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SYMPHYSIS PUBIS DYSFUNCTION. Beyond Category 2 Antwerp 19 th -21 st September 2008 Dr Eric Pierotti DC. DO. Ch.D (Adel) DIBAK. Introduction. Increasing number of patients presenting with pain to lower back and or sacroiliac joint area No obvious pattern of pain or aetiological incidence - PowerPoint PPT Presentation



    Antwerp 19th-21st September 2008

    Dr Eric Pierotti DC. DO. Ch.D (Adel) DIBAK

  • IntroductionIncreasing number of patients presenting with pain to lower back and or sacroiliac joint area No obvious pattern of pain or aetiological incidenceMany also had pain of left or right lower abdominal quadrant (s) and or groin pain

  • IntroductionTherapy localisation and challenge of lumbars, pelvic bones and joints all negativeNo visceral fixations or mal-positioning Postural analysis essentially normal except for;

  • IntroductionMinor loss of lumbar lordosis with associated posterior pelvic tiltStandard quadriceps and rectus femoris test negative Beardalls test showed marked inhibition of quadriceps groupOccasionally functionally inhibited abdominals, adductors and piriformis muscles unilaterally or bilaterally

  • IntroductionTherapy localisation to all factors of the IVF failed to isolate one common reflex which facilitated the inhibitionPossible association with pubic symphysis dysfunction was recognised after examining a patient postpartum

  • Case history32 year old female 8 weeks postpartum second child Presenting symptoms of general lumbar spine pain and acute bilateral groin and pubic painParticularly difficult pregnancy and instrument assisted delivery Difficult walking and erecting after sitting or lyingNo previous history of spinal related problems

  • Case historyExamination elicited normal ranges of motion of the lumbar spine and sacroiliac joints Exquisite tenderness at the pubic tubercles, medial joint and inferior ramus bilaterallyPalpatory widening of symphysis Bilateral weakness of quadriceps (Beardalls) and rectus abdominus Negative TL and challenge to all lumbars, SIJs and innominates

  • Case historyTL to pubis negated muscle weakness

    Diagnosis; symphysis pubis diastasis associated with ligamentous compromise

  • Case history

    Correction of pubic subluxation using activator and blocking techniques 95% reduction of lumbar and pubic pain immediately after first correction Correction and remedial exercises over 2 weeks completely resolved all symptoms and findings

  • Normal Anatomy A fibrocartilaginous joint with a cleft at the confluence of the two pubic bonesA thick intra pubic fibrocartilaginous disc is sandwiched between thin layers of hyaline cartilage

  • Normal AnatomyMajor stability is provided by the inferior pubic (arcuate) ligamentThe superior pubic ligament connects the bones from above and provides superior support and stability

  • Normal Anatomy Further support is provided by an aponeurosis created by the tendons of the rectus abdominis above and the gracilis and adductor longus below giving anterior and inferior support where they merge with the acuate ligament

  • BiomechanicsLittle in literature regarding biomechanics of the symphysis pubisGrays Anatomy states angulation, rotation and displacement are possible but slight, and are likely in activities at the sacroiliac joints. Some separation is held to occur late in gestation and child birth

  • BiomechanicsMore recent authors in keeping with early research(1937) have stated quite categorically that;Pelvic biomechanics should be viewed from the perspective of the symphysis pubis P.E. GreenmanMovement at the symphysis pubis consists of two movements

  • BiomechanicsNo.1A superior to inferior translatory movement that occurs during one legged standing (Chamberlain)On prolonged one legged standing, the ipsilateral pubes moves cephaladThis should return to normal on standing on the opposite leg or on prolonged two-legged standing

  • BiomechanicsNo.2

    As an axis of rotation for the alternating anterior to posterior rotation of the right and left innominate bones during gait (Pitkin and Pheasant et al)

  • Patho-mechanicsHabitual one legged stances may result in muscle imbalances between the abdominals and the adductors with the resultant restriction of the pubic bone in aberrant relationship with its partnerA leg length discrepancy of 1cm or more causes torsion to occur in the pelvic girdle resulting in changes in the sacrum and pubis which frequently results in sacroiliac pain (Bellamy et al)

  • Biomechanicsthe most reliable clinical sign of instability of the sacroiliac joints is disruption of normal function at the symphysis pubis resulting in increased mobility when alternate weight bearing on either legP.E.Greenman

