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The most common things I find clinically are:

• Sacral fractures, hemi • Hemorrhoids The Male and bilateral, acute and • Erectile dysfunction chronic non‐healed • Kenneth Lossing D.O. Coccygodynia • Pelvic pain • BPH • Prostate Cancer

The Patients That Return Too Often Wish You were a Magician?

• Chronic Pain • You’ve tried everything • Sciatica you know, the patient • Chronic Fatigue gets a little better, but continues to return • Headaches • You wish you could pull a rabbit out of your hat (Osteopathic bag of tricks)

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Sacrum Type A Minimally Displaced Non • The sacral segments normally Union Sacral Fractures fuse at about age 25. • Approximately 25% of the population has one or more sacral segments that don’t fuse properly. This leaves that segment more vulnerable to injury, if they should fall on their backside. (This number was arrived at by checking in the “bone room” in Kirksville.)

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Sacral Fractures, Acute and Chronic Right Lateral View, Old • After a fall, the sacral segments don’t always refuse, sacral hypermobility • Note line at has been found on pt.’s that S1‐2 hadn’t fallen in over 30 • Crosses years. articu lar • In this sacrum, note non surface ossification of S1‐2, and S2‐ • Note line at 3. Also on S1‐2 laterally, S2‐3 note hairline space. • Note line at S4‐5

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Planes of Displacement Sacrum‐ Diagnosis

• The displacement of the • Sacral fractures have a line segments can occur in one or of increased heat across the all 3 planes. hypermobile segment, also • Coronal plane-segments fascial listening in opposite directions. laterallyy( translated ( side • bending). MiMotion testing on the inferior sacrum will not • Saggital plane - translate all the way to the anterior/posterior upper sacrum. (flexion/extension) • This patient’s overall MTD • transverse plane (rotation) . 1st level is typically at 1.5cm, instead of 10cm.

Atlas of Human Anatomy, Sobatta 9 10

Structures to Test and Treat Before Sacral Treatment Reduction • Lab: One finger is inserted into • Spinal Dura the rectum, as close to the fracture as possible, the thumb is • Bilateral fixations of thoracic spine. used posteriorly. Add a slight compression and follow the listening until the parts realign. • Pelvic structures and floor. Your other hand stabilizes the upper sacrum. The pt is prone, • Sacrotuberous and Sacrospinous . and draped. • Additionally: treatment of • Ankles. anterior longitudinal and sacral lymph nodes • Upper Cervical spine. • Additionally: palpate attachments of SS and ST ligaments to the sacrum, looking for rough areas that are tender. Press in direction of tension until it softens. (trigger bands)

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Sacral Fractures Sometimes our model is right, sometimes not. • Approximately 600 cases treated • Is it a fracture? • Approximately 80% improved • Is it a disc remnant? • Approximately 2% got worse • Is it an intraosseous • Approximately 4% never stabilized strain? • Treatments internally, usually 1‐2 • Is it a pseudoarthrosis? • Treatments total, 1‐30, average of 16 • All of the above? • Not considered stable for 4 months.

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References of Sacral Fractures • Orthopedics References • Borelli, Koval, Helfet, Posterior Fracture Dislocations of the Sacroiliac , Clinical Orthopedics and • Neurosurgery Related Research, number 329, August, 1996

• Sports medicine • Hatem, Wet, Vertical Fracture of the Central Sacral Canal: Plane and Simple, Journal of Trauma:Injury, Infections, and Critical Care, vol. 40. No. 1 • Gynecology • Ebraheim, Savolaine, Skie, Baril, Longitudinal Fracture of the Sacrum: Case Report, The journal of • Chiropractic Trauma Vol. 36. No. 3 • Rheumatology • Ebraheim, Biyani, Salpietro, Zone III Fractures of the Sacrum. A Case Report. Spine Volume 21, Number 20,pp2390-2396 • Radiology • Fanciullo, Bell, Stress Fractures of the Sacrum and Lower Extremities, Current Opinion in • Trauma Rheumatology, 1996, 8:158-162 • McFarland, Giangarra, Sacral Stress Fractures in Athletes, Clinical Orthopedics and Related Research, • Pediatrics Number 329,PP 240-243

