Muscle Energy: Pelvic Dysfunctions PDF

Muscle Energy: Pelvic Dysfunctions Burrell College of Osteopathic Medicine Feb 26st, 2024 Victoria Chang DO  Objectives 1. Diagnose and treat innominate dysfunctions using muscle energy technique: - anteriorly rotated innominate, - pos...

Muscle Energy: Pelvic Dysfunctions Burrell College of Osteopathic Medicine Feb 26st, 2024 Victoria Chang DO  Objectives 1. Diagnose and treat innominate dysfunctions using muscle energy technique: - anteriorly rotated innominate, - posteriorly rotated innominate, - superior innominate shear, - inferior innominate shear, - innominate outflare, - innominate inflare. 2. Diagnose and treat pubic dysfunctions: superior pubic shear, inferior pubic shear, pubic compression, and gapped pubic symphysis using muscle energy technique.  Readings and Videos Atlas of Osteopathic Techniques, 4th ed. Nicholas, Ch. 10 Muscle Energy Pelvic Region, Videos 10.28-10.29, 10.33, 10.35-10.37, 10.40 An Osteopathic Approach to Diagnosis and Treatment, 4th ed. DiGiovanna, Ch. 61 Muscle Energy: Pelvic Dysfunctions ICOM Videos: Pelvic Landmarks, Pelvic Diagnosis Sequence, Pubic Symphysis Reset Technique ME, Anterior Innominate Rotation ME, Superior Innominate Shear ME, Posterior Innominate Rotation ME, Innominate Outflare ME, Innominate Inflare ME Steps to Diagnosing the Pelvis for Somatic Dysfunction 1. Perform lateralization test(s) to identify the side of the innominate and/or pubic symphysis somatic dysfunction Standing Flexion Test or ASIS compression test (or other test of lateralization) 2. Align the pelvis for assessment of anterior landmarks 3. Compare anterior landmarks - Pubic Tubercle heights, ASIS heights, Distance from ASIS to Umbilicus 4. Align the pelvis for assessment of posterior landmarks - PSIS heights  Protocol for diagnosis of the Innominate 1. Perform a test of lateralization in order to determine which sacroiliac joint is dysfunctional as well as to have a reference point for landmark heights (Standing flexion test or ASIS compression test) 2. Measure landmark heights with patient supine (ASIS, PSIS, Pubic rami, ASIS to umbilicus) 3. Identify the diagnosis that fits your findings  How to Find PSIS Start with standing on the side of your eye dominance. Then place your extended hands and fingers at the level of the iliac crests. Your thumbs should be at a right angle to your fingers and rest on L4. Move your thumbs inferiorly for 1-2 cm, depending on the height of the person you are examining, to move to L5. Move another 1-2 cm inferiorly to S1. Move another 1-2 cm inferiorly to S2. Move your thumbs laterally to find the PSIS and place your thumb PADS BELOW the PSIS. Keep your thumbs fully extended so that you may use them as levels to judge PSIS height.  Standing Flexion Test * Tight hamstrings can give a false positive or false negative standing flexion test  Standing Flexion Test 1. Patient stands with feet shoulder width apart 2. Physician positions themselves behind patient with eyes at the level of the PSIS 3. Physician places thumbs on the inferior surface of the the patient’s PSIS 4. Patient is instructed to bend forward 5. A positive test and side occurs when one PSIS moves more cephalad at the end of the range of motion (must be at least one thumb breath height difference) Modified from Kuchera WA, Kuchera ML. Osteopathic Principles in Practice. 2nd Ed  How to find ASIS Start with standing on the side of your eye dominance. Then place the palm of your hands on the anterolateral surface of the person's legs at the level of the greater trochanter. Slide your hands superiorly away from "sacred" space/genitalia. Continue sliding your palms superiorly until you feel the ASIS in the center of your palms via stereognosis. Once you have found the ASIS, place your thumb PADS BELOW the ASIS. Keep your thumbs fully extended so that you can use them as levels to judge the height of the ASIS.  ASIS Compression Test Modified from Kuchera WA, Kuchera ML. Osteopathic Principles in Practice. 2nd Ed * Failing to reset the pelvis can lead to false positive or false negative ASIS compression test  ASIS Compression Test 1. Physician’s palms or thenar eminences are placed over the patient’s ASISs. 2. The physician alternately introduces a mild to moderate compressive force directed medially and posteriorly through the ASISs. 