinded observers.
Inter-observer correlation was 0.89-0.95 between observers. The mean total pubic translation was 1.4mm (SD1.0), 1.6mm (SD0.8), and 3.1mm (SD1.5) for males, nulliparous, and multiparous females, respectively. There was no significance between males and nulliparous females (p,0.63). Multiparous females had significantly more translation from nulliparous females (p,0.002) and males (p,0.0005). There was significance between the number of pregnancies and TT (p,0.0001). No significance was found for smoking or age, but we had a small sample of smokers (6).
Our findings support Chamberlain's result and provides normal population measurements of pubic motion. As expected, multiparous females have greater pubic motion than nulliparous females and males. This laxity increases with the number of pregnancies.
Pubic Symphysis Q & A
These are questions and answers that I provided to a list serve on the topic of Symphysis Pubis Pain and Dysfunction, Primary related to pregnancy. Carrie, had middle of the night additional thoughts.
The email replies seem to encourage flexion of the trunk, pelvis and hips and with some vertical force:
1. Navigating stairs in sitting, in which trunk, pelvis and hips are moderately flexed and weight bearing on the ischial tuberosities-very close to the symphysis pubis-would impart a vertical force in flexion to the symphysis pubis.
2. Ascending stairs backwards, in standing. In addition to different use of muscle strategy, the trunk, pelvis and hips utilize flexion primarily. As I practice this, my knees do of course achieve extension to end-range, but my trunk and pelvis and hips do not.
I think this supports the belief that the pubes do migrate inferiorly, in addition to laterally with a significant separation. Additionally, the pregnancy also encourages the same with enhanced lordosis in some and anterior weight gain, etc.
This leads me to an exercise I believe to be relevant. Client supine with hips and knees flexed, feet flat. Client brings the left foot to rest just above the opposite knee where it will remain. With left hip and knee in a Patrick-Fowler position. She clasps the left knee with both hands and draws it towards the opposite shoulder and maintains that position for 2-5 minutes allowing creep. She repeats with the opposite side, repeats sequence x3. Holds times relative to comfort. This exercise should traction the ilium at the ilio-femoral joint and induces a vertical and medial force to the symphysis pubis. The oblique vector can be reduced to a medically directed force and a vertically directed force. I practiced and using palpation I remain quite confident that the above forces do in fact impact the symphysis pubis.
I can easily visualize how the SI joints participate in this "open book lesion". This exercise would bring the ilia away from the sacrum, in direct apposition to what the separation induced.
I have concern regarding an apparent vertical pubic bone. I am concerned that it is simply a matter of degree and that both still need to move superiorly and medially. Thus any attempt to move it inferiorly would probably be meet with more pain and greater dysfunction. A gentle superior force could be tested using contact on inferior pubic bone.
If anyone should try the above exercise with this type of presentation, please share your results. As Jill stated, there is very little research publication to guide us.
I hope this is additive.
Sincerely,
Jerry Hesch
[email protected]
702-558-6011
www.heschinstitute.com
Carrie,
Another thought.
The pelvic belts provide circumferential support, and pressure =force/area. Thus there is a small force compressing the pubic joint medially.
the goal for healing is to compress the symphysis pubis, in addition to correcting any other dysfunction such as a vertical, A-P/P-A, rotational, while correcting dysfunction at SIJ and of course the other goals of pain, strength, proper body mechanics etc., etc. Re joint compression:
1. If a towel roll or foam roll (2-3" diameter x 8" long) is placed vertically directly on each PSIS with coverage above and below, it will encourage anterior glide and compress the ilia against the sacrum, enhancing SIJ stability. Perhaps 2 minutes or more to allow gentle creep. Client is supine. I can easily image how this could reduce the open-book phenomenon that would occur posteriorly at the SIJ.
2. In side lying the same towel roll or foam roller placed vertically just lateral to the ASIS with contact above and below, maintained 2 minutes or more to allow creep into medial compression of the symphysis pubis, via the weight bearing ilium pushing the pube and ischium. Then repeat same on opposite side.
The unknown. Does significant separation cause a tendency for the pubic bones to migrate superiorly? Inferiorly? I appreciate that one may travel farther than the other. I think this is in the land of the unknown at present. How could we evaluate it on a case to case basis?
Jerry Hesch
Carrie,
A brutal presentation. This is in advance of reading the other replies.
Please let me know if you need any further clarification, pictures, etc. I am also available by phone.
Referral to home health care is probably a crap shoot, though a phone call to ask for a skilled therapist may be more successful. I know your phone time re care for this client already qualifies you for sainthood.
Maybe reduced frequency of seeing you.
I am in complete agreement that a lower placement is much more appropriate for symphysis pubis separation than for SI, based on logic, anatomical location, etc. Surprisingly, one study negates that, but me agrees with you in this case.
I am concerned that the upslip pube may actually be a downslip pube on the opposite side, and again I advocate direct testing, gently gaining purchases above and below the pubic bone and performing the gentlest of passive motion tests, or better yet; creep. It in fact is the same as the treatment I use; creep with same purchase.
Alternately, a vertical support on the low side may be helpful.
If you get x-ray, and there is unique info re the SI joints, please let me know. I am skeptical that there will be any useful info, whether or not the SI joints are involved (they are). I summarily reject Dilman's radiographic analysis, even though it correlates with Hesch method of eval (Kramer poster presentation, elaboration upon request). I do have a copy of his out of print book on x-ray of the SI.
Please keep us posted.
Sincerely
Jerry Hesch, MHS, PT
702-558-6011 Pacific Time
www.heschinstitute.com
From:
Sent: Saturday, July 19, 2008 9:09 AM
Subject: Re: coccyx pain post delivery
Stephanie,
You have got some good tips so far. One thing that I have found pivotal to alleviating coccyx pain is ensuring that the pelvic floor is treated--Trigger points released and PFM strengthened, especially after delivery. I find that coccyx mobs are not very helpful unless done soon after trauma to coccyx. In terms of modalities I have found good-old US and EStim to be very helpful.
Hi Susan,
Thank you for reply Susan,
I thought I should share how to treat as a start between now and when you access the info on the Most Common Pattern.
To treat the pattern of posterior pube, client is supine with legs straight, a 2.5" (6cm) foam roll or firmly rolled towel is placed horizontally, beneath the ischium, just above the ischial tuberosity, where the ischium is relatively flat. Take care not to encompass the sacrum.
For a true posterior glide of the pubic bone (palpable step-off going across from the right to left pubic bones) clients remains for 5 minutes.