• Google show over 38,000 entries • Leroux,Denat, Thomas, Biotman, Bonnel, Sacral Insufficiency Fractures Presenting as Acute Low-back Pain, Spine, volume 18, Number 16,pp2502-2506

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Take Home Points Indications to Evaluate and Treat Sacral Fractures • Sacral fractures are common, not uncommon. • General listening takes you there. • Most are older, non union fractures, not • Fascial listening in opposite directions the acute ones mentioned in literature. intersegmentally on the sacrum. • MjMajor ity respond well to OOtsteopa thic • Chihronic Fatigue. reduction. • Fibromylgia. • Need to find a consistent imaging technique. • Chronic back or neck pain. • Often a can of worms. • Chronic headaches.

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Anterior Longitudinal Ligament Sacral Lymph • Remember that the ALL is Nodes only a thickening of the • “Found along the median and connective tissue around the lateral sacral vessels and an spine. obturator node, sometimes • Test: Patient supine, knees occurring in the , they are outlying bent, palpate gently and members of the internal iliac deeply to the promontory. Do group. There is considerable a listening test, also motion bypassing in the iliac groups of test laterally, superior and lymph nodes. inferior. Lymphangiographic studies have demonstrated the • Treat: with either fascial connections between the right release or a recoil. and left groups”. • You can also palpate this • Lab: Either internally or internally as presacral . externally, palpate the lymph Check and treat with both flow on the anterior sacrum, listening and motion testing. until it flows correctly.

The Fascia, Paoletti 19 Atlas of Human Anatomy, Netter 20

Coccyx • Posteriorly, the posterior • The coccyx has an sacroccygeal ligaments are articulation with the sacrum. continuous with the Anteriorly, the anterior and sacroccygeal ligaments are has fibers also from the fascially continuous with . the: anterior longitudinal • The sacrotuberous ligament and fibers of the ligaments are a . continuation of the tendon • The sacrospinous ligaments of the bicepts femoris, attach along the anterior attaching onto the ishial and lateral borders of the tuberosity, then the coccyx, sacrum and coccyx, with the sacrum, and continue as the fibers extending anterior posterior sacroiliac and inferior to the spinous ligaments. process of the ishium.

Thieme Atlas of Anatomy 21 Thieme Atlas of Anatomy 22

Diagnosis of SS ligament Diagnosis of ST ligament • With the patient prone, • With the patient prone, palpate the ishial palpate lateral to S5, tuberosity, then follow the sacrotuberous the ishial spine will be ligaments medially and found in a small posteriorly to the coccyx depression. Press this and sacrum. Press the ligaments laterally, noting area anteriorly, noting ease of distensabilty length of distensibility bilaterally. and end feel. Compare • New: also palpate the both sides. attachment of the ligament to the sacrum, looking for tender areas (trigger‐bands). Thieme Atlas of Anatomy 23 24

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Motion Testing Coccyx Abnormal Test Interpretation

• While palpating the coccyx • When side bending the “body” to the right, with a finger on each side of the coccyx, side bend the the coccyx will side bend to the right, unless patient to the right. If the the left ligaments ( ST or SS) are too tight. motion is good, the coccyx will first side bend to the • If the left ST or SS ligaments are too tig,ght, the right, then with further coccyx will not side bend to the right at the body side bending, the beginning of “body” right side bending, but coccyx will side bend to the left. will side bend to the left at the end of “body” • Repeat testing procedure to side bending. the left.

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Indications to Evaluate and Treat the Coccyx Manipulation, Rectal Coccyx • If anterior ligaments are • General listening takes you there. tight‐ stretch • Pain in the area with sitting. posteriorly. • Pain in the coccyx when pressed. • If posterior ligaments • Declining quality of sexual relationships. are tight‐stretch • Recurrent cystitis. anteriorly. • Urogenital ptosis. • Stretch a little, let the • Urinary incontinence. coccyx return, and • Prostatitis and Hemmorhoids. stretch again. • Generalized devitilization and depression.

