Incorporating Critical Thinking into Physical Therapy Practice
PROBLEMS WITH ISOLATION WITH THIGH THRUST TEST The thigh thrust test can be very non-specific. Prior to performing it one should clear the hip joint, especially for possible FAI, labral tear, etc meaning screen for these ase to discern if they are present and are the primary pain generators. If ruled out, then the clinician can palpate the dorsal ligaments of the SIJ, just medial to the PSIS to discern when forces are localized there, which is very proximal to the mid-joint. Further isolation can be achieved with adduction. The clinician can also palpate the lumbosacral junction. There is great intra, and sometimes inter-individual differences in isolation of forces in the proximity of the SIJ such that the 90 degree angle can yield false positives and false negatives. The anteriro SIJ capsule and ligament has an upper lumber nerve supply, whereas the posterior SIJ ligaments and capsule has a lower lumbar and S1, S2 =/- S3 contribution. The old macromotion “SIJ mobility tests” do not, cannot isolate the SIJ are actually pelvic mobility tests (Hesch 1990, 1992), Sturesson et al did several nice studies affirming the SIJ does not move with these typical tests, except for a very small amount of motion such as end-range straddle position. Passive forces imparted tot he pelvic structure do induce compression and release in the SIJ, demonstrating that normative motion goes through the SIJ, a much more functional perspective than “motion IN the SIJ”. This was demonstrated with fluroscopy. True SIJ hypermobility and symphysis p[ubis hypermobility and pain such as post-partum is valid, although it effects a minority, fortunately. However, itt is easily over-interpreted as a case study demonstrated in which a cleint in late pregnancy presented with all classical signs and symptoms of “instability”. Her symptoms were most likely mediated by her pelvic organs, because her SIJ and pubic joints were surprisingly void of descernible motion. One treatment yielded significant pain relief, resolved antalgia, resolved urinary frequency and perhaps facilitated a very easy delivery. It also greatly lessened a 15-year diagnosis of “interstitial cystitits”. Another proximal concept is that of sacroiliac supports. Applied at the ASIS’ they actually enhance lower pubic and lower sacroiliac hypermobility in the post-partum state. Much more appropriate is aplication at the trochanters which imparts up to 40% greater compression of pubic joint and SIJ. There is ample research to undergird this. Jerry Hesch, Hesch Institute
Jerry – this is great info regarding placement of belt at trochanters. Do you have research references? I’m interested in finding that. Also, you shared in the case study that it was “most likely mediated by pelvic organs” and that one treatment yielded relief. What was the treatment then? Visceral? Or still using your manual pelvic treatments? Thanks, Tracy
The treatement was mobilization to resolve a bilateral inflare and posterior glide fixation of the sacrum and then address bilateral anterior ilium. Here are the references. Best regards, Jerry
Bottlang M, Simpson T, Sigg J, et. al. Noninvasive reduction of open-book pelvic fracture by circumferential compression. J Ortho Trauma. 2002;16(6):367-73.
Bottlang M, Krieg JC, Mohr M, et al. (2002) Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg. 84(2):43-7.
Gardner M.J., Krieg J.C., Thompson PS, et al. Displacement after Simulated Pelvic Ring Injuries: A Cadaveric Model of Recoil. J Trauma. 2010;68(1):159-165.
Suzuki T., Morgan S. J., et. al. Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type 1 pelvic injuries. J Trauma. 2010;69(4):880-885.
Sagi HC, Coniglione FM, Stanford JH. Examination under anesthetic for occult pelvic ring instability. J Ortho Trauma. 2011;25(9):529-36.
Hefzy MS, Ebraheim N, Mekhail A, et. al. Kinematics of the human pelvis following open book injury. Med Eng & Physics. 2003;25:259-74.
Kowalk DL, Perdue PS, Bourgeois FJ, et al. Disruption of the symphysis pubis during vaginal delivery. A case report. J Bone Joint Surg Am. 1996;78(11):1746-8.
Thornton DD. (May 2011). Pelvic ring fracture imaging. Web, http://emedicine.medscape.com/article/394515-overview. Accessed October 23, 2012.