For the postural pattern, 2 minutes should suffice. This produces an anterior glide force to the ischium and pubic bone on that side, via creep.
Retest, and then go on to treat sacrum if involved and then the rest of the Most Common Pattern.
With either pattern the ischium will be posterior/prominent in prone and will lack P-A spring. Sacrotuberous ligament oftentimes will be hypertonic and I think there are implications for the many structures within the sciatic notch, the pudendal nerve, etc. After treatment the ischium should be normal re palpation and spring.
Jerry Hesch
It would be nice if you would palpate the sacrum before and after addressing the pube shift and share your findings. It is possible that a) sacrum will initially be symmetrical, but after correcting the pube, will rotate left about a vertical axis b) be symmetrical before and after pube correction, or c) other (?).
If the pelvis as a unit is rotated (in which greatest rotation is apparent at the lower pelvis, then the left pubic bone will appear to be posterior, but the palpatory eval will be different than that of a true bony shift at symphysis. Taking your index finger from the right pube, across the fibrocartilage onto left pubic bone will be as though you are sliding down an inclined plane.
However, if a true pubic bone shift, there will be a discernable step-off going from the right pubic bone onto the left, and this step-off will resolve after treatment.
Regardless of which scenario is present, the treatment is the same. I will defer explanation at this time because there is a sequence of permutations that occur. This is covered thoroughly in Chapter 42 The Most Common Pattern of SIJD in Movement Stability and LBP: The Essential Role of the Pelvis, Vleemng et al 1997 Churchill Livingstone. It is an expensive text, but inter-library loan is a good way to go.
I cover other (rare) types of lower pelvic dysfunction elsewhere, so if the above does not adequately resolve this person's presentation, please let me know.
Please let me know if you have any questions and if conversation format more helpful we can schedule that.
Please keep us posted. Info on the possible permutation of the sacrum would be very informative.
Sincerely,
Jerry Hesch, MHS, PT
www.heschinstitute.com
From:
Sent: Monday, March 03, 2008 7:45 AM
Subject3/3/08
Hi Everybody,
I know I ask a lot of question but I have another one. I apologize in advance for the long, detailed patient history.
This question is about another IC patient. I have only seen her twice. Pain started in 1999 with a bladder infection. Her c.c. is pain in the bladder region. It's there all the time and doesn't fluctuate in intensity. She also has pain that lasts for approximately 5-10 minutes after having a BM. She does not have any LBP, vulvar, or vaginal pain. She is 52 years old and her last menstrual period was 4 years ago. She has never been pregnant and pelvic/abd surgeries include cystoscopy with hydrodistension in 2000, removal of uterine fibroids 2001, and gall bladder tests (?) in 2001. She has a good diet and good fluid intake. She is hypothyroid. She has tried Elavil, Elmiron, and Lyrica but most tx has been Narcotics. She takes Darvocet 4x/day, Kadian 3x/day, and 300 mg of Lyrica. She has tried Opana and Duragesic patch on a rotating schedule. She is having urinary retention and constipation at least partially related to her pain meds. She does not have urinary urgency or frequency. She started renting a TENS unit on her own just before starting to see me but it isn't helping. I've tried interferential with moist heat with her and she reports feeling very relaxed but it doesn't change her pain. I also showed her different electrode placements for the TENS unit.
Trunk AROM is WNL's. Repeated movements are ok. The only external trigger or tender point that I can elicit is in her left Psoas. In standing, she has a right frontal plane asymmetry, left foot pronation, hypertonus of the lumber and lower thoracic paraspinals, no scoliosis, anterior pelvic tilt, and she is forward bent. Pelvic alignment was different on her first and second visits. On the first visit (lying down), the medial malleoli were level, the left ASIS was elevated, the left pube was slightly elevated and posterior, and she had a positive standing forward bend test on the left side. On the second visit (this past Friday), the right medial malleolus was elevated, the left pube remained posterior but level in the frontal plane, and the right and left PSIS were level. She has no external PFM trigger points. The only internal (vaginal) TP I could elicit was in the left periurethral muscles at the level of the PIP. She reported abdominal cramping after TPR to that area. I have not done a rectal exam yet but plan to. I also haven't evaluated her L-spine as much as I could and plan to.
Just one more comment. I think she may have Lichens Sclerosis around the perineal body and have told her to make an appointment with her gyn to evaluate this. Her HEP right now includes hamstring, piriformis, and quadriceps stretches.
So, here's my question - Does anyone have ideas about what is going on with her pelvis, esp. the left posterior pube? I know how to correct a depressed or elevated pube but am not sure what to do about a posterior pube.
Thank you in advance for any suggestions,
Susan
Thank you for reply Susan,
I thought I should share how to treat as a start between now and when you access the info on the Most Common Pattern.
To treat the pattern of posterior pube, client is supine with legs straight, a 2.5" (6cm) foam roll or firmly rolled towel is placed horizontally, beneath the ischium, just above the ischial tuberosity, where the ischium is relatively flat. Take care not to encompass the sacrum.
For a true posterior glide of the pubic bone (palpable step-off going across from the right to left pubic bones) clients remains for 5 minutes.
For the postural pattern, 2 minutes should suffice. This produces an anterior glide force to the ischium and pubic bone on that side, via creep.
Retest, and then go on to treat sacrum if involved and then the rest of the Most Common Pattern.
With either pattern the ischium will be posterior/prominent in prone and will lack P-A spring. Sacrotuberous ligament oftentimes will be hypertonic and I think there are implications for the many structures within the sciatic notch, the pudendal nerve, etc. After treatment the ischium should be normal re palpation and spring.
Jerry Hesch
Shirlene and Group,
Just read my post and wanted to add that medial compression of the ilium on sacrum can also be helpful in the latter stages, after achieving anterior glide as previously described.
Client supine, towel roll vertical under the lateral buttock, 2 - 5 minutes.
Leave towel roll there, client in sideling at 30 degree angle 2-5 minutes and then at 60 degrees 2- 5 minutes.
These are all appropriate to teach for home program, hard to get through all in one clinical visit.
jh
From: Jerry Hesch, MHS jerry Hesch, MHS
To:
Sent: Wednesday, November 28, 2007 11:59 AM
Subject: Re: Sheared Symphysis Pubis
Dear Shirlene and Group,
Do you know how wide the symphyseal diastasis is?
Duke University has posted on surgical correction for severe symphyseal diastasis, but of course we all try to promote natural healing.
The pelvis is of course designed for stability and when one does achieve appropriate form closure, the joint mechanoreceptors are significantly quieted in terms of muscular inhibition, pain etc.