Urogenital Manipulatipon, Barral 27 28

The Prostate Gland Cross Section of Prostate • “The prostate is a firm, partly glandular, partly fibromuscular body, • The lymphatic surrounding the beginning of the capillaries arise in male urethra. It lies at a low level in the glandular acini, the lesser pelvis, behind the inferior and anastamose to border of the pubis and form a perilobular pubic arch and anterior to the rectal ampulla, through which it may be network. The palpated. Being somewhat conical, it lhlymph vessels are presents: above, a base or vesical smaller near the aspect; below, an apex and also a center of the posterior, an anterior and two gland, and form a inferolateral surfaces’. periprostatic • Grays Anatomy subcapsular network.

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Frontal Section of Prostate Sagital Section of Prostate • The base is largely contiguous with the neck of the bladder • The inferolateral above it; the urethra enters here, nearer its anterior border. surfaces are related to • “The anterior surface, transversely narrow and convex, the anterior parts of extends from the apex to the the levatores ani, base, about 2 cm behind the from which it is which are separated separated by a venous plexus and loose adipose tissue. Near from them by a plexus its superior limit it is connected to the pubic bones by the of veins embedded in puboprostatic ligaments. The the fibrous prostatic urethra emerges from this surface anterosuperior to the sheath. apex of the gland.”

Atlas of Human Anatomy, Netter 31 Atlas of Human ANatomy, Netter 32

Posterior Prostate Prostate Lymphatics • Preaortic • The apex is inferior • Promontory and in contact with • Internal iliac the fascia on the • Middle and lateral superior aspects of sacral the sphincter urethrae and • External iliac transversi perinei profundi .”

Atlas of Human ANatomy, Netter 33 Atlas of Human Anatomy, Netter 34

Lymphatic Drainage of Prostate Enlarged Prostate

• ‘Collecting vessels from the • An enlarged prostate ductus end in the external iliac nodes, while those from the gland can compress the seminal vesicle go to the urethra, thus causing internal and external iliac problems with urination. nodes. Prostatic vessels end mailinly in ilinternal iliac and Prostate enlargement sacral nodes; a vessel from the may be caused by posterior surface accompanies prostate overgrowth the vesical vessels to the (benign prostatic external iliac nodes and one from the anterior surface gains hypertrophy or the internal iliac group by hyperplasia) or prostate joining vessels of the cancer. membranous urethra”. Grays Anatomy 35 36

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• Benign prostatic BPH hypertrophy is a non‐ IPSS cancerous enlargement of • Pt self assessment for BPH,(although it cannot be the prostate gland, used to establish a diagnosis of BPH) used to guide commonly found in men treatment options and monitor the response to over the age of 50. treatment.1‐7=mild, 8‐19=moderate, 20‐ • Symptoms: slower and 35=severe. weaker urinary stream, frequency, urgency, sensation of incomplete emptying, nocturia. • Digital rectal exam shows: Homogenous, symmetrical enlargement of the prostate.

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• Antidepressants, PSA antihistamines and bronchodilators can increase the • PSA is organ specific, not disease specific. symptom score by several points. • As many as 75% of men presenting with • Anticholinergics elevated PSA levels are not found to have iiimpair bla dder prostate cancer after biopsy. contractility. • In the absence of prostate cancer, serum PSA • A clinical useful correlation exists levels vary with age, race, and prostate between prostate volume. volume and serum PSA.

Campbell‐Walsh Urology, 9th ed 39 Campbell‐Walsh Urology 40

TURP• Transurethal resection is Medical Therapy the most common • Relative to TURP has fewer side effects, surgery for BPH, but has reversible side effects, less serious side effects. decreased by 50% in the last decade. • Terazosin and doxazsin are long acting Alpha • An absolute indication adrenergic blockers that have shown to be safe for TURP is recurrent and effective for the treatment of BPH. urinary tract infections. • Finasteride significantly decreases the long term • Stents can be placed for risk of acute urinary retention and surgical patients unfit for TURP intervention. surgery.