3. Note the quality and quantity of motion on each side. This determines which sacroiliac joint is most restricted. The side that doesn’t move is restricted. * Failing to reset the pelvis can lead to false positive or false negative ASIS compression test “Set” the Pelvis- Supine Patient bends knees Asks the patient to lift hips up off table Patient is then asked to return hips to table and straighten legs - Passively or Actively This can also be done passively by the physician picking up the pelvis and placing it down. (Method of choice in patients with knee dysfunction or pain) Physician can also grab the ankles and use as levers to “wiggle” pelvis to reset  How to find pubic symphysis Stand on the side of the patient so that your dominant eye is over the midline Use the heel of your dominant hand to palpate the abdomen Start below the umbilicus and gently move the heel of your hand inferiorly until you perceive bone Switch to using your index finger PADS to press on the TOP of the SUPERIOR surface of the pubic rami Keep your fingers extended so that you may use them as a level to judge the height of the pubic rami. Anterior Pelvic Landmarks used for Diagnosis Iliac Crest ASIS Pubic Symphysis Pubic Ramus Place the tips of 2nd fingers on the superior aspect of each pubic ramus. Are they level? - Is the lateralized side inferior or superior relative to the non-lateralized side? Anterior Pelvic Landmarks used for Diagnosis Iliac Crest ASIS Pubic Symphysis Pubic Ramus Put thumbs horizontally under the ASIS’s - Are they level? - Is the lateralized side inferior or superior relative to the non- lateralized side? Posterior Pelvic Landmarks used for Diagnosis Iliac Crest Sacral Sulcus PSIS Place thumbs horizontally under the PSIS’s - Are they level? - Is the lateralized side inferior or superior relative to the non-lateralized side?  Transverse Axis between ASIS’s Triangulate to the umbilicus Drop a perpendicular Compare the distances Is lateralized side relatively farther from (outflare) or closer (inflare) to umbilicus?  Motion testing to diagnose flare Stand on the side of eye dominance with the patient supine. Place your palms over the ASISs as previously described. Direct a lateral force from right to left. This tests whether the right innominate can inflare and the left innominate can outflare. Then direct a lateral force from left to right. This tests whether the left innominate can inflare and the right innominate can outflare. This means that you are doing a direct action and perceiving motion with the active hand and perceiving motion with the receiving hand.  ME: Pubic Dysfunction (superior shear, inferior shear, gapped, or compressed) 1. Hold the knees in adduction with both arms 2. Patient abducts their hips by pushing their knees apart while you provide an isometric counterforce 3. Maintain this contraction and counterforce for 3-5 seconds 4. Instruct the patient to relax 5. Place a fist between the patient’s knees 6. Patient adducts their hips, squeezing your fist between their knees 7. Maintain this contraction and counterforce for 3-5 seconds Manual of Selected Osteopathic Techniques, 1st ed. Furlano and Prest  ME: Pubic Dysfunction 8. Repeat steps 2-4 9. Place two fists side-by-side between the patient’s knees 10. Patient adducts their hips, squeezing your fists between their knees 11. Repeat steps 2-4 12. Place your forearm between the patient’s knees with your palm against one knee and your elbow against the other 13. Patient adducts their hips, squeezing your forearm between their knees 14. Return the patient to neutral 15. Reassess Manual of Selected Osteopathic Techniques, 1st ed. Furlano and Prest  Innominate Rotation Causes The hypertonic muscle is pulling the innominate into its rotation. Tight flexors (quadriceps femoris) cause anterior innominate rotation. Tight extensors (biceps femoris, semimembranosus and semitendinosus) cause posterior innominate rotation. *Full mechanism is more involved and has to do with how muscles contract (both agonist and antagonist) to stabilize a particular joint  Innominate Rotation Treatment Principles using Combined mechanisms of MET For anteriorly rotated innominate: Flexing the hip will rotate the innominate posteriorly towards its restrictive barrier and hip extenders (biceps femoris, semimembranosus, semitendinosus and gluteus maximus) will provide the activating force *by changing the origin and insertion of the muscle allowing the innominate to attain its physiologic position. For posteriorly rotated innominate: Extending the thigh will rotate the innominate anteriorly towards its restrictive barrier and hip flexors (biceps femoris) will provide the activating force, *by changing the origin and insertion of the muscle allowing the innominate to attain its physiologic position.  