The symphysis pubis is inextricably linked to the SIJ's so any answer will be incomplete.
There is not adequate literature to guide us in the acute phase of these presentations.
If you think of it as "an open book" spread of the symphysis that may give some understanding for the following suggestions:
1. create 2 firmly rolled towels of 2"-2-1/2" diameter, by 8" length or cut 2 foam rolls.
2. place them laterally under each ischium, just above the ischial tuberosities, client supine 5 minutes if tolerated, stop this and all other efforts if painful. This will glide the ischia anteriorly and might enhance approximation.
3. place the rolls vertically under each ilium, as lateral as you can, client supine, same time.
4. progressively place the rolls medially with final position being just lateral and slightly on the PSIS', with 1/2 of roll above and 1/2 below the PSIS. This will glide the ilia anteriorly and will capture" the sacrum and have same effect. Same time frames.
5. client sideling on roll placed on or just above the trochanters. This will enhance medial glide of the pubic bone. Repeat on the other side, same time length. You can add a weight to the pelvis on the side facing up.
6. Any SI support used can be worn for a short period of time directly on the trochanters, or just above and this greatly enhances the medial compression of the symphysis pubis, whereas when worn higher, primarily effects the SIJ. This can be worn when resting, and if not too tight can even be tolerated when walking, and will certainly reduce abduction.
7. Hopefully, gentle strengthening can be progressed over time. There is an anecdotal case of spontaneous reduction when performing isometric exercise.
8. Ongoing screening is appropriate as the pelvis by its very nature undergoes several permutations. One somewhat common pattern with big babies is a posterior glide fixation of sacrum.
I will close for now. Please keep us posted on the progress and if need for clarification, I am happy to do so by phone or e-mail.
Maybe in 100 years we will have adequate research publication on all facets of the complexity of the pelvis/SIJ/symphysis pubis.
Sincerely,
Jerry H
From:
Sent: Wednesday, November 28, 2007 10:59 AM
Subject: RE: Sheared Symphysis Pubis
If the patient can manage it, an assistive device to decrease lower extremity weight bearing can be helpful. Sometimes mom's use the Baby Bjorn system so they are carrying baby in a sling like device on the front or back. This allows the patient to normalize ambulation in a partial weight bearing position and then she can gradually increase stride length and full weight bearing. Even if she can use a walker/crutches part of the time, this can help.
Otherwise, I agree with everything Erin had to contribute.
Carrie
From:
Sent: Wednesday, November 28, 2007 4:58 AM
To:
Subject: ReSheared Symphysis Pubis
Hi All,
Can anyone help me with experience of treating a sheared symphysis pubis (split)? I may not have the correct term. The patient is 36y/o female who gave birth to a more than 10lb baby 1 month ago. Split of symphysis pubis evident on X-Ray. She has pubic pain and difficulty walking. How long shall we expect before this will heal. I am treating with MFR and energy work (to balance the upslip of pelvis) and Ultrasound. She also has a diastasis which we are addressing. Any insights appreciated.
Shirlene
Chrissy,
It is unclear re position of pubic bones relative to each other. If left is
posterior relative to the right, that is a common cause of adductor
tendon/proximal soft tissue tenderness. A firmly rolled towel 2.5" diameter
under same sided ischium (client supine, hips and knees in neutral) placed
horizontally for 5 minutes will restore normal apposition, and decrease
pain.
Otherwise, maybe she has old-fashioned adductor tendonitis?
If the A-P divot of the fibrocartilage represents a posterior glide of the
fibrocartilage as opposed to normal anatomy; it will be quite tender with
gentle A-P pressure at midline such as with your 5th metacarpal less than
10# force (can practice on bathroom scale). Treatment is same as in the
above example except that it is done with towel rolls bilateral for 5
minutes, repeated prn.
A good rest position for anyone at this stage of pregnancy is actually same
as rx for bilateral anterior ilium-in which symmetry is the norm,
Sacrotuberous ligaments are tight, palpation reveals both ASIS much lower
than PSIS per her norm, age and body type norms and a fair assumption given
the anterior weight she is carrying. In standing, sitting, supine or
sideling, she approximates right bent knee to outside the right axilla for
2-5 minutes repeated a few times a day and same on left side. see picture
below.
This posture/pattern does overload ilio psoas and adductors, alters resting
length and MIGHT explain her bilateral sx.
BILATERAL ANTERIOR ILIUM
Bilateral anterior ilium is common with an anterior pelvic tilt and
increased lordosis. Realize that anterior pelvic tilt is only a positional
description, whereas bilateral anterior ilium is not so much a positional
description as a bilateral mobility dysfunction. Bilateral anterior ilium
may become apparent after correcting a unilateral dysfunction (one or
several components of the most common pattern). After correcting a
unilateral dysfunction, such as what appears to be a unilateral anterior
ilium the pelvis will appear symmetrical. Upon performing the spring tests
to reevaluate mobility, one may realize that there is a bilateral mobility
dysfunction which might not have been readily apparent earlier. This is a
common phenomenon; the pelvis tends to undergo serial permutations until the
dysfunction(s) is/are ultimately resolved. Flexion exercises are very
appropriate with this population. This includes stretching the spinal
extensors, Psoas, iliacus, rectus femoris, ITB, TFL, hamstrings and
gastroc-soleus muscle groups. Strengthening the spinal flexors and hip
extensors is very appropriate.
Positional Dysfunction: Anterior tilted pelvis. The ASIS's are lower that
the PSIS's and they are anterior to the pubic tubercles as tested in supine.
Movement Dysfunction: Reduced posterior mobility, as tested in supine.
Increased anterior mobility.
Treatment: The same as for unilateral anterior ilium, except that it is
performed bilaterally.
Retest: Retest mobility with appropriate spring test. After pattern is
resolved test for pelvic side-glide dysfunction.
Home Program: 1-2x days x 1 week, 2x week thereafter.
SPRING TESTS
Hypomobile Hypermobile
Mandatory Spring Tests
Supine
*1. Bilateral Posterior Rotation of the Anterior Ilium. (page ).
x
SELF TREATMENT FOR BILATERAL ANTERIOR ILIUM
Patient: Use self treatment for anterior ilium on each side for two minutes,
switch sides and repeat once.
Alternate treatment method: Use any of the treatment approaches described
earlier for right anterior ilium in the most common pattern treat the left
side also.
Retest: Retest mobility with appropriate spring test.
Home Program: 1-2x days x 1 week, 2x week thereafter.