  • BiomechanicsIt appears that the symphysis;Provides an axis of rotation during normal gait patterns via both interosseous and reciprocal flexing around the joint without actual separation or translatory shearAs long as this bound but flexible union is maintained, normal biomechanics of the innominates and sacrum can occur without undue strain placed upon their joints

  • BiomechanicsWhen this firmly bound union fails or becomes hypermobile;It allows the normal synchronous forward and backward motion of the innominates and combined lumbar side bending and rotation during gait, to move beyond their normal range (usually unilateral)Causing undue and repetitive strain on the ligamentous supports of the spine and SIJs

  • Aetiology of DysfunctionThere appears many and diverse reasons for dysfunction of pubic symphysis1. PregnancyNormal widening of the symphysis due to laxity of connective tissue under hormonal (relaxin, oestrogen) control which peaks at around 38 weeks Separation usually occurs around 20 weeks with gradual progression to its maximum at around 30-35 weeks gestation (Pierotti)

  • Aetiology of DysfunctionThe normal spacing 0.5-5 mm

    Pregnancy: 9.0-12mm

    Abnormal : 1 cm and above

  • Aetiology of DysfunctionIf widening is excessive or too rapid, instability results with increased ranges of motion at one or both SIJs causing a repetitive type strain with resultant pain and usually inflammation Male Soccer Player

  • Aetiology of Dysfunction

    Post partum 28 year old female, 3rd child

  • Aetiology of DysfunctionAccording to the Office of National Statistics:

    In 2002 there were 594,634 pregnancies in the UK

    Figures from Manchester University and Leeds Royal Infirmatory showed that 1:36 of those women did or would suffer pelvic dysfunction

  • Aetiology of Dysfunction2. Failure of symphysis to close after delivery

    During delivery as the babys head breaches the pelvic rim, a further slight separation occurs at the symphysisWhich in some sort of body logic effects a rebound type motion closing the symphysis over the next 24-26 hours

  • Aetiology of Dysfunction

    2. Failure of symphysis to close after deliveryWithin 24 hours of parturition blood levels of relaxin markedly reduce and ligaments begin to tighten regardless of joint positionFailure to elicit this rebound in the presence of reducing relaxin levels contribute to maintaining the joint in a separated or dysfunctional position

  • Aetiology of DysfunctionFailure to separate can be as counterproductive as excessive widening as; Separation provides extra space in the birth canal for the babys head to breach the bony pelvic rim Failure of separation requires the sacroiliac joints to compensate to a greater degree than normalCausing both instability and pain especially during the last trimester

  • Aetiology of DysfunctionThis condition is responsible in part, for long and difficult labours and in many cases responsible for failure of the cervix to adequately dilate resulting in many emergency caesarean sections (Pierotti)Failure to separate

  • Aetiology of Dysfunction3. Direct Trauma such as;Falling in split leg position Sports and activities such ballet, dance or callisthenics requiring the splits4. Postural StrainStanding stationary for extended periods of time (hairdressers, sales assistants, production workers)Secondary to positions of coitus

  • Aetiology of DysfunctionDuring prolonged standing there is a natural tendency to gravitate to one leg to relieve the stress. Resultant muscle imbalances effect the shearing type subluxation

    Shearing Subluxation

  • Aetiology of DysfunctionThis is particularly more relevant around the time of menses with resultant ligament laxity due to fluctuations in hormone levels Shearing Subluxation

  • Aetiology of Dysfunction5. Repetitive StrainFaulty gait mechanics associated with asymmetrical stride length can cause a specific torque pattern to the side of short stride not dissimilar to a dural torque pattern but resulting in a pubic subluxation

  • Aetiology of DysfunctionRecent spate of osteitis pubis in AFL players is as a result of strong repetitive torque of the symphysis during the follow through in the action required to kick the ball in excess of 50 metres

  • Aetiology of Dysfunction

    Traumatically induced as a result of sporting incidences

  • Signs and SymptomsCan range from; Acute pain at the pubes or groinMedial aspect of the thigh unilaterally or bilaterallySupra pubic painPain on weight bearing activities (walking, negotiating stairs)

  • Signs and SymptomsParting the legs or turning over in bedDysfunction of the urogenital diaphragm (frequency and stress incontinence)Dyspareunia Exquisite palpatory tenderness around the pubis on examination

  • Signs and SymptomsA large percentage of patients present with this subluxation but are not aware of any symptoms other than vague or diffuse lumbar spine pain

  • Postural ExaminationMain postural feature in most but not all cases is a hypo-lordosis of the lumbar spine and posterior tilt of the pelvi