SYMPHYSIS PUBIS DYSFUNCTION

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

2. 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

3. Introduction • Therapy localisation and challenge of lumbars, pelvic bones and joints all negative • No visceral fixations or mal-positioning • Postural analysis essentially normal exceptfor;

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

5. 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

6. 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

7. 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 (Beardall’s) and rectus abdominus • Negative TL and challenge to all lumbars, SIJ’s and innominates

8. Case history • TL to pubis negated muscle weakness • Diagnosis; symphysis pubis diastasis associated with ligamentous compromise

9. 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

10. 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

11. 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

12. 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

13. Biomechanics • Little in literature regarding biomechanics of the symphysis pubis • Gray’s 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”

14. 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

15. 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

16. 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)

17. 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)

18. 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

19. 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

20. 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 SIJ’s

21. 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)

22. Aetiology of Dysfunction • The normal spacing 0.5-5 mm • Pregnancy: 9.0-12mm • Abnormal : 1 cm and above

23. Aetiology of Dysfunction • If widening is excessive or too rapid, instability results with increased ranges of motion at one or both SIJ’s causing a repetitive type strain with resultant pain and usually inflammation Male Soccer Player

24. Aetiology of Dysfunction • Post partum 28 year old female, 3rd child

25. 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 1:36 of those women did or would suffer pelvic dysfunction

26. Aetiology of Dysfunction • 2. Failure of symphysis to close after delivery • During delivery as the baby’s 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

27. 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

28. Aetiology of Dysfunction • Failure to separate can be as counterproductive as excessive widening as; • Separation provides extra space in the birth canal for the baby’s 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. Aetiology of Dysfunction • Traumatically induced as a result of sporting incidences

36. 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)

37. 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

38. 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

39. 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

40. Postural Examination • Note the subtle anterior pelvic tilt (24 year old hockey player nulliparous)

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

42. Postural Examination Pre Correction Post Correction

43. Postural Examination

44. Radiological • Weight bearing X-rays in a “Flamingo” stance best illustrates symphysis instability

45. 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 Beardall’s test • This weakness is classically accompanied by hypertonic hamstrings

46. Muscle Weakness • Beardall’s 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

47. 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

48. 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

49. Biomechanics of Muscle Weakness • This test will show a significant percentage of pubic symphysis subluxations • When suspected but Beardall’s test is negative, incorporating 10-20˚ of external leg rotation will show the rest

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