Please let me know if you need any clarification and it would be nice to
know final findings/outcome. Thank you.
Jerry Hesch, MHS
From: "Christine >
Sent: Thursday, March 22, 2007 1:13 PM
Subject: RE: Pubic symphysis pain
I feel I can rule out hip pathology - no pain with passive movement or
overpressure or scour, posterior provocation tests are negative and I feel
also I can rule out SI involvement also, as standing flexion, knee to chest
and palpation tests do not reveal any alignment issues (as of today, this
was a problem on evaluation).
Initially she had severe pain with active hip flexion, especially when the
adductor was biased, especially with walking and lower body ADL's. This has
improved significantly but pain is still reproducible with resistance
testing hip flexion on the left AND the right.
She still has palpable pain at the adductor insertion and on the L side of
the symphysis. When I palpate across the top, I feel the symphysis are
level right and left and I feel a dip where I assume the cartilage lies -
anteriorly and superiorly to the bones themselves. She is tender on the
left in this area.
She has no numbness, tingling or loss of sensation around the pelvis or
lower extremities, and no pain along the inguinal ligament, just at the
tubercle.
Thanks for the ideas everyone - - -
Chrissy
From: jerry Hesch, MHS
Sent: Thu 3/22/2007 2:20 PM
To:
Subject: Pubic symphysis pain
Chrissy,
To evaluate the ilioinguinal nerve, scratch the skin just lateral to the
ASIS, as there is a sensory branch there. As stated in earlier posts there
can be normal sense of touch (yes I feel that) but with an enhanced
discomfort (allodynia) or enhanced abnormal sensation such as provoking
tingling, waterfall sensation, referred sx (dysesthesia) thus asking if it
is felt can be enhanced with does this provoke any unusual sensation or
pain. Follow that along with pressure along the inguinal ligament all the
way to the pubic tubercle, and if tender could indicate ilioinguinal
neuropathy, tenderness from subtle SI/symphysis dysfunction, muscle pull,
hernia, or any medical condition that impacts the T12-L1-L2 segments give or
take 1 segment.
In the subject line you list symphysis pain. If you palpate the top of each
pubic bone (crest) allowing 1/4" space in the midline, what do you find?
If you palpate along the entire length of the pubic bones, how do they
compare?
If you move your index finger across from one pubic bone to the other, what
do you feel with respect to the fibrocartilage? In other words, is the
fibrocartilage equal to pube bone, or forward or posterior-and if so, by how
much would you estimate?
Good news-the palpatory findings at the symphysis correlate very nicely with
passive motion tests and therefore I do not teach spring tests at the
symphysis pubis.
Also, does any of the pube/fibrocartilage palpation provoke tenderness?
There are a few thoughts rattling in my head but will leave it here for now.
Sincerely,
jerry h
From: "Christine >
Sent: Thursday, March 22, 2007 9:25 AM
Subject: Pubic symphysis pain
I have an obstetric patient, 28 weeks along, who came to me with L groin
pain. She has responded well to muscle energy techniques to correct an
iliac Inflare on the L and her previous symptoms of pain with standing,
walking, and lifting the left leg have all but resolved. The one persisting
symptoms, and most aggravating, is the L groin pain when she is sideling.
Any pelvic compression aggravates this symptom, which is also becoming as
much of a problem in right sideling. She is following a stretching and
pelvic stability program and sleeps with an adductor pillow, but her sleep
continues to be disturbed. Manual therapy is my weak point - so I am sure
there is something I am missing. Any ideas would be helpful.
Chrissy
A brutal presentation. This is in advance of reading the other replies.
Please let me know if you need any further clarification, pictures, etc. I am also available by phone.
Referral to home health care is probably a crap shoot, though a phone call to ask for a skilled therapist may be more successful. I know your phone time re care for this client already qualifies you for sainthood.
maybe reduced frequency of seeing you.
I am in complete agreement that a lower placement is much more appropriate for symphysis pubis separation than for SI, based on logic, anatomical location, etc. Surprisingly, one study negates that, but me agrees with you in this case.
I am concerned that the upslip pube may actually be a downslip pube on the opposite side, and again I advocate direct testing, gently gaining purchases above and below the pubic bone and performing the gentlest of passive motion tests, or better yet; creep. It in fact is the same as the treatment I use; creep with same purchase.
Alternately, a vertical support on the low side may be helpful.
If you get x-ray, and there is unique info re the SI joints, please let me know. I am skeptical that there will be any useful info, whether or not the SI joints are involved (they are). I summarily reject Dilman's radiographic analysis, even though it correlates with Hesch method of eval (Kramer poster presentation, elaboration upon request). I do have a copy of his out of print book on x-ray of the SI.
Please keep us posted.
Sincerely
Jerry Hesch, MHS, PT
Dear Group,
Another thought.
The pelvic belts provide circumferential support, and pressure =force/area. Thus there is a small force compressing the pubic joint medially.
the goal for healing is to compress the symphysis pubis, in addition to correcting any other dysfunction such as a vertical, A-P/P-A, rotational, while correcting dysfunction at SIJ and of course the other goals of pain, strength, proper body mechanics etc., etc. Re joint compression:
1. If a towel roll or foam roll (2-3" diameter x 8" long) is placed vertically directly on each PSIS with coverage above and below, it will encourage anterior glide and compress the ilia against the sacrum, enhancing SIJ stability. Perhaps 2 minutes or more to allow gentle creep. Client is supine. I can easily image how this could reduce the open-book phenomenon that would occurr posteriorly at the SIJ.
2. In sidelying the same towel roll or foam roller placed vertically just lateral to the ASIS with contact above and below, maintained 2 minutes or more to allow creep into medial compression of the symphysis pubis, via the weight bearing ilium, pushing the pube and ischium. Then repeat same on opposite side.
The unknown. Does significant separation cause a tendency for the pubic bones to migrate superiorly? Inferiorly? I appreciate that one may travel farther than the other. I think this is in the land of the unknown at present. How could we evaluate it on a case to case basis?
Jerry hesch
Dear Group,
I Had middle of the night additional thoughts.
The email replies seem to encourage flexion of the trunk, pelvis and hips and with some vertical force:
1. Navigating stairs in sitting, in which trunk, pelvis and hips are moderately flexed and weight bearing on the ishcial tuberosities-very close to the symphysis pubis-would impart a vertical force in flexion to the symphysis pubis.
2. Ascending stairs backwards, in standing. In addition to different use of muscle strategy, the trunk, pelvis and hips utilize flexion primarily. As I practice this, my knees do of course achieve extension to end-range, but my trunk and pelvis and hips do not.
