Laterally Transposed Pelvis: a New and Proper Name for an Old Problem

• Laterally transposed pelvis: A new and proper name for an old problem

DAVID A. PATRIQUIN, DO

There is need for specific ter- Council on Osteopathic Principles (ECOP), a minology for osteopathic findings, includ- dedicated group of teachers of osteopathic princi- ing the findings in postural examination. ples, have spearheaded the effort. They meet A static test for laterally transposed pel- several times a year to discuss questions of com- vis is sometimes critical to the establish- mon concern relating to terminology, concepts ment of a diagnosis of postural imbalance, and philosophy, teaching methods, and course particularly in the minor forms of this im- content. A concern for standardization is an portant clinical entity. There is need for ongoing part of the proceedings. Among its a word or phrase that identifies this clini- other interests, EC OP specifically looks at cal finding and nothing else. terminology related to postural evaluation. The phrase laterally transposed pelvis Static and motion evaluations are separate is nominated to indicate a specific finding phases of the postural examination, each re- in the static evaluation of pelvic position quiring specific nomenclature. It is clear then in the frontal (coronal) plane in relation that the use of terminology applied, only by to the vertical extension of the midheel universal agreement, to the static phase of ex- line (sagittal plane). The definition of later- amination would provide a reinforcing signal ally transposed pelvis is: With the patient that a static postural finding is being reported. standing, knees fully extended bilaterally This etymologic device helps to clarify the ap- and the feet together on a flat horizontal plication of descriptors found in medical re- surface, the median (midsagittal) plane of cords. It reduces to a minimum the ambiguity the pelvis is observed to lie laterally to the too often found in clinical descriptions. vertically extended midheel line (median/ The search for laterally transposed pelvis midsagittal plane). is the third step in the three-step postural (Key words: Laterally transposed screening examination. It is undertaken after pelvis, osteopathic medical terminology, the examiner has decided whether there are posture) clinically significant anteroposterior and lateral spinal curves, and whether there is un- During the past 15 years, the osteopathic leveling of the iliac crests. The presence of profession has made great advances in the de- either or both of these findings strongly sug- velopment of standardized terminology. The gests that a laterally transposed pelvis will be members of the American Association of Col- present. leges of Osteopathic Medicines Educational Finding a laterally transposed pelvis provides additional information supporting the di- Dr Patriquin is professor of family medicine, Ohio Uni- agnosis of postural imbalance, especially when versity College of Osteopathic Medicine, Athens. there is minimal "suggestive" lateral spinal Reprint requests to David A. Patriquin, DO, Ohio Uni- curving and iliac crest unleveling. In this case versity College of Osteopathic Medicine, Grosvenor Hall, Athens, OH 45701. having a third "suggestive finding" in hand

472 • JAOA • Vol 92 • No 4 • April 1992 Clinical practice • Patriquin steps in the examination. A positive finding may help the examiner to decide that minor postural imbalance exists and requires further documentation and management. Make no mis- take, it is often critical to identify the presence of a minor sacral base unleveling. Irvin underlines the importance of a minor unlevelness of the pelvis as he asks why widely known medical writers think that large differences in leg length have a deleterious ef- fect on scoliosis and small differences do not. He cites Greenmans view that low back pain followed unlevelness of the sacral base of 4 mm or more, even though he did not use a heel lift for the treatment of the associated lumbar scoliosis. Terminology used in postural examination Postural descriptors related to the previous dis- cussion are found in the osteopathic literature. They include lateral shift of the pelvis, lateral displacement of the pelvis, lateral shift of the sacrum, hip shift, and pelvic sideshift. Each of these terms has multiple definitions and applications. None of them is used universally to refer solely to the static finding of pelvis acral position in the coronal plane in relation to the vertically extended midheel line. • Lateral shift of the pelvis was described by Strachan2: Figure 1. Laterally transposed pelvis, in this case to the "When a normal standing subject later- right, of the vertical extension of the midheel line with oflexes to the right he avoids the tendency counterbalancing of the upper body to the left of the to fall to the right by shifting the weight of midheel line. the pelvis and lower trunk to the left, while bearing more weight on the right foot." This could nudge the clinician to pursue the possi- description refers to a dynamic motion/bal- bility that pelvic imbalance (obliquity) exists, ance response pattern. and to order x-ray films of the patient in the • Lateral displacement of the pelvis is a con- standing position for documentation. comitant (balancing) motion in the walking In clinical situations where the identifica- cycle in which " the center of gravity is dis- tion of spinal curving and iliac crest unleveling placed laterally over the weight-bearing ex- remains uncertain, the finding of asymmetric tremity twice during the cycle of motion."3 position of the pelvis in the frontal plane, rela- This description again includes dynamic mo- tive to the vertically extended midheel line, tion/balance content and meaning. can help to determine the presence or absence • Lateral shift of the sacrum was used by of sacral base unleveling and postural imbal- Hoover and Nelson4: ance. In this instance, the finding of a later- "... while lifts on the long leg tend to increase ally transposed pelvis plays a critical role in the compensatory lateral shift of sacrum and diagnosis when added to the minimal abnor- pelvis...." This usage may limit itself to de- malities identified in either or both of the other scribing a static finding while at the same