Doro CJ, Forward DP, Kim H, Nascone JW, et. Al. Does 2.5 cm of symphyseal widening differentiate anteroposterior compression I from anteroposterior compression II pelvic ring injuries? J Orthop Trauma. 2010;24(10):610-5.
Hesch J. Biomechanical evaluation & treatment considerations for patients with pelvic pain. Lecture presented at International Pelvic Pain Society workshop, Las Vegas, NV October 24, 2011.
Hesch J. Biomechanical evaluation & treatment considerations for patients with pelvic pain: advanced patterns of lumbo-pelvic-hip pathomechanics. Workshop presented at International Pelvic Pain Society workshop, Las Vegas, NV October 26, 2011
Kreig JC, Mohr M, Mirza AJ, et al. Pelvic circumferential compression in the presence of soft tissue injuries: a case report. J Trauma Injury Infection, Critical Care .Figure 2. 2005;59(2):469.
Krieg JC, Mohr M, Mirza A, et al. Pelvic circumnferential compression in the presence of soft-tissue injuries: a case report. Figure 2. J Trauma Inf Crit Care. 2005:468.
Just wondering is this debate still on-going?
I’ve just spent the weekend teaching a group of physios and imploring them to ditch the palpation findings of ASIS, ILA’s etc. when assessing & treating SIJD. I have also had the opportunity to review my own material before the course & trawl through the research to ensure I present to them the most balanced view based on current research findings.
In case anyone has not read my previous comments, my position is this: “The current osteopathic model based on altered positional findings implying faulty mechanics IS NOT supported by the current evidence”.
I do accept the numerous studies that show poor reliability & validity of bony pelvic palpation (I do not teach any of this on my course) and some of the motion studies and in any case the whole idea of this is based on a faulty premise and not supported by the known biomechanics of this joint i.e. these sacral & innominate dysfunctions have not been identified by the research. However there are some studies that have shown reasonable reliability of some portions of the motion testing (Hungerford et al, Physical Therapy 2007: Evaluation of the Ability of Physical Therapists to Palpate Intrapelvic Motion With the Stork Test on the Support Side). I know this is just one study but I do take issue with those who similarly take the findings from only a handful of studies on the pain provocative tests as if they are any better.
So I do teach the stance phase of the Stork test based on the work of Hungerford et al in Clinical Biomechanics 2004: Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers (I’ve followed both this discussion & other but I’m always amazed that these references are never mentioned!). In addition the ASLR (active SLR test) continues to stand up to research scrutiny as a valid test of load transfer across the pelvis and is supported by the form-force closure conceptual model. Based on this evidence it would be misleading to imply that we do not have at least some way of assessing SIJ-pelvic dysfunction.
I draw all your attention to the article by Christopher McGrath, International Journal of Osteopathic Medicine (2010): Composite sacroiliac joint pain provocation tests: A question of clinical significance. He presents compelling argument for why the provocative tests may lack clinical significance even though they may show some ‘statistical significance’. Don’t get me wrong I’m not knocking the study by Laslett et al 2010 but it’s wrong to present these findings of the provocative tests as some form of ‘gold standard’ when it’s only part of the story. There are methodological issues with the injections which invalidates them as the supposed gold standard procedure or benchmark on which to base everything else at. The McGrath article also presents amongst other issues a clear anatomical & histological alternative for why these tests may provoke pain.
Once again I would have to state my position that the current conceptual model is flawed and needs reviewing but the clinical model in some ways does get results what needs to be determined is why & what this mechanism may be. We definitely need to move away from telling patients their pelvis ‘is out of alignment’ and we have to stop teaching this to new graduates but at the same time let’s not throw the proverbial baby out with the water. For a more balance view I’d ask all to read the McGrath article otherwise practitioners may start developing ‘strong held beliefs’ based on limited studies and simply replace one model for another without some scrutiny with what we are replacing it with.
Would appreciate any comments & discussion even though it seems like we are flogging a bit of a dead horse!
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