I think this supports the belief that the pubes do migrate inferiorly, in addition to laterally with a significant separation. Additionally, the pregnancy also encourages the same with enhanced lordosis in some and anterior weight gain, etc.
This leads me to an exercise I believe to be relevant. Client supine with hips and knees flexed, feet flat. Client brings the left foot to rest just above the opposite knee where it will remain. With left hip and knee in a Patrick-Fowler position. She clasps the left knee with both hands and draws it towards the opposite shoulder and maintains that position for 2-5 minutes allowing creep. She repeats with the opposite side, repeats sequence x3. Holds times are relative to comfort. This exercise should traction the ilium at the ilio-femoral joint, and induce a vertical and medial force to the symphysis pubis. The oblique vector can be reduced to a medically directed force and a vertically directed force. I practiced and using palpation i remain quite confident that the above forces do in fact impact the symphysis pubis.
I can easily visualize how the SI joints participate in this "open book lesion". This exercise would bring the ilia away from the sacrum, in direct apposition to what the separation induced.
I have concern regarding an apparent vertical pubic bone. I am concerned that it is simply a matter of degree and that both still need to move superiorly and medially. Thus any attempt to move it inferiorly would probably be meet with more pain and greater dysfunction. A gentle superior force could be tested using contact on inferior pubic bone.
If anyone should try the above exercise with this type of presentation, please share your results. As Jill stated, there is very little research publication to guide us.
I hope this is additive.
Sincerely,
Jerry Hesch
[email protected]
Article: Single-Leg-Stance (Flamingo) Radiographs to Assess Pelvic Instability: How Much...
Garras et al. J Bone Joint Surg Am.2008; 90: 2114-2118
The following is actually the poster presentation, I do not have the above published article, but wanted to reference it. soon, the abstract will be available online.
2007 AAOS Annual Meeting Poster Presentations Single-leg stance (flamingo) radiographs to assess pelvic instability: how much motion is abnormal? Poster Presentation Number: P470
Location: San Diego Convention Center, Sails Pavilion
Trauma
Joshua Tolbert Carothers, MD Albuquerque NM (n)
Steven A Olson, MD Durham NC (n)
David N Garras, MD Philadelphia PA (n)
This study provides acceptable total translation values in healthy, non-pathologic subjects as measured on flamingo AP pelvis radiographs described by Chamberlain.
Pelvic instability is an uncommon cause of pelvic/back pain. Chamberlain advocated measuring the translation in position of the pubic bones on alternating right and left single-leg stance AP Pelvis radiographs (flamingo views) but did not describe normal values. We hypothesized that multiparous females will have greater motion than nulliparous females or males in patients without pelvic pathology.
45 patients (15 males, 15 multiparous, and 15 nulliparous females, mean age 31.8 years) were evaluated with three standing AP pelvic radiographs (two leg stance, right and left flamingo views). Patients completed a questionnaire to determine appropriateness of participation and an examination to exclude certain physical anomalies (limb-length discrepancy, gait abnormality). Total translation (TT) was measured by 3 blinded observers.
Inter-observer correlation was 0.89-0.95 between observers. The mean total pubic translation was 1.4mm (SD1.0), 1.6mm (SD0.8), and 3.1mm (SD1.5) for males, nulliparous, and multiparous females, respectively. There was no significance between males and nulliparous females (p,0.63). Multiparous females had significantly more translation from nulliparous females (p,0.002) and males (p,0.0005). There was significance between the number of pregnancies and TT (p,0.0001). No significance was found for smoking or age, but we had a small sample of smokers (6).
Our findings support Chamberlain's result and provides normal population measurements of pubic motion. As expected, multiparous females have greater pubic motion than nulliparous females and males. This laxity increases with the number of pregnancies.
Pubic Symphysis Q & A
These are questions and answers that I provided to a list serve on the topic of Symphysis Pubis Pain and Dysfunction, Primary related to pregnancy. Carrie, had middle of the night additional thoughts.
The email replies seem to encourage flexion of the trunk, pelvis and hips and with some vertical force:
1. Navigating stairs in sitting, in which trunk, pelvis and hips are moderately flexed and weight bearing on the ischial tuberosities-very close to the symphysis pubis-would impart a vertical force in flexion to the symphysis pubis.
2. Ascending stairs backwards, in standing. In addition to different use of muscle strategy, the trunk, pelvis and hips utilize flexion primarily. As I practice this, my knees do of course achieve extension to end-range, but my trunk and pelvis and hips do not.
I think this supports the belief that the pubes do migrate inferiorly, in addition to laterally with a significant separation. Additionally, the pregnancy also encourages the same with enhanced lordosis in some and anterior weight gain, etc.
This leads me to an exercise I believe to be relevant. Client supine with hips and knees flexed, feet flat. Client brings the left foot to rest just above the opposite knee where it will remain. With left hip and knee in a Patrick-Fowler position. She clasps the left knee with both hands and draws it towards the opposite shoulder and maintains that position for 2-5 minutes allowing creep. She repeats with the opposite side, repeats sequence x3. Holds times relative to comfort. This exercise should traction the ilium at the ilio-femoral joint and induces a vertical and medial force to the symphysis pubis. The oblique vector can be reduced to a medically directed force and a vertically directed force. I practiced and using palpation I remain quite confident that the above forces do in fact impact the symphysis pubis.
I can easily visualize how the SI joints participate in this "open book lesion". This exercise would bring the ilia away from the sacrum, in direct apposition to what the separation induced.
I have concern regarding an apparent vertical pubic bone. I am concerned that it is simply a matter of degree and that both still need to move superiorly and medially. Thus any attempt to move it inferiorly would probably be meet with more pain and greater dysfunction. A gentle superior force could be tested using contact on inferior pubic bone.
If anyone should try the above exercise with this type of presentation, please share your results. As Jill stated, there is very little research publication to guide us.
I hope this is additive.
Sincerely,
Jerry Hesch
[email protected]
702-558-6011
www.heschinstitute.com
Carrie,
Another thought.
The pelvic belts provide circumferential support, and pressure =force/area. Thus there is a small force compressing the pubic joint medially.
the goal for healing is to compress the symphysis pubis, in addition to correcting any other dysfunction such as a vertical, A-P/P-A, rotational, while correcting dysfunction at SIJ and of course the other goals of pain, strength, proper body mechanics etc., etc. Re joint compression:
1. If a towel roll or foam roll (2-3" diameter x 8" long) is placed vertically directly on each PSIS with coverage above and below, it will encourage anterior glide and compress the ilia against the sacrum, enhancing SIJ stability. Perhaps 2 minutes or more to allow gentle creep. Client is supine. I can easily image how this could reduce the open-book phenomenon that would occur posteriorly at the SIJ.