Clinical practice • Patriquin JAOA • Vol 92 • No 4 • April 1992 • 473 time it seems to deal with a response to a demand for/of compensation. The application of this phrase is ambiguous. • Hip shift has been used by Johnston,5 who said, "In the case of positive hip shift there will be resistance to motion laterally in one direction while there will be a free and un- restricted movement in the opposite direction." This clearly is a response to force applied by the examiner in "dynamic" testings. • Pelvic sideshift is defined as follows: "Deviation of the pelvis to the right or left of the central axis, usually observed in the standing position."67 This description appears to deal with a static examination finding. It uses the word shift, which carries with it a connotation of motion. A brief review of these descriptors and definitions reveals confusing and nonspecific use of words, none having one meaning alone. The literature reveals no conventions about the meaning of these words except those assigned by the authors. However, we need descriptors having clear meanings which, by agreement, mean one thing only. Figure 2. The examiner crouches behind the patient, For an example of the multiple confusing eyes at the level of the iliac crests, both arms fully ex- and individualized applications of a term, here tended with the palms against the most lateral portion is how several authors use the phrase pelvic of the trochanteric area. The examining physician com- shift: pares the distances from his or her palms to the vertically (1) A shift of the symphysis.8 extended midheel line. When the distances are unequal, laterally transposed pelvis exists. (2) Lateral movement of the whole pelvis in relation to a perpendicular line from between the two heels.9 however, in need of a word or words to describe (3) The symphysis and the pubes being off a pelvic positional finding on static postural ceilter.1° evaluation. Clearly, the different authors say, and The word shift appears frequently in descrip- mean, different things while using the same tors of lateral displacement of the pelvis. It words. One must agree that the meanings has, as I have indicated, a connotation of mo- approximate each other. They lack, however, tion. Wide use of the word suggests the spe- the clearness, conciseness, and specificity that cial need for a descriptor of lateral pelvic posi- we need in osteopathic medical language. tioning. I must admit that I have had a strong Their general use is fuzzy, the result of multi- preference for the word shift, but this prefer- ple applications. ence has greatly weakened as I have come to Some words and phrases are beyond the recognize that shift carries with it a strong no- scope of this paper. They are clearly reserved tion of change or motion, which better fits it for description of findings resulting from other for description of a motion test response. The than static examination. For example, hip shift attendant idea of motion clearly rules out its is meant, by Johnston,5 to represent a response use in the definition of a static postural ex- to a translational force applied to the hip by amination finding. If any phrase using the the examiner, which is a motion test. We are, word shift is powerfully misleading, even in-