Combined Mechanism of Action ME: Anteriorly Rotated Innominate (example right anterior innominate; ) 1. The patient lies supine, and the physician is seated on the table facing the patient 2. The physician places the patient’s right heel on the right shoulder and passively flexes the patient’s right hip and knee until the edge of the restrictive barrier is reached 3. An acceptable modification is to have the patient’s right knee locked in full extension and the leg flexed at the hip with the patient’s right leg on the physician’s right shoulder *Alternatives: Monitoring hand contacts PSIS and SI joint; Performing contact places patient’s tibia (with hip & knee flexed) against anterior/superior aspect of physician’s chest wall OR tibia joint below knee is contacted with the palm of hand with knee placed on physician’s anterior shoulder just lateral to the coracoid process (The patient’s prime mover: hip extensors, hamstrings and gluteus maximus (minor))  Combined Mechanism of Action ME: Anteriorly Rotated Innominate (example right anterior innominate; ) 4. The physician instructs the patient to push the knee into the physician’s hands, extending the right hip while the physician applies an equal counterforce 5. This isometric contraction is maintained for 3 to 5 seconds, and then the patient is instructed to stop and relax 6. Once the patient has completely relaxed, the physician flexes the patient’s right hip to the edge of the new restrictive barrier 7. Steps 4 to 6 are repeated three to five times 8. Reassess landmarks / TART (The patient’s prime mover: hip extensors, hamstrings and gluteus maximus (minor))  Combined Mechanism of Action ME: Posteriorly Rotated Innominate (example right posterior innominate; ) 1. The patient lies supine on a diagonal, so the right sacroiliac joint is off the edge of the table 2. The physician stands at the right side of the table 3. The physician’s cephalad hand is placed over the patient’s left ASIS to prevent the patient from rolling off the table. The caudad hand is placed distal to the patient’s knee 4. The physician’s caudad hand passively extends the patients right hip bringing the innominate into anterior rotation until the edge of the restrictive barrier is reached 5. The physician instructs the patient to lift the right leg toward the ceiling while the physician applies an equal counterforce (The patient’s prime mover: hip flexors, rectus femoris)  PIR ME: Posteriorly Rotated Innominate (example right posterior innominate; ) 6. The isometric contraction is maintained for 3 to 5 seconds and then the patient is instructed to top and relax 7. Once the patient has completely relaxed the physician extends the patient’s right hip to the edge of the new restrictive barrier 8. Steps 5-7 are repeated three to five times 9. Re-asses landmarks / TART (The patient’s prime mover: hip flexors, rectus femoris)  PIR ME: Superior Innominate Shear (example right superior innominate shear; ) 1. The patient lies supine with both feet off the end of the table. 2. The physician stands at the foot of the table and grasps the patient’s right tibia and fibula above the ankle 3. The physician internally rotates the right leg to close-pack the hip joint, locking the femoral head into the acetabulum  Respiratory Assist ME: Superior Innominate Shear (example right superior innominate shear; ) 4. The physician abducts the patient’s right leg 5 to 10 degrees to take tension off the right sacroiliac ligament 5. The physician gently leans back, maintaining axial traction on the patient’s right leg, and instructs the patient to inhale and exhale 6. With each exhalation, the tractional force is increased. 7. Steps 5 to 6 are repeated five to seven times. 8. With the last exhalation, the patient may be instructed to cough as the physician simultaneously tugs on the leg. 9. Re-assess landmarks / TART  PIR (Variant) ME: Superior Innominate Shear (example right superior innominate shear; ) 4. The physician abducts the patient’s right leg 5 to 10 degrees to take tension off the right sacroiliac ligament 5. The physician gently leans back, maintaining axial traction on the patient’s right leg, and instructs the patient to pull hip towards their head. 6. With each repetition, the tractional force is increased in a caudal direction. 