2. In side lying the same towel roll or foam roller placed vertically just lateral to the ASIS with contact above and below, maintained 2 minutes or more to allow creep into medial compression of the symphysis pubis, via the weight bearing ilium pushing the pube and ischium. Then repeat same on opposite side.
The unknown. Does significant separation cause a tendency for the pubic bones to migrate superiorly? Inferiorly? I appreciate that one may travel farther than the other. I think this is in the land of the unknown at present. How could we evaluate it on a case to case basis?
Jerry Hesch
Carrie,
A brutal presentation. This is in advance of reading the other replies.
Please let me know if you need any further clarification, pictures, etc. I am also available by phone.
Referral to home health care is probably a crap shoot, though a phone call to ask for a skilled therapist may be more successful. I know your phone time re care for this client already qualifies you for sainthood.
Maybe reduced frequency of seeing you.
I am in complete agreement that a lower placement is much more appropriate for symphysis pubis separation than for SI, based on logic, anatomical location, etc. Surprisingly, one study negates that, but me agrees with you in this case.
I am concerned that the upslip pube may actually be a downslip pube on the opposite side, and again I advocate direct testing, gently gaining purchases above and below the pubic bone and performing the gentlest of passive motion tests, or better yet; creep. It in fact is the same as the treatment I use; creep with same purchase.
Alternately, a vertical support on the low side may be helpful.
If you get x-ray, and there is unique info re the SI joints, please let me know. I am skeptical that there will be any useful info, whether or not the SI joints are involved (they are). I summarily reject Dilman's radiographic analysis, even though it correlates with Hesch method of eval (Kramer poster presentation, elaboration upon request). I do have a copy of his out of print book on x-ray of the SI.
Please keep us posted.
Sincerely
Jerry Hesch, MHS, PT
702-558-6011 Pacific Time
www.heschinstitute.com
From:
Sent: Saturday, July 19, 2008 9:09 AM
Subject: Re: coccyx pain post delivery
Stephanie,
You have got some good tips so far. One thing that I have found pivotal to alleviating coccyx pain is ensuring that the pelvic floor is treated--Trigger points released and PFM strengthened, especially after delivery. I find that coccyx mobs are not very helpful unless done soon after trauma to coccyx. In terms of modalities I have found good-old US and EStim to be very helpful.
Hi Susan,
Thank you for reply Susan,
I thought I should share how to treat as a start between now and when you access the info on the Most Common Pattern.
To treat the pattern of posterior pube, client is supine with legs straight, a 2.5" (6cm) foam roll or firmly rolled towel is placed horizontally, beneath the ischium, just above the ischial tuberosity, where the ischium is relatively flat. Take care not to encompass the sacrum.
For a true posterior glide of the pubic bone (palpable step-off going across from the right to left pubic bones) clients remains for 5 minutes.
For the postural pattern, 2 minutes should suffice. This produces an anterior glide force to the ischium and pubic bone on that side, via creep.
Retest, and then go on to treat sacrum if involved and then the rest of the Most Common Pattern.
With either pattern the ischium will be posterior/prominent in prone and will lack P-A spring. Sacrotuberous ligament oftentimes will be hypertonic and I think there are implications for the many structures within the sciatic notch, the pudendal nerve, etc. After treatment the ischium should be normal re palpation and spring.
Jerry Hesch
It would be nice if you would palpate the sacrum before and after addressing the pube shift and share your findings. It is possible that a) sacrum will initially be symmetrical, but after correcting the pube, will rotate left about a vertical axis b) be symmetrical before and after pube correction, or c) other (?).
If the pelvis as a unit is rotated (in which greatest rotation is apparent at the lower pelvis, then the left pubic bone will appear to be posterior, but the palpatory eval will be different than that of a true bony shift at symphysis. Taking your index finger from the right pube, across the fibrocartilage onto left pubic bone will be as though you are sliding down an inclined plane.
However, if a true pubic bone shift, there will be a discernable step-off going from the right pubic bone onto the left, and this step-off will resolve after treatment.
Regardless of which scenario is present, the treatment is the same. I will defer explanation at this time because there is a sequence of permutations that occur. This is covered thoroughly in Chapter 42 The Most Common Pattern of SIJD in Movement Stability and LBP: The Essential Role of the Pelvis, Vleemng et al 1997 Churchill Livingstone. It is an expensive text, but inter-library loan is a good way to go.
I cover other (rare) types of lower pelvic dysfunction elsewhere, so if the above does not adequately resolve this person's presentation, please let me know.
Please let me know if you have any questions and if conversation format more helpful we can schedule that.
Please keep us posted. Info on the possible permutation of the sacrum would be very informative.
Sincerely,
Jerry Hesch, MHS, PT
www.heschinstitute.com
From:
Sent: Monday, March 03, 2008 7:45 AM
Subject3/3/08
Hi Everybody,
I know I ask a lot of question but I have another one. I apologize in advance for the long, detailed patient history.
This question is about another IC patient. I have only seen her twice. Pain started in 1999 with a bladder infection. Her c.c. is pain in the bladder region. It's there all the time and doesn't fluctuate in intensity. She also has pain that lasts for approximately 5-10 minutes after having a BM. She does not have any LBP, vulvar, or vaginal pain. She is 52 years old and her last menstrual period was 4 years ago. She has never been pregnant and pelvic/abd surgeries include cystoscopy with hydrodistension in 2000, removal of uterine fibroids 2001, and gall bladder tests (?) in 2001. She has a good diet and good fluid intake. She is hypothyroid. She has tried Elavil, Elmiron, and Lyrica but most tx has been Narcotics. She takes Darvocet 4x/day, Kadian 3x/day, and 300 mg of Lyrica. She has tried Opana and Duragesic patch on a rotating schedule. She is having urinary retention and constipation at least partially related to her pain meds. She does not have urinary urgency or frequency. She started renting a TENS unit on her own just before starting to see me but it isn't helping. I've tried interferential with moist heat with her and she reports feeling very relaxed but it doesn't change her pain. I also showed her different electrode placements for the TENS unit.
