SYMPHYSIS PUBIS DYSFUNCTION

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SYMPHYSIS PUBIS DYSFUNCTION

• Beyond Category 2
• Antwerp 19th-21st September 2008
• Dr Eric Pierotti DC. DO. Ch.D (Adel) DIBAK

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Introduction

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

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Introduction

• Therapy localisation and challenge of lumbars,
  pelvic bones and joints all negative
• No visceral fixations or mal-positioning
• Postural analysis essentially normal except for

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Introduction

• Minor loss of lumbar lordosis with associated
  posterior pelvic tilt
• Standard quadriceps and rectus femoris test
  negative
• Beardalls test showed marked inhibition of
  quadriceps group
• Occasionally functionally inhibited abdominals,
  adductors and piriformis muscles unilaterally or
  bilaterally

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Introduction

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

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Case history

• 32 year old female 8 weeks postpartum second
  child
• Presenting symptoms of general lumbar spine pain
  and acute bilateral groin and pubic pain
• Particularly difficult pregnancy and instrument
  assisted delivery
• Difficult walking and erecting after sitting or
  lying
• No previous history of spinal related problems

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Case history

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

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Case history

• TL to pubis negated muscle weakness
• Diagnosis symphysis pubis diastasis associated
  with ligamentous compromise

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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

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Normal Anatomy

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

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Normal Anatomy

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

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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

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Biomechanics

• Little in literature regarding biomechanics of
  the symphysis pubis
• Grays 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

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Biomechanics

• More 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.
  Greenman
• Movement at the symphysis pubis consists of two
  movements

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Biomechanics

• No.1
• A superior to inferior translatory movement that
  occurs during one legged standing (Chamberlain)
• On prolonged one legged standing, the ipsilateral
  pubes moves cephalad
• This should return to normal on standing on the
  opposite leg or on prolonged two-legged standing

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Biomechanics

• No.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)

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Patho-mechanics

• Habitual 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
  partner
• A 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)

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Biomechanics

• the 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 leg P.E.Greenman

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Biomechanics

• It 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 shear
• As 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

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Biomechanics

• When 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

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Aetiology of Dysfunction

• There appears many and diverse reasons for
  dysfunction of pubic symphysis
• 1. Pregnancy
• Normal 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)

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Aetiology of Dysfunction

• The normal spacing 0.5-5 mm
• Pregnancy 9.0-12mm
• Abnormal 1 cm and above

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Aetiology of Dysfunction

• If 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
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Aetiology of Dysfunction

• Post partum 28 year old female, 3rd child

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Aetiology of Dysfunction

• According 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 136 of those women
  did or would suffer pelvic dysfunction

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Aetiology of Dysfunction

• 2. Failure of symphysis to close after delivery
• During delivery as the babys head breaches the
  pelvic rim, a further slight separation occurs at
  the symphysis
• Which in some sort of body logic effects a
  rebound type motion closing the symphysis over
  the next 24-26 hours

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Aetiology of Dysfunction

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

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Aetiology of Dysfunction

• Failure 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
  normal
• Causing both instability and pain especially
  during the last trimester

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Aetiology of Dysfunction

• This 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
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Aetiology of Dysfunction

• 3. Direct Trauma such as
• Falling in split leg position Sports and
  activities such ballet, dance or callisthenics
  requiring the splits
• 4. Postural Strain
• Standing stationary for extended periods of time
  (hairdressers, sales assistants, production
  workers)
• Secondary to positions of coitus

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Aetiology of Dysfunction

• During 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
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Aetiology of Dysfunction

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

Shearing Subluxation
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Aetiology of Dysfunction

• 5. Repetitive Strain
• Faulty 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

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Aetiology of Dysfunction

• Recent 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

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Aetiology of Dysfunction

• Traumatically induced as a result of sporting
  incidences

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Signs and Symptoms

• Can range from
• Acute pain at the pubes or groin
• Medial aspect of the thigh unilaterally or
  bilaterally
• Supra pubic pain
• Pain on weight bearing activities (walking,
  negotiating stairs)

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Signs and Symptoms

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

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Signs and Symptoms

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

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Postural Examination

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

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Postural Examination

• Note the subtle anterior pelvic tilt (24 year old
  hockey player nulliparous)

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Postural Examination

• Pubis separation widens the pelvis causing an
  increase in Q angle which gives rise to knee
  symptoms and instability

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Postural Examination
Pre Correction
Post Correction
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Postural Examination
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Radiological

• Weight bearing X-rays in a Flamingo stance best
  illustrates symphysis instability

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Muscle Weakness

• There is a specific and recurrent bilateral
  muscle weakness now correlated in well over 1000
  patients
• That is a bilateral quadriceps muscle weakness
  tested as a group but only on Beardalls test
• This weakness is classically accompanied by
  hypertonic hamstrings

