Common Presentations and Diagnostic Techniques

7 Chapter 2 Common presentations and diagnostic techniques CHAPTER CONTENTS The sacroiliac joint 9 Pelvic obliquity 65 Anatomy, development and aging 11 In standing 68 SI joint mobility 17 In sitting and lying supine or prone 68 Axes of motion 18 Bony landmarks of the pelvis 68 Biomechanics 19 In alignment and with leg length equal 70 Trunk flexion 21 In alignment, with an anatomical (true) Trunk extension 21 leg length difference 70 Landing on one leg 26 Sacroiliac joint ‘upslip’ 70 Vertical forces on the sacrum 26 ‘Rotational malalignment’ 72 Ambulation 26 ‘Outflare and inflare’ 72 Kinetic function and stability 26 ‘Sitting-lying’ test 73 Panjabi: active, passive and neural control Clinical correlation: ‘sitting-lying’ test 76 systems 27 Torsion of the sacrum 84 ‘Self-locking’ mechanism and ‘form’ and ‘force’ Sacral landmarks 84 closure 29 Sacral torsion patterns 85 Sacroiliac joint ‘form’ and ‘force’ closure 31 Clinical correlation: sacral torsion 87 Sacroiliac joint function during the gait Curves of the spine and vertebral rotational cycle 39 displacement 87 Common presentations of pelvic malalignment 40 Clinical correlation: curves of the spine 95 ‘Rotational malalignment’ 41 Examination of the symphysis pubis 96 Aetiology of ‘rotational malalignment’ 42 Clinical correlation: alignment at the symphysis Sacroiliac joint ‘upslip’ and ‘downslip’ 58 pubis 97 Sacroiliac joint: unilateral ‘upslip’ 58 Hip joint ranges of motion 99 Sacroiliac joint: ‘bilateral upslip’ 60 Assessment of ligaments and muscles 99 Sacroiliac joint: ‘downslip’ 60 Tests used for the examination of the pelvic girdle 100 Pelvic ‘outflare’ and ‘inflare’ 61 Tests for mobility and stability 101 ‘Outflare’/’inflare’ in the normal gait cycle 61 Leverage tests 101 The malalignment presentations of ‘outflare’ Spring tests 104 and ‘inflare’ 62 Functional or dynamic tests 106 Establishing the diagnosis of malalignment 65 Flexion and extension tests 108 © 2013 Elsevier Ltd. All rights reserved. DOI: 10.1016/B978-0-443-06929-1.00002-8 8 The Malalignment Syndrome Ipsilateral kinetic rotational test (Gillet test, Symmetrical movement of the innominates relative stork test) 111 to the sacrum 120 Single-support ‘kinetic’ test 111 Excessive ‘bilateral anterior’ innominate Clinical correlation: kinetic tests 114 rotation 120 Evaluation of load transfer ability: active straight Excessive ‘bilateral posterior’ innominate leg raising 115 rotation 121 Form closure (passive system) to supplement Sacral rotation around the coronal axis 121 ASLR 118 ‘Bilateral sacrum anterior’ 121 ‘Force’ closure (active, motor control system) to ‘Bilateral sacrum posterior’ 121 supplement ASLR 119 The standard back examination can be Simultaneous bilateral SI joint malalignemnt 120 misleading 122 An understanding of the ‘malalignment syn- about 25% and disc protrusion in 1-2% of the drome’ requires a knowledge of the common pregnant women. The findings were confirmed by presentations of malalignment and the techniques further CAT scan and eventually MRI studies, such used to diagnose and treat these. Key to this is an as the one by Boos et al. (1995) who, in a study of understanding of the sacroiliac (SI) joint and the asymptomatic subjects, found that as many as 75% role it plays in the normal and abnormal function- had evidence of disc degeneration and some an ing of the unit formed by the lumbosacral spine, actual disc protrusion. pelvic ring and hip joints (henceforth referred to From the late 1930s into the 1990s, research as the ‘lumbo-pelvic-hip complex’). Interestingly, focused largely on SI joint anatomy and biome- in the early 20th century, the SI joint was thought chanics (Bernard & Kirkaldy-Willis 1987; Bowen & to be the main source of low back pain and was Cassidy 1981; DonTigny 1985; Vleeming et al. the focus of many scientific investigations. The 1989a, 1989b, 1990a, 1990b, 1992a, 1992b). More recent publication, in 1934, of a paper by Mixter and Barr interest in rehabilitation involving the SI joint may be on rupture of the intervertebral disc quickly attributable in large part to the following two factors: changed the direction of these investigations; over 1. Publications of studies in the mid-1990s the next four decades, the SI joint was more or less suggesting initially that approximately 20–30% of ignored in favour of the disc as a primary cause of low back and referred pain came from the SI joint back pain. itself and/or the surrounding ligaments, muscles The resurgence of interest in the SI joint since and other soft tissues involved in the functioning the 1970s can be attributed in large part to the of the joint (Maigne et al. 1996, Schwarzer et al. following: 1995). 