OSTEOPATHIC APPROACH TO - PDF Document

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  1. OSTEOPATHIC APPROACH TO PELVIC DYSFUNCTION & RELATED ANATOMY Kevin Holmewood, D.O. FM/NMM September, 2018

  2. No financial relationships or interests to disclose

  3. Objectives • Address certain anatomical relationships surrounding our center of gravity • Reinforce our philosophy (and science) that the body is a unit and everything is connected • Explore common medical complaints by addressing specific anatomical areas • Discuss pain referral patterns and their relationship to treatment using Ligamentous Articular Strain/Balanced Ligamentous Tension

  4. Introduction -Pelvic girdle foundation for body support and locomotion -Alterations & restrictions can have a profound effect on vertebral function, thoracoabdominal diaphragm, pelvic/urogenital diaphragm, the lower extremities, and the craniosacral mechanism -Somatic dysfunction may be causative, contributory, or diagnostic for a wide range of patient complaints

  5. • Common complaints requiring evaluation of pelvis include abdominal pain, pelvic pain, dysmenorrhea, dyspareunia low back pain, urinary tract issues, lower gastrointestinal issues, and neuralgia of the lower extremities • Lumber spine evaluation is integrated into sacral/pelvic diagnosis • Goal is restoration of functional symmetry between arthrodial, neural, vascular, lymphatic, and connective tissue elements • Complaints may be somatic, visceral, or emotional in nature

  6. Low back pain • Lifetime prevalence is 70% • Most frequent cause of activity limitation in people 45 years of age and older • Second most frequent reason for physician visits • Fifth most frequent for hospitalization • Third ranking reason for surgical procedures • Sacroiliac joint often implicated

  7. History of SI dysfunction • No pathognomonic clinical picture • Pain referral to groin is suggestive • Pain referred to medial buttock, lateral to sacrum, and below iliac crest is a reasonable indication of SIJ problem • Quality of pain is usually described as sharp, dull, or aching • Can also refer to posterior thigh, and occasionally below the knee • Symptoms usually unilateral, aggravated by sitting and relieved by standing or walking

  8. frequently present in SIJ dysfunction • If short leg syndrome and sacral base un-leveling are present, will complain of low back pain and SIJ pain that is worse as the day goes on • Describe SI pain to the physician as “hip” pain • Since hip joint affects position and motion of the ilium, it also affects the sacrum and therefore lumbar distribution. • Hamstring tightness is

  9. Hip Joint related groin pain-when to image? Diagnosis uncertain AND will affect management decisions -Diagnosis is obvious, but EXTENT of injury is unclear -Options: Plain X- Ray(weight bearing and then supine) -MRI/MR arthrography(offers greater specificity for Labral pathology) -CT scan -Ultrasound

  10. Hip Joint Stability of joint provided by bony configuration; specifically the depth of the joint augmented by the labrum and strong capsular ligaments Labrum contains free nerve endings which has potential to be source of pain -Creates a suction effect on femoral head, generation a negative atmospheric pressure, enhancing stability Joint capsule reinforced by ligaments; strongest superiorly where under most loads during gait and stance

  11. Functional anatomy • True pelvis located inferior and posterior to abdomen • Begins at level of sacral promontory, pectinate line, and pubic bones • Ends w/ inferior fascia of pelvic diaphragm

  12. Accessory ligaments • Iliolumbar ligament • Sacrotuberous ligament-biceps femoris, piriformis, and gluteus maximus • Sacrospinous ligament

  13. Muscles and Connective Tissue • Thoracoabdominal wall aids in coordinating movements and pressures between the thoracic cage and pelvic girdle • Muscles acting on or through the pelvis can be classified as primary, Intrinsic muscles of the pelvic diaphragm and secondary, muscles considered to have partial attachment to the true pelvis

  14. Primary Intrinsic Pelvic Muscles Pelvic diaphragm: muscular partition formed by levator ani(pubococcygeus, puborectalis, and iliococcygeus) Urogenital Diaphragm: Spans area between the ischiopubic rami and formed by deep transverse perineal and sphincter urethrae muscles and their fascia

  15. Pelvic diaphragm

  16. Pelvic Diaphragm -Slants downward from the lateral wall to the midline perineal membrane -Provides support during defecation, inhibit bladder activity, and assist in providing lumbosacral pelvic support.