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Muscle Weakness

• Beardalls Test
• Patient supine, flex the leg to 45 from the
  table with the knee in full extension. The
  opposite leg remains fully extended on the
  examination table

Note inability to fully extend the legs
from hypertonic hamstrings
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Biomechanics of Muscle Weakness

• Hypothetically contraction of say the right
  quadriceps in the supine position performing a
  resisted muscle test requires,
• The left ilium to be forced posteriorly into the
  examination table to stabilize the pelvis and
  provide a fulcrum point for the muscle to
  maintain an isometric contraction
• This torque motion is centred around an intact
  symphysis

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Biomechanics of Muscle Weakness

• If the symphysis fails and the resulting
  translatory motion is too great, general pelvic
  instability occurs and inhibition of the test
  muscle results
• This is bourn out by having the patient flex the
  opposite knee with the foot flat on the table
• This now provides the missing stabilizer and the
  positive test is negated

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Biomechanics of Muscle Weakness

• This test will show a significant percentage of
  pubic symphysis subluxations
• When suspected but Beardalls test is negative,
  incorporating 10-20 of external leg rotation
  will show the rest

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Therapy Localisation

• TL to the pubis will negate the weakness of the
  associated quadriceps
• TL will weaken a previous normal facilitated
  indicator muscle

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Challenge

• Challenge is directed to the ramus of the pubis
  with a thenar contact in either caudal, medial,
  lateral or cephalad or combination of these
• For separation dysfunction use a double hand
  contact to the lateral aspects of the ramus in a
  compressive rebound fashion

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Challenge

• Most frequent subluxation found is the shearing
  or translatory type with one pubis superior and
  the other in an inferior configuration along the
  coronal plane or Y axis

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Respiratory Challenge

• During inhalation
• The innominates move anteriorly in a rotation
  motion around the Y axis
• The bony arch separates and moves inferiorly
• The opposite occurs on exhalation

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Respiratory Challenge

• Respiratory challenge only seems valid in
  facilitating the inhibited quadriceps when the
  pubis is either separated or compressed, that is
  
• Strong inhalation will facilitate the inhibited
  quadriceps when the pubis is compressed
• Strong exhalation will facilitate the quadriceps
  when the pubis is separated

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Correction

• Correction is performed in the opposite direction
  to the positive manual challenge by either
• Using an impact instrument (activator)

Correction right inferior pubis (on exhalation)
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Correction

• Activator correction for left superior pubis (on
  inspiration)

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Correction

• Manual correction
• Bring patients right leg into flexion, abduction
  and external rotation with the sole of the foot
  to the medial thigh left leg
• Right thenar contact to left pubic tubercle, left
  hand grasps patients right knee

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Correction

• Manual correction
• At point of maximal stretch apply a short sharp
  low amplitude thrust in an inferior lateral
  direction

Correction for left superior pubis
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Correction

• Manual correction
• Repeat the procedure on the opposite side
  contacting more inferiorly on the right tubercle
  and thrust in a cephalad and lateral direction

Correction right inferior pubis
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Correction

• Separation subluxations requires both manual and
  activator correction
• Patient supine place DeJarnette blocks under each
  hip joint at 90 to the spine

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Correction

• Take a bilateral thenar contact to the lateral
  aspect of pubic tubercles
• As patient exhales apply a compressive force in a
  medial direction increasing the force towards the
  end of the exhalation

Correction separation subluxation
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Pre-correction
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Post-correction
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Pre and Post Correction
Pre-correction
Post-correction
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Pre and Post Correction
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Rehabilitation

• There appears little in way of remedial exercise
  as we are essentially dealing with a ligament
  laxity regardless of origin
• One procedure has proven useful in at least
  creating some stability to the symphysis in these
  cases
• But, requires an assistant to gain the best
  benefit

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Rehabilitation

• Patient supine, knees flexed to 90 heels
  together and soles of feet flat on the table
• Assistant contacts lateral aspect of knees and
  provides resistance to the patient abducting the
  knees to 45
• Repeat twice

First Contact
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Rehabilitation

• With the knees in 45 abduction assistant
  contacts the medial aspect of the knees and
  resists the patients adduction to the neutral
  position
• Repeat twice

Second contact
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Conclusion

• Corrective techniques shown have addressed the
  joint predominantly, be aware that the secondary
  support structure of the adductors, gracilis and
  abdominals can in many cases be dysfunctional as
  a result of micro avulsion of these muscles
• Addressing this problem is beyond the time
  constraints of this presentation, just be aware
  that

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Conclusion

• This condition can and is multi factorial
• Applied kinesiology teaches us the triad of
  health and the importance of looking at every
  patient from the point of view of structure,
  chemical and emotional implications
• This technique makes the assumption that all
  facets of the triad have been assessed and any
  dysfunction corrected before embarking on this
  course

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Conclusion

• Treating this condition as part of a holistic
  approach will ensure a positive and lasting result

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Thanks for your Attention