1. a failure of disc resection and subsequent 2. Presentation of the first International World desperation measures, such as disc-to-disc or Congress on ‘Low Back Pain and its lumbo-pelvic fusions, to relieve the persisting Relationship to the Sacroiliac Joint’, hosted by low back pain San Diego in 1992 and, subsequently, by other 2. the recognition of the short-and long-term major cities on a tri-annual basis. The congress complications of chymopapaine ‘discectomy’ has become a forum for the presentation of 3. the evolution of the computed tomography clinical experience and ongoing research on the (CAT) scan and, subsequently, magnetic SI joint and the lumbo-pelvic hip complex and resonance imaging (MRI), with gradual has led to the publication of a number of books recognition of the fact that disc protrusions and articles in this field (e.g. Vleeming et al. were common but did not necessarily cause 2007; Lee 2011). back pain. Over the past decade, ongoing integration of clinical A CAT scan study of fetuses in utero by Magora & experience and research (e.g. Willard 2007, DeRosa Schwarz (1976) was the first to report the coinciden- & Porterfield 2007; Barker & Briggs 1998, 1999, 2004, tal finding that disc degeneration was evident in 2007) has led us to recognize that: Chapter 2 Common presentations and diagnostic techniques 9 1. The ‘inner core’ muscles help stabilize the pelvis back pain and referred pain symptoms from this and lumbar spine and, in tandem with the ‘outer site, or ‘pain generator’ (Vleeming & Stoeckart core’ muscles, ligaments and myofascia form a 2007). Pain may localize to the structure initially system of well-defined ‘slings’ or ‘cylinders’ involved (i.e. vertebra, lumbosacral junction, SI that can: joint or other) but even at the onset can present as a. absorb shock referred pain felt only nearby or at a distant site b. help support the bony structure of the spine, on the same or opposite side (see ‘Introduction pelvis and hip joints and allows for weight 2002’; Fig. 3.63). Eventually, the abnormal stress transfer through the acetabular, sacroiliac and pelvic malalignment exerts on soft tissues and lumbosacral regions joints throughout the body may cause them to c. provide stability in preparation for carrying become painful and a source of referred pain, so out activities with other parts of our body that the actual site or sites where the pain is felt d. ensure balance and facilitate motion of the may be misleading to the person reporting the pelvis, spine/trunk and the limbs to carry out a pain and to those trying to determine and treat specific action, such as throwing a ball the underlying problem that precipitated this 2. As a result of the functional kinetic interlinkage chain of events. An example is the common of the skeleton with these core muscles and complaint of pain ‘from the hip joint’ on one side, myofascial ‘slings’, pathology affecting any of when the pain is actually: these structures can stress other proximal and a. originating from the nearby SI joint or trigger even distal sites, sometimes to the point of points in piriformis (Fig. 3.45), or interfering with their proper function and b. referred from the iliolumbar or sacroiliac causing them to become another ‘pain generator’ ligaments to the hip joint, groin or greater (Vleeming & Stoeckart 2007; see also Ch. 8). trochanter regions (Figs 3.46, 3.62, 3.63). Rotation of a vertebra, pelvic malalignment, 5. Recognition of malalignment and the typical excessive tension in a particular ligament or problems it can cause is, therefore, a key factor in muscle are all interlinked and affect the function helping determine whether the symptoms and of the rest of the musculoskeletal system. signs on clinical examination are attributable to Treatment needs to address that fact; it cannot be the malalignment per se, or whether the restricted to one site and will often require use of malalignment is covering up an underlying more than one treatment modality in order to be clinical problem. successful. This chapter will examine some old and new con- 3. Malalignment of the pelvis and spine initially cepts regarding the SI joint and lumbo-pelvic-hip may not be painful. However, with time the complex, then proceed to look at what will be the stress on an increasing number of structures is focus of this book: the common presentations of more and more likely to result in: malalignment - ‘rotational malalignment’, ‘upslip’ a. irritation and eventual hypersensitivity of the and ‘downslip’, ‘outflare/inflare’, sacral torsion nociceptive nerve fibres supplying these and ‘vertebral rotational displacement’ - before dis- structures (Willard 2007) cussing some of the tests that have, over the past b. chronic reactive contraction of specific decade, gained acceptance as being the more reli- muscles that are attempting to decrease able ones for examining the pelvis and spine in movement of a painful structure and/or to order to diagnose an alignment problem. stabilize a lax joint, with eventual complicating compromise of their own blood supply to the point where the muscles become THE SACROILIAC JOINT symptomatic as well c. adaptive changes in gait as a result of the The SI joints are planar joints that function to: biomechanical changes and/or in reaction 1.

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