presentation - wedel, f.p. · monitor at the lumbo-sacral junction 1. flex the knees and hips until...
TRANSCRIPT
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F. P Wedel, D.O.,HMDCAssistant Adjunct Professor for Midwestern University Associate Adjunct Professor in Osteopathic Principles and PracticeA.T. Still University School of Osteopathic Medicine in Arizona, and Private practice in Family Medicine in Tucson, Arizona
The Long and Short of It
Evaluation, Diagnosis and Treatment of Selected Somatic Dysfunctions
related to the
THE LONG AND SHORT LEG
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Disclosures
• None
Learning Objectives
Review and Use the following anatomic landmarks and maneuvers to diagnose and correct the Short Leg
Anatomic LandmarksASIS AND PSISSacrum (base and ILA) for ID of the deepsulcus and position of the ILAMalleoli for comparison of leg lengths
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Maneuvers
Standing flexion test for iliac dx
Seated flexion test for sacral dx
Learning Objectives
Techniques Covered:
ME and HVLA for :
Innominate dysfunction: anterior and posterior rotation
ANDsacral torsions: anterior and posterior
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1) ASIS 2) PSIS 3) MALLEOLI 4) SACRUM AND SULCUS 5) INFERIOR LATERAL ANGLE
Landmarks we need:
OBJECTIVE FINDINGS SHEET WITH ANATOMIC LANDMARKS
ASIS SUPERIOR R___ L___ASIS INFERIOR R___ L___MALLEOLUS SHORT R___ L___MALLEOLUS LONG R___ L___PSIS SUPERIOR R___ L___PSIS INFERIOR R___ L___SULCUS DEEP R___ L___ILA INF/ POST R___ L___SEATED FLEXION + R___ L___STANDING FLEXION+ R___ L___
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TODAY -we will do the most common presentations of short leg-
POSTERIOR/ ANTERIOR INNOMINATE
ANTERIOR / POSTERIOR SACRAL TORSION
Background and Basis
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Somatic Dysfunction - Defined• “Impaired or altered function of related components
of the somatic (body framework) system:
• Skeletal, arthrodial, and myofascial structures,
• And…
• Related vascular, lymphatic, and neural elements”
All somatic dysfunctions have a restrictive barrier which are considered “pathologic.”
This restriction inhibits movement in one direction which causes asymmetry within the joint:
The goal of osteopathic treament is to eliminate the restrictive barrier thus restoring symmetry….
Treatment Options for Somatic Dysfunctions
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Somatic Dysfunction: CHARACTERISTICS“The acronym TART is used to remember the abnormal changes that accompany somatic dysfunction. (Tenderness by itself is not always an indication of somatic dysfunction):
•Tissue texture changes•Asymmetry•Restricted range of motion•Tenderness
Kimberly Manual, chapter 3
Indirect – movement away from the barrier and more functional than structural :
◦ Cranial-sacral◦ Counterstrain◦ Balanced ligamentous tension (BLT)◦ Facilitated Positional Release
Treatment Methodologies
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Direct – engagement of the restrictive barrier and movement through it and to it by using the body part as a lever
Muscle Energy and MyoFascialR HVLA Chapman’s and Lymphatics
Treatment Methodologies
THE SACRUMMeans “sacred” because of its density it is the last bone to decay and because it protects the reproductive system
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SACRAL ANATOMICAL AXESTransverse axis
Superior: the cranial&primary respiratory mechanism creates motion around this axis
Middle: sacral base anterior and posterior (FB/BB) occur around this axis
Inferior: the innominates rotate around this axis
SACRAL PHYSIOLOGIC AXES
•Oblique: both left and right oblique axes are named for the superior pole• Sagittal: includes both mid-sagittal and an infinite
number of parasagittal axes• Horizontal: functional axis of sacral flexion/extension
occur around this axis (analogous to the middle transverse axis above)
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Why are the Oblique Axes so significant?
They are the Axes of Walking.
The walking cycle as it applies to our discussion1. From a standing (neutral) position, when you take a step forward,
your weight is shifted onto one lower extremity.2. This induces spinal column SB to the weight bearing side, and pins
the upper pole of the sacrum on the side of the SB.3. As the free lower extremity swings forward, it carries the free pole of
the sacrum anterior, creating rotation of the sacrum about theOblique Axis, towards the weight bearing extremity.
Bottom Line: You form Oblique Axes with every step you take!
Ex.: RL on LOA RR on ROA
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The other aspect of the walking cycle is the movement of the torso.
1. From a standing (neutral) position, as you step forward, note how your body compensates. What does your torso do?2. Answer: Rotates towards the moving lower extremity
(ie.: away from the weight bearing lower extremity).
So your sacrum rotates L and lumbar rotate R when you take a step onto R foot thus your spine (most notably Lumbar spine) rotates in the opposite direction of the sacrum in a neutral moving
situation.