41 Campbell‐Walsh Urology, 9th ed 42

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Digital Rectal Exam Prostate Cancer • Prostate cancer is common, and should be palpated for during a rectal exam. The • 70% of men with PSA prostate will feel enlarged, and may have bumps. An area of hardness in the gland between 4 and 10ng/mL have suggests cancer, but can also be due to organ confined disease. prostatic stones, chronic inflammation, and • Treatment of prostate cancer other conditions. varies depending on the stage • DRE and PSA are the most useful first line of the cancer, it may include tests for prostate cancer. surgery, radiation, • The median sulcus may be obscured. chemotherapy, hormonal manipulation, or a combination of these.

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Digital Rectal Exam Palpation

• The patient is left side lying or prone, • If you cannot advance, have covered with a sheet. patient contract and release • Glove both hands, anus a few times. apply lubricant to your index finger. • If you still cannot advance, • Lift sheet and you may be in a pocket, separate the slightly retract finger and try patient’s buttock again. checks to visualize the anus. • Try to appreciate superficial • Place pad of index on and deep external anus, wait for sphincters, levator ani. sphincter to relax, insert index, palmar • Palpate the prostate aspect of finger towards the sacrum.

Clinical Examination, Epstein 45 46

• Have pt tighten sphincter, note Anal Musculature tone. • Rotate finger to examine rings, • External look for trigger • Corrugator cutis ani Sphincter points. muscle • Deep External • Examine lateral • External anal sphincter Sphincter and posterior walls. muscle • Mosby’s Guide • Internal anal sphincter to Physical • Levator Ani muscle Examination, Seidel • Deep external anal sphincter muscle

Mosby's Guide to Physical Examination, Atlas of Human Anatomy, Netter 47 48 Seidel

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Sphincter Ani Common Anal Lesions

• TP’s : aching pain in the anorectal region and occasionally painful bowel movements. • Internal exam: Finger inserted to past anal sphincter, then slightly withdrawn to between internal and external ring.

49 Clinincal Exam, Epstein 50

Hemorrhoids Palpating the Prostate • Hemorrhoids are swollen (enlarged, dilated) veins (varicose veins) inside or outside the anus that are usually caused by increased pressure, such as straining when constipated or during pregnancy. • Check liver mobility and congestion, also check sigmoid. Sometimes the hemorrhoids will reduce when you treat these structures.

51 Clinical Examination, Epstein 52

Prostate Mobility Tests Pelvic Floor Muscles

• Motion tests: • Superficial: • compression anteriorly • Bulbospongiousis • decompression • Superior transverse • Superior translation • Ishiocavernosus • Inferior translation • External anal sphincter • lateral to left • In males, the • Lateral to right bulbospongiousis and • Rotation to right and left ishiocaverosus contribute to erections.

Manual Therapy for the Prostate, Barral English version due in June 53 Myofascial Pain and Dysfunction, Travell 54

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Referred Pain Patterns Referred Pain Patterns

• Right: • Gluteus • Sphincter ani Maximus • Levator ani • coccygeus

Myofascial Pain and Dysfunction, Travell 55 Myofascial Pain and Dysfunction, Travell 56

Referred Pain Patterns Referred Pain Patterns

• Gluteus medius • Gluteus Minimus

Myofascial Pain and Dysfunction, Travell 57 Myofascial Pain and Dysfunction, Travell 58

Indications for Evaluation and Referred Pain Patterns Treatment of the Pelvic Floor. • Piriformis • General listening takes you there. • Urogenital problems. • Lower extremity problems. • Generalized low vitality. • Congestion in the cecum or sigmoid colon.

Myofascial Pain and Dysfunction, Travell 59 60

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Pelvic Floor Myofascial Trigger Points: Manual Therapy for Interstitial Cystitis and the Urgency‐ Obturator Internus Muscle Frequency Syndrome • Repetitive • Compression and compression to stretching of pubococcygeus tenderpoints while muscle. having the patient • Stretching of abduct the thigh urogenital against resistance. diaphragm.

THe Journel of Urology, December 2001, 61 Weiss 62 Jerome Weiss

Results The Can become entrapped in Alcock’s canal. • 70% of cases of interstitial Supplies much of the pelvis cystitis had marked to moderate improvement.83% of urggyency‐freqqyuency syndrome had marked to moderate improvement. • 1‐2 visits weekly. • They were able to show EMG improvement on pelvic floor hypertonus.

Weiss 63 Atlas of Anatomy, Netter 64

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