7. Steps 5 to 6 are repeated three to five times. 8. Re-assess landmarks / TART Respiratory Assist ME: Inferior Innominate Shear (example right inferior innominate shear) 1. The patient lies in the lateral recumbent position, with dysfunctional side up. The leg on the side of the dysfunction is up and away from the table and is flexed and placed on the physician's shoulder. 2. The physician sits on the table behind the patient. 3. The physician places one hand placed on both the pubic and ischial rami of the dysfunctional side, with the other hand placed on both the ischial tuberosity and the posterior superior iliac spine of the dysfunctional side. 4. With the patient relaxed, the physician laterally distracts the innominate bone. Respiratory Assist ME: Inferior Innominate Shear (example right inferior innominate shear) 5. Maintaining this position, the physician then applies a cephalad force on the pubic and ischial rami, ischial tuberosity, and posterior inferior iliac spine of the dysfunctional side. 6. The physician then instructs the patient to inhale deeply and exhale completely. 7. The physician maintains the cephalad force on the distracted innominate during the inspiratory phase of the patient's respiratory cycle. 8. During the expiratory phase of the patient's respiratory cycle, the physician increases the cephalad force on the distracted innominate, 9. The steps may be repeated.  PIR ME: Innominate Outflare (example right outflared innominate; ) 1. The patient lies supine, and the physician stands at the left side of the table 2. The patient’s right hip and knee are flexed to about 90 degrees, and the right foot is lateral to the left knee 3. The physician’s right hand is placed under the patient’s right innominate, grasping the medial aspect of the right PSIS 4. The physician’s left hand adducts the patient’s right knee until the edge of the restrictive barrier is reached (The patient’s prime mover: hip abductors/external rotators, gluteus medius/minimus, piriformis)  PIR ME: Innominate Outflare (example right outflared innominate; ) 5. The physician instructs the patient to abduct the flexed hip while the physician applies an equal counterforce 6. This isometric contraction is maintained for 3 to 5 seconds, and then the patient is instructed to stop and relax 7. Once the patient has completely relaxed, the physician further adducts the patient’s right knee to the edge of the new restrictive barrier and draws traction laterally on the right PSIS 8. Steps 5 to 7 are repeated three to five times 9. Re-assess landmarks / TART (The patient’s prime mover: hip abductors/external rotators, gluteus medius/minimus, piriformis)  PIR ME: Innominate Inflare (example right inflared innominate; ) 1. The patient lies supine, and the physician stands at the left side of the table 2. The patient’s right hip and knee are flexed, and the right foot is on the lateral aspect of the left knee 3. The physician’s cephalad hand is placed on the patient’s left ASIS 4. The physician’s caudad hand is placed on the patient’s right knee and the right hip is externally rotated until the edge of the restrictive barrier is reached (The patient’s prime mover: hip adductors/ hip internal rotators)  PIR ME: Innominate Inflare (example right inflared innominate; ) 5. The physician instructs the patient to push the right knee into the physician’s hand, which applies an equal counterforce 6. This isometric contraction is maintained for 3 to 5 seconds, and then the patient is instructed to relax 7. Once the patient has completely relaxed, the physician further externally rotates the hip to the edge of the new restrictive barrier 8. Steps 5 to 7 are repeated three to five times 9. Re-assess landmarks / TART (The patient’s prime mover: hip adductors/ hip internal rotators)  Any Questions? References: Foundations of Osteopathic Medicine, 3rd ed. Chila, Ch. 10 An Osteopathic Approach to Diagnosis and Treatment, 3rd ed. DiGiovanna, Ch. 61 Manual of Selected Osteopathic Techniques, 1st ed. Furlano and Prest, Pelvis chapter Atlas of Osteopathic Techniques, 3rd ed. Nicholas and Nicholas, Ch. 10.