Trunk AROM is WNL's. Repeated movements are ok. The only external trigger or tender point that I can elicit is in her left Psoas. In standing, she has a right frontal plane asymmetry, left foot pronation, hypertonus of the lumber and lower thoracic paraspinals, no scoliosis, anterior pelvic tilt, and she is forward bent. Pelvic alignment was different on her first and second visits. On the first visit (lying down), the medial malleoli were level, the left ASIS was elevated, the left pube was slightly elevated and posterior, and she had a positive standing forward bend test on the left side. On the second visit (this past Friday), the right medial malleolus was elevated, the left pube remained posterior but level in the frontal plane, and the right and left PSIS were level. She has no external PFM trigger points. The only internal (vaginal) TP I could elicit was in the left periurethral muscles at the level of the PIP. She reported abdominal cramping after TPR to that area. I have not done a rectal exam yet but plan to. I also haven't evaluated her L-spine as much as I could and plan to.
Just one more comment. I think she may have Lichens Sclerosis around the perineal body and have told her to make an appointment with her gyn to evaluate this. Her HEP right now includes hamstring, piriformis, and quadriceps stretches.
So, here's my question - Does anyone have ideas about what is going on with her pelvis, esp. the left posterior pube? I know how to correct a depressed or elevated pube but am not sure what to do about a posterior pube.
Thank you in advance for any suggestions,
Susan
Thank you for reply Susan,
I thought I should share how to treat as a start between now and when you access the info on the Most Common Pattern.
To treat the pattern of posterior pube, client is supine with legs straight, a 2.5" (6cm) foam roll or firmly rolled towel is placed horizontally, beneath the ischium, just above the ischial tuberosity, where the ischium is relatively flat. Take care not to encompass the sacrum.
For a true posterior glide of the pubic bone (palpable step-off going across from the right to left pubic bones) clients remains for 5 minutes.
For the postural pattern, 2 minutes should suffice. This produces an anterior glide force to the ischium and pubic bone on that side, via creep.
Retest, and then go on to treat sacrum if involved and then the rest of the Most Common Pattern.
With either pattern the ischium will be posterior/prominent in prone and will lack P-A spring. Sacrotuberous ligament oftentimes will be hypertonic and I think there are implications for the many structures within the sciatic notch, the pudendal nerve, etc. After treatment the ischium should be normal re palpation and spring.
Jerry Hesch
Shirlene and Group,
Just read my post and wanted to add that medial compression of the ilium on sacrum can also be helpful in the latter stages, after achieving anterior glide as previously described.
Client supine, towel roll vertical under the lateral buttock, 2 - 5 minutes.
Leave towel roll there, client in sideling at 30 degree angle 2-5 minutes and then at 60 degrees 2- 5 minutes.
These are all appropriate to teach for home program, hard to get through all in one clinical visit.
jh
From: Jerry Hesch, MHS jerry Hesch, MHS
To:
Sent: Wednesday, November 28, 2007 11:59 AM
Subject: Re: Sheared Symphysis Pubis
Dear Shirlene and Group,
Do you know how wide the symphyseal diastasis is?
Duke University has posted on surgical correction for severe symphyseal diastasis, but of course we all try to promote natural healing.
The pelvis is of course designed for stability and when one does achieve appropriate form closure, the joint mechanoreceptors are significantly quieted in terms of muscular inhibition, pain etc.
The symphysis pubis is inextricably linked to the SIJ's so any answer will be incomplete.
There is not adequate literature to guide us in the acute phase of these presentations.
If you think of it as "an open book" spread of the symphysis that may give some understanding for the following suggestions:
1. create 2 firmly rolled towels of 2"-2-1/2" diameter, by 8" length or cut 2 foam rolls.
2. place them laterally under each ischium, just above the ischial tuberosities, client supine 5 minutes if tolerated, stop this and all other efforts if painful. This will glide the ischia anteriorly and might enhance approximation.
3. place the rolls vertically under each ilium, as lateral as you can, client supine, same time.
4. progressively place the rolls medially with final position being just lateral and slightly on the PSIS', with 1/2 of roll above and 1/2 below the PSIS. This will glide the ilia anteriorly and will capture" the sacrum and have same effect. Same time frames.
5. client sideling on roll placed on or just above the trochanters. This will enhance medial glide of the pubic bone. Repeat on the other side, same time length. You can add a weight to the pelvis on the side facing up.
6. Any SI support used can be worn for a short period of time directly on the trochanters, or just above and this greatly enhances the medial compression of the symphysis pubis, whereas when worn higher, primarily effects the SIJ. This can be worn when resting, and if not too tight can even be tolerated when walking, and will certainly reduce abduction.
7. Hopefully, gentle strengthening can be progressed over time. There is an anecdotal case of spontaneous reduction when performing isometric exercise.
8. Ongoing screening is appropriate as the pelvis by its very nature undergoes several permutations. One somewhat common pattern with big babies is a posterior glide fixation of sacrum.
I will close for now. Please keep us posted on the progress and if need for clarification, I am happy to do so by phone or e-mail.
Maybe in 100 years we will have adequate research publication on all facets of the complexity of the pelvis/SIJ/symphysis pubis.
Sincerely,
Jerry H
From:
Sent: Wednesday, November 28, 2007 10:59 AM
Subject: RE: Sheared Symphysis Pubis
If the patient can manage it, an assistive device to decrease lower extremity weight bearing can be helpful. Sometimes mom's use the Baby Bjorn system so they are carrying baby in a sling like device on the front or back. This allows the patient to normalize ambulation in a partial weight bearing position and then she can gradually increase stride length and full weight bearing. Even if she can use a walker/crutches part of the time, this can help.
Otherwise, I agree with everything Erin had to contribute.
Carrie
From:
Sent: Wednesday, November 28, 2007 4:58 AM
To:
Subject: ReSheared Symphysis Pubis
Hi All,
Can anyone help me with experience of treating a sheared symphysis pubis (split)? I may not have the correct term. The patient is 36y/o female who gave birth to a more than 10lb baby 1 month ago. Split of symphysis pubis evident on X-Ray. She has pubic pain and difficulty walking. How long shall we expect before this will heal. I am treating with MFR and energy work (to balance the upslip of pelvis) and Ultrasound. She also has a diastasis which we are addressing. Any insights appreciated.
Shirlene
Chrissy,
It is unclear re position of pubic bones relative to each other. If left is
posterior relative to the right, that is a common cause of adductor
tendon/proximal soft tissue tenderness. A firmly rolled towel 2.5" diameter
under same sided ischium (client supine, hips and knees in neutral) placed
horizontally for 5 minutes will restore normal apposition, and decrease
pain.
Otherwise, maybe she has old-fashioned adductor tendonitis?