L on L, or L on R, ; R on R, or R on L
The 1st Letter is the side of Rotation
It is also :
the posterior or backward edge of the sacral base (NB- there is an anterior /forward edge too)
The Short leg side
The side of the posterior/ inferior ILA
Sacral Naming Conventionsfor Torsions
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Sacral Naming Conventionsfor Torsions
The second letter ( R on R etc) refers to the Oblique Axis side of the sacrum that it is rotated on so- a L on L sacral torsion means the sacrum is rotated Left on its Left axis;A R on R torsion means the sacrum is rotated right on its R axis –A R on L means right rotation on the Left axisWhen the letters are the same You areDealing with an Anterior sacral base issue – when not –a Posterior sacral
base issue
A sacral torsion requires a deep sulcus and a posterior and inferior ILA to be on oppositesides
So for example,
A deep right sulcus must have a posterior andinferior ILA on the Left by the above definition
Sacral Torsion Diagnosis
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Sacral Torsion Rules
Seated flexion test is + on the side of the dysfunctional edge which will be either forward or backward
The seated flexion test is the hallmark objective exam to determine your torsion (OR shear) diagnosis side and thus what edge to treat
Long leg will be deep sulcus and = anterior edgeShort leg on posterior edge
Forward lesions no + spring test (they do move) Just to be confusing +spring test means NO SPRING
Backward lesions do have + spring test (they do not move)
Sacral Torsion Rules
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◦ TESTS REQUIRED to Diagnose
Today’s Dysfunctions
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The patient stands - feet are hip’s width apart- knees extended
The physician’s - fingers on the iliac crest
thumbs rest on the posterior superior iliac spines (PSIS).
Ask the patient, “Bend forward slowly without flexing the knees”
Physician feels and observes the superior movement of the PSIS (The side which moves first and
furthest indicates restriction of the iliosacral joint on that side.)
STANDING FLEXION TEST
THE + FINDING OF EITHER THE STANDING OR SITTING FLEXION TESTS
WILL BE THE DETERMINANT OF WHETHER YOU HAVE AN :
ILIAC OR SACRAL DIAGNOSIS
KEY CONCEPT
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IF YOU HAVE A +STANDING FLEXION RESULT – YOU ARE DEALING WITH
A ILIAC/ INNOMINATE DYSFUNCTION
IF YOU HAVE A +SEATED FLEXION RESULT – YOU ARE DEALING WITH
A SACRAL DYSFUNCTION
KEY CONCEPT
Patient supine Knees up, feet on
table, lift buttocks off table, then down again, and straighten legs
Hip flop to start off exam
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ASIS Levelness
PSIS Levelness
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Medial malleolus position
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Grasp ankles bilaterally, with thumbs Inferior to medial malleolus on each side
Make sure lower extremities are lying straight
Assess relative levelness of medial malleolus (superior/inferior)
Record position of Side of Lateralization
Sacral Sulcus Depth Palpable groove just medial
to PSIS. Space between sacral spines
and lateral sacral crest. Place thumbs in inferior
border of PSIS. Move ½-1” up and medial to
PSIS. Push thumb tips on sacral
base. Pads of thumbs are on ilium
and tips on sacral base.◦ Measure the depth of
each sacral sulcus relative to opposite sulcus?
◦ Record even, deep, or shallow, comparing one side to the other.
◦ Both sides may be shallow or deep as well.
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Inferior Lateral Angle 1. Place flat of hand over sacrum
near its caudal end and identify the coccyx.
2. Thumbs approximately 1” apart. Place thumbs in gluteal area about 1” caudal and on each side of coccyx.
3. Push thumbs cephalad until pads rest on inferior margin of ILA. Take a reading on the lateralized side: Inferior or superior? Possibly even?
4. Move thumbs approximately 1” cephalad from the inferior margin of the ILAs and place the pads of the thumbs over the posterior surface of the ILAs near the apex of the sacrum.
5. Use moderate equal pressure & judge if one side is more anterior or posterior than the other one or are they equal? Record on the lateralized side.