474 • JAOA • Vol 92 • No 4 • April 1992 Clinical practice • Patriquin accurate, then how shall we define this physi- vis is identified by a combination of position- cal examination finding which is so helpful in ing of the examiners eyes and hands and care- diagnosing postural imbalance? ful observation. The examiner crouches or I offer the phrase laterally transposed pelvis kneels, at arms length, behind the patient who to indicate the lateral location of the midline stands straight with knees fully extended, feet of the pelvis in the coronal plane in relation together, the arms at the sides, and head fac- to the vertically extended midheel line (sagit- ing forward. The examining physicians arms tal plane), with the patient standing motion- should be extended and palms placed against less with the feet together on a flat surface. the most laterally projecting areas of the pa- The phrase is a composite of the several ideas tients trochanteric (lateral hip) areas without already noted. It clearly establishes a basic ref- attempting to move or displace them in any erence to the static postural evaluation. It sug- way. The examiner, eyes positioned at the ap- gests that the pelvic position has changed from proximate horizontal level of his or her hands, some earlier position. It is universal and spe- then visually extends a reference line or plane cific. Its usage obviously depends on broad ac- vertically from between the two heels of the ceptance and specific application throughout patient up through the pelvisacral area. As the profession. noted, the examining physician may require some vertical reference in the examining room Laterally transposed pelvis to establish the vertical midheel line. The ex- The proposed definition of laterally transposed aminer then compares the distance from the pelvis is as follows: With the patient standing, palm of each hand to the imagined vertical knees fully extended bilaterally and the feet midheel line. A laterally transposed pelvis ex- together on a flat, horizontal surface, the me- ists when the distances from each hand to the dian (midsagittal) plane of the pelvis is ob- vertical midheel line appear to be unequal (Fig- served to lie laterally to the vertically extended ure 2). midheel line (median/midsagittal plane). An Other visual cues aid the examiner in the example of this condition is shown in Figure 1. identification and quantification of laterally This definition provides the inclusions and transposed pelvis if the situation is not obvi- exclusions necessary for the application of the ous. The lateral outline of one flank, just above designation. It clearly refers only to the stand- the iliac crest, may appear flat and vertical ing (weight-bearing, knees extended–feet to- whereas the other flank is noticeably concave. gether) position. The textbook definition of me- One often sees a deep, unilateral, anteropos- dian plane includes the idea of the sagittal terior skin fold at the posterolateral flank of plane that specifically bisects the pelvis. This the side toward which lateral transposition of plane bisects both the sacrum and the pubic the pelvis has occurred. Finally, on the side symphysis. Whenever this plane does not co- of the pelvis toward which there is lateral trans- incide with the vertically extended midheel (me- position, the hand and wrist of the patient may dian sagittal plane) line, a laterally transposed be in close proximity to or in contact with the pelvis exists. Early on, the examiner may re- lateral surface of the hip, whereas the other quire a plumb bob and string to assist in the hand and wrist hang well clear of the lateral establishment of a visually "vertically ex- hip structures. tended midheel line." Later, any vertical line or structure in the examining room may pro- Comment vide sufficient reference. This definition ex- This paper has discussed a specific aspect of cludes the special situation, often seen in stand- the static postural examination, more specifi- ing x-ray films, in which the midline of the cally the definition and language rules ap- sacrum is on one side of the midheel line and plicable to the description of the altered the pubic symphysis is on the other side (pel- "static" position of the pelvis in relation to the vic rotation around a vertical axis). vertical extension of the midheel line. Vari- The presence of a laterally transposed pel- ous conflicting and ambiguous terminologies

Clinical practice • Patriquin JAOA • Vol 92 • No 4 • April 1992 • 475 have been used to describe and record this par- ture, in American Academy of Osteopathy 1950 Year Book. New- ark, Ohio, American Academy of Osteopathy, 1950. ticular finding on postural static examination. 5.Johnston WL: Hip shift: Testing a basic postural dysfunc- The specific terminology suggested, if applied tion. JAOA 1964;63:923-930. universally, would eliminate a semantic prob- 6. Glossary of osteopathic terminology, in AOA Yearbook and lem currently found in clinical literature and Directory of Osteopathic Physicians 1990. Chicago, Ill, Ameri- can Osteopathic Association, 1990. discussions. 7. Kappler R: Postural balance and motion patterns, in Pos- tural Balance and Imbalance. Newark, Ohio, American Acad- 1.Irvin RE: Reduction of lumbar scoliosis by use of a heel lift emy of Osteopathy, 1983, pp 7,11. to level the sacral base. JAOA 1991;91:34-44. 8. Kerr HE, Grant JH, MacBain RN: Some observations on the 2. Strachan WF: Lateral imbalance and the use of lifts. JAOA anatomical short leg in a series of patients presenting them- 1941;51:190-192. selves for treatment of low back pain. JAOA 1943;52:437-440. 3. Sanders M, Inman VT, Eberhart HD: The major determi- 9. Schwab WA: Principles of manipulative treatment. III: Low nants in normal and pathological gait. J Bone Joint Surg back problem. JAOA 1932;253-261. 1953;35-A:551. 10.Pearson WM: The mechanism of sacral base unlevelling. J 4. Hoover HV, Nelson CR: Effects of gravitational forces on struc- Osteopathy 1939;46(January):18-21.

476 • JAOA • Vol 92 • No 4 • April 1992 Clinical practice • Patriquin