If the A-P divot of the fibrocartilage represents a posterior glide of the
fibrocartilage as opposed to normal anatomy; it will be quite tender with
gentle A-P pressure at midline such as with your 5th metacarpal less than
10# force (can practice on bathroom scale). Treatment is same as in the
above example except that it is done with towel rolls bilateral for 5
minutes, repeated prn.
A good rest position for anyone at this stage of pregnancy is actually same
as rx for bilateral anterior ilium-in which symmetry is the norm,
Sacrotuberous ligaments are tight, palpation reveals both ASIS much lower
than PSIS per her norm, age and body type norms and a fair assumption given
the anterior weight she is carrying. In standing, sitting, supine or
sideling, she approximates right bent knee to outside the right axilla for
2-5 minutes repeated a few times a day and same on left side. see picture
below.
This posture/pattern does overload ilio psoas and adductors, alters resting
length and MIGHT explain her bilateral sx.
BILATERAL ANTERIOR ILIUM
Bilateral anterior ilium is common with an anterior pelvic tilt and
increased lordosis. Realize that anterior pelvic tilt is only a positional
description, whereas bilateral anterior ilium is not so much a positional
description as a bilateral mobility dysfunction. Bilateral anterior ilium
may become apparent after correcting a unilateral dysfunction (one or
several components of the most common pattern). After correcting a
unilateral dysfunction, such as what appears to be a unilateral anterior
ilium the pelvis will appear symmetrical. Upon performing the spring tests
to reevaluate mobility, one may realize that there is a bilateral mobility
dysfunction which might not have been readily apparent earlier. This is a
common phenomenon; the pelvis tends to undergo serial permutations until the
dysfunction(s) is/are ultimately resolved. Flexion exercises are very
appropriate with this population. This includes stretching the spinal
extensors, Psoas, iliacus, rectus femoris, ITB, TFL, hamstrings and
gastroc-soleus muscle groups. Strengthening the spinal flexors and hip
extensors is very appropriate.
Positional Dysfunction: Anterior tilted pelvis. The ASIS's are lower that
the PSIS's and they are anterior to the pubic tubercles as tested in supine.
Movement Dysfunction: Reduced posterior mobility, as tested in supine.
Increased anterior mobility.
Treatment: The same as for unilateral anterior ilium, except that it is
performed bilaterally.
Retest: Retest mobility with appropriate spring test. After pattern is
resolved test for pelvic side-glide dysfunction.
Home Program: 1-2x days x 1 week, 2x week thereafter.
SPRING TESTS
Hypomobile Hypermobile
Mandatory Spring Tests
Supine
*1. Bilateral Posterior Rotation of the Anterior Ilium. (page ).
x
SELF TREATMENT FOR BILATERAL ANTERIOR ILIUM
Patient: Use self treatment for anterior ilium on each side for two minutes,
switch sides and repeat once.
Alternate treatment method: Use any of the treatment approaches described
earlier for right anterior ilium in the most common pattern treat the left
side also.
Retest: Retest mobility with appropriate spring test.
Home Program: 1-2x days x 1 week, 2x week thereafter.
Please let me know if you need any clarification and it would be nice to
know final findings/outcome. Thank you.
Jerry Hesch, MHS
From: "Christine >
Sent: Thursday, March 22, 2007 1:13 PM
Subject: RE: Pubic symphysis pain
I feel I can rule out hip pathology - no pain with passive movement or
overpressure or scour, posterior provocation tests are negative and I feel
also I can rule out SI involvement also, as standing flexion, knee to chest
and palpation tests do not reveal any alignment issues (as of today, this
was a problem on evaluation).
Initially she had severe pain with active hip flexion, especially when the
adductor was biased, especially with walking and lower body ADL's. This has
improved significantly but pain is still reproducible with resistance
testing hip flexion on the left AND the right.
She still has palpable pain at the adductor insertion and on the L side of
the symphysis. When I palpate across the top, I feel the symphysis are
level right and left and I feel a dip where I assume the cartilage lies -
anteriorly and superiorly to the bones themselves. She is tender on the
left in this area.
She has no numbness, tingling or loss of sensation around the pelvis or
lower extremities, and no pain along the inguinal ligament, just at the
tubercle.
Thanks for the ideas everyone - - -
Chrissy
From: jerry Hesch, MHS
Sent: Thu 3/22/2007 2:20 PM
To:
Subject: Pubic symphysis pain
Chrissy,
To evaluate the ilioinguinal nerve, scratch the skin just lateral to the
ASIS, as there is a sensory branch there. As stated in earlier posts there
can be normal sense of touch (yes I feel that) but with an enhanced
discomfort (allodynia) or enhanced abnormal sensation such as provoking
tingling, waterfall sensation, referred sx (dysesthesia) thus asking if it
is felt can be enhanced with does this provoke any unusual sensation or
pain. Follow that along with pressure along the inguinal ligament all the
way to the pubic tubercle, and if tender could indicate ilioinguinal
neuropathy, tenderness from subtle SI/symphysis dysfunction, muscle pull,
hernia, or any medical condition that impacts the T12-L1-L2 segments give or
take 1 segment.
In the subject line you list symphysis pain. If you palpate the top of each
pubic bone (crest) allowing 1/4" space in the midline, what do you find?
If you palpate along the entire length of the pubic bones, how do they
compare?
If you move your index finger across from one pubic bone to the other, what
do you feel with respect to the fibrocartilage? In other words, is the
fibrocartilage equal to pube bone, or forward or posterior-and if so, by how
much would you estimate?
Good news-the palpatory findings at the symphysis correlate very nicely with
passive motion tests and therefore I do not teach spring tests at the
symphysis pubis.
Also, does any of the pube/fibrocartilage palpation provoke tenderness?
There are a few thoughts rattling in my head but will leave it here for now.
Sincerely,
jerry h
From: "Christine >
Sent: Thursday, March 22, 2007 9:25 AM
Subject: Pubic symphysis pain
I have an obstetric patient, 28 weeks along, who came to me with L groin
pain. She has responded well to muscle energy techniques to correct an
iliac Inflare on the L and her previous symptoms of pain with standing,
walking, and lifting the left leg have all but resolved. The one persisting
symptoms, and most aggravating, is the L groin pain when she is sideling.
Any pelvic compression aggravates this symptom, which is also becoming as
much of a problem in right sideling. She is following a stretching and
pelvic stability program and sleeps with an adductor pillow, but her sleep
continues to be disturbed. Manual therapy is my weak point - so I am sure
there is something I am missing. Any ideas would be helpful.
Chrissy