  17. Urogenital diaphragm --Rather level -Creates a small potential space(ishchiorectal fossa) bilaterally

  18. Secondary muscles • Partial pelvic attachment • Rectus abdominus, Transverse abdominus, Internal/External oblique, Quadratus lumborum • External oblique: forms inguinal ligament as it courses between ASIS and pubic tubercle. • Each compartment of LE has unique actions on the sacrum and pelvis

  19. Fascia and aponeurosis

  20. Fascia and aponeurosis

  21. Anterior & medial compartments of thigh may affect iliac and pubic motion -Quadriceps femoris -Pectineus -Sartorius -Gracilus -Adductor group -Iliopsoas

  22. Anterior & Medial Compartment Can give rise to pain referral pattern

  23. Pectineus

  24. Adductor Magnus Longus/Brevis

  25. Adductor muscle injury • Common in sports w/ sudden change in direction(hockey, soccer, rugby, etc.) • Adductor Longus(70%), Magnus(15%), other (Gracilus, Pectineus, Brevis=15%) • May be local tenderness, pain on passive abduction, pain on resisted adduction or combined flexion/adduction • Types of adductor injury include: • 1) Bony avulsion • 2) Avulsion of fibrocartilage(enthesis) • 3)Partial or complete tear and M-T junction

  26. Adductor injury -Sports hernia patient w/ associated R adductor longus origin tendonitis -Hypoechoic thickening that most involved the more superficial fibers(ARROWS) and could be seen to merge superiorly w/ conjoint insertion -Dotted arrow indicates a further small area of accentuated tendon hypoechogenicity that reflects an additional component of focally more severe tendinosis

  27. Conjoint tendon -Previously known as inguinal aponuerotic falx -Formed from lower part of the common aponeurosis of internal oblique and transversus abdominis as it inserts into crest of pubis and pectineal line immediately behind superficial inguinal ring Forms medial part of posterior wall of inguinal canal

  28. Myositis ossificans • Formation of bone tissue inside muscle tissue after trauma • Can present as warmth, swelling, a lump, decreased ROM • Somewhat common sports injury sustained at any level of competition • Treatment tends to be conservative: NSAIDs, topical treatments, heat, gentle stretching • If problem persists, treatment may include physical therapy for stretching and strengthening exercises to help decrease size of bony deposit • Surgery rarely needed • If calcification is removed too early and before it’s “mature”(6 to 12 months), it’s highly likely the deposit will form again in muscl

  29. Myositis ossificans

  30. Lateral compartment Tensor fascia lata and Iliotibial band The deep fascia of the thigh(fascia lata) is continuous w/ the superficial thoracolumbar fascia of thorax and spits to form the compartments of the LE

  31. Posterior compartment -Gluteus maximus, medius, and minimus -Piriformis -Obturator externus -Gemelli Sup/Inf -Biceps femoris -Semimembranosus -Semitendinosus Dysfunction of muscles or fascia may effect function of the pelvic girdle Fascia covering post aspect of piriformis and biceps femoris have been found continuous w/ SI ligament

  32. Implications •Physical activity and diagnostic tests, such as straight leg raising could stress the SIJ •Inflammation of SIJ could affect the piriformis and biceps femoris through reactive muscle spasm •Collectively, the muscles of gluteal region, the quadratus femoris, and iliopsoas comprise the rotator cuff of the hip

  33. “Rotator Cuff” of hip

  34. Pain patterns produced by myofascial trigger points

  35. Anatomic dissections • Traction on the posterior layer of thoracolumbar fascia transmitted force to the contralateral side, specifically into the fascia of the gluteus maximus • Contralateral latisimus dorsi to the involved gluteus maximus could affect stability of SIJ owing to the connecting fascia • Stability of SI region is achieved by a combination of ligamentous and dynamic muscular function crossing the SIJs • Tendons of the Erector spinae run inferiorly from the paraspinal areas to attach to the posterior surface of sacrum directly through the perimysial membranes of the multifidus