EVERYONE NEEDS TO PARTNER UP
GO TO THE TABLES WITH THE OBJECTIVE FINDINGS SHEET
LOCATE THE LANDMARKS-
PERFORM THE SEATED AND STANDING EXAM-
PALPATE FOR THE ILIAC AND SACRAL FINDINGS-
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Anatomic –congenital or acquired Posterior/Anterior Innominate Sacral Torsion Sacral Shear - relatively rare and Not today
SHORT/LONG LEG CONDITIONS
Effects of Short Leg Pelvis side shifts and rotates
toward long leg Innominate rotates anterior
on side of short leg or posterior on side of long leg
Foot of long leg pronates, internally rotating lower leg
Lumbosacral angle increases by 2 to 3 degrees
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Posterior Innominate
Standing Flexion will be + on the side of:
ASIS will be superior
PSIS will be inferior
Leg will be Short
HVLA POSTERIOR INNOMINATE Grasp above ankle Raise leg 0-5 degrees off table Internally rotate leg Have patient breathe in Tug entire leg during exhalation
NB- YOU ARE PULLING THE SHORT LEG
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ME POSTERIOR INNOMINATE
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Standing Flexion will be + on the side of:
ASIS will be inferior
PSIS will be superior
Leg will be Long
Anterior Innominate
Grasp above ankle Raise leg 20-30 degrees off table Internally rotate leg Have patient breathe in Tug entire leg during exhalation
NB- YOU ARE PULLING THE LONG LEG
HVLA ANTERIOR INNOMINATE
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HVLA for Anterior Innominate
ME Anterior Innominate
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ANTERIOR SACRAL
TORSIONS
Anterior (forward) Sacral TorsionWill be named either R on R or L on L
Will have deep sulcus on side of +seated flexion and ILA on opposite
Remembering that the 1st letter is the posterior edge – you will be treating the opposite edge as the name of the lesion – so the left edge for R on R( and the seated flexion will be + on the L side as well)
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Neutral - Left Oblique Axis FindingsName: L on LOA, RL on LOA,
Landmarks – Static:Sacral Base: L
posteriorSacral Sulcus: L
shallowILA: L
Post/ Inf.STL: L
TightMotion Testing:
Spring: - (neg)L5: SLRR
Left Right
Midline
A +
P+/-
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Neutral - Right Oblique Axis Findings:
Name: R on ROA, RR on ROA,
Landmarks – Static: Sacral Base: R posteriorSacral Sulcus: R shallowILA: R Post/Inf.STL: R tight
Motion Testing:Spring: - (neg)L5: SRRLSacral Base:L + R -ILA: L +/- R +/-
Right Forward TorsionRR on ROA
Left Right
Midline
P+/-
A+
Forward/AnteriorSacral Torsion
Treatment
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HVLA FOR ANTERIOR SACRUM
Forward Sacral Torsion ME(a right on right sacral torsion)
1. Axis side down; chest on the table
1. Monitor at the lumbo-sacral junction
1. Flex the knees and hips until motion is felt at the lumbo-sacral junction
1. Support legs/knees with thigh or pillow
1. Apply pressure downward on lower legs/ankles
1. Ask patient to try to raise feet towards the ceiling while you resist
1. Rest
1. Re-engage barrier by repositioning ankles downward
1. Repeat 6, 7, 8
1. Recheck
Relative contra‐indications‐acute sacroiliac sprain, acute sacrum fracture, severe knee arthritis, deep venous thrombosis, or premature labor
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POSTERIOR SACRAL
TORSIONS
Posterior (backward) Sacral TorsionWill be named either R on L or L on R
Will have shallow sulcus on side of +seated flexion and ILA that is posterior and inferior on same side as well
Remembering that the 1st letter is the posterior edge – you will be treating the same edge as the name of the lesion –the left edge for L on R and
the R for a R on L
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Non-Neutral: Left Oblique Axis Findings(right on left sacral torsion)
Name: R on LOA, RR on LOA,
Landmarks –Static:
Sacral Base: L Anterior
Sacral Sulcus: L Deep
ILA: L Ant/ Sup
STL: L LooseMotion Testing:
Spring: + (positive)
L5 R S
Left Right
Midline
P+/-
A+
Non-Neutral: Right Oblique Axis Findings(left on right sacral torsion)
Name: L on ROA, RL on ROA,
Landmarks:Sacral Base:R AnteriorSacral Sulcus: R DeepILA: R Ant./Sup.STL: R loose
Motion Testing:Spring: +L5: RRSRSacral Base: L +/- R -ILA: L +/- R +
A+
P+/-
Left Right
Midline
Right Backward TorsionRL on ROA
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Posterior Sacral Torsion Treatment
HVLA FOR POSTERIOR SACRUM
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Backward Sacral Torsion Muscle Energy ( left on right torsion)
1. Have the patient lie on the table axis side down
1. Monitor at the lumbosacral junction
1. Rotate the upper torso posteriorly until motion is felt at the lumbosacral junction
1. Hold the position of torso rotation
1. Flex the top leg until motion is felt at the lumbosacral junction; bend the knee and adduct the hip until motion is felt
1. Ask the patient to push their knee up towards the ceiling while you resist
1. Rest
1. Re-engage the barrier by adducting the knee/hip until motion is felt at the lumbosacral junction
1. Repeat 6, 7, 8
1. Recheck
SACRAL DIAGNOSIS
Diagnosis Seated Flexion
Test
Sacral
Base/Sulci
ILA levelness L5
Rot
Spring
Test
LS Flexion Asymmtry
Left on left Right Anterior right Posterior left Right Negative Decreased
Left on Right Left Anterior right Posterior left Right Positive Increased
Right on right Left Anterior left Posterior Right Left Negative Decreased
Right on Left Right Anterior Left Posterior Right Left Positive Increased
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KIMBERLY MANUAL-2006 EDITION POCKET MANUAL OF OMT-2ND EDITION PRINCIPLES OF MANUAL MEDICINE-GREENMAN OMT REVIEW-SAVARESE-3RD EDITION LECTURES FROM OMM FACULTY – A.T.STILL UNIVERSITY-
PHOENIX AZ- WITH PERMISSION JAOA Vol 91 No 3 March 1991 CLINICAL APPLICATION OF COUNERSTRAIN – MYERS 2006
SOURCES AND RESOURCES
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I HAVE NO DISCLOSURES TO MAKE