Biomechanical Approach to the Evaluation and Treatment of the Low - - PowerPoint PPT Presentation

Biomechanical Approach to the Evaluation and Treatment of the Low Back

Charles R. Thompson, MS, ATC Princeton University EATA January 7, 2007 Boston, MA

Purposes and Goals Purposes and Goals

• Develop a sound biomechanical approach

to your evaluation.

• Change how we look at backs, hips, and

groins.

• Eliminate the term “low back pain” as a

diagnosis.

Purposes and Goals Purposes and Goals

Reduce the use of the terms “groin strain”,

“hip flexor strain”, and “lumbar strain/ sprain”.

Learn to treat what you see.

There are

actually only three bones:

Two

innominates.

One sacrum.

Simplify Everything Simplify Everything

Simplify Everything Simplify Everything

There are only

three joints:

Right and left

sacroiliac joint.

Pubic

symphasis.

Simplify Everything Simplify Everything

There are 45

muscles that attach on the pelvis.

However, we

will mostly deal with them in groups.

Os Os Innominate Innominate

Ilium Ishium Pubis

Os Os Innominate Innominate

PSIS

Os Os Innominate Innominate

Ishium

Acetabulum Ischial Tuberosity Obturator Foramen

Os Os Innominate Innominate

Pubis

Pubic Symphysis

Sacrum Sacrum

The sacrum

is the result

• f the fusion
• f 5 vertebral

elements.

Inferior Lateral Angle Sacral Base

Important Bony Landmarks Important Bony Landmarks

ASIS AIIS Pubic Tubercles Iliac Crest

Important Bony Landmarks Important Bony Landmarks

PSIS

Musculature of Note Musculature of Note

How do “muscular” issues become

resolved without the use of Muscle Energy?

Which muscle groups are most involved?

Musculature of Note Musculature of Note

As mentioned, there

are 45 muscles that attach somewhere on the pelvis.

16 attach on the

ilium

13 attach on the

ischium

16 attach on the

pubes

Musculature of Note Musculature of Note

Transverse Abdominus

Musculature of Note Musculature of Note

Quadratus Lumborum

Musculature of Note Musculature of Note

Psoas Iliacus Rectus

Femoris

Sartorius

Musculature of Note Musculature of Note

Six Outward

Rotators

Piriformis,

• bturator

internus and externus, quadratus femoris, and the inferior and superior gemelli.

Musculature of Note Musculature of Note

• Muscles of the

Muscles of the Buttocks Buttocks

• Gluteus

Gluteus maximus maximus

• Gluteus

Gluteus medius medius

• Gluteus

Gluteus Minimus Minimus

Musculature of Note Musculature of Note

• Hamstrings

Hamstrings-

• Biceps Femoris

Semitendinosus Semimembranosus

Musculature of Note Musculature of Note

Musculature of Note Musculature of Note

Sacroiliac Joint Sacroiliac Joint

Diarthrodial joint

OR amphiarthrodial with diarthrodial characteristics.

Auricular

shaped, with the “long leg” meeting the “short leg” anteriorly.

Normal Mechanics Normal Mechanics

Pubic Motions Caliper Rotation Superior/

Inferior Shear

Normal Mechanics Normal Mechanics

Iliosacral = ilium moving on the sacrum with

the sacrum being the fixed point-

Standing flexion and extension.

Three types of motion:

Caliper (flaring) Anterior and Posterior Rotation Superior and Inferior Shearing

Normal Mechanics Normal Mechanics

Iliosacral

Caliper motion

The ilium moves posteriorly and laterally =

• utflare OR

The ilium moves anteriorly and medially =

inflare.

Normal Mechanics Normal Mechanics

Iliosacral

Anterior Rotation,

referred to as an Anterior Innominate Rotation OR

Posterior Rotation,

referred to as a Posterior Innominate Rotation

Normal Mechanics Normal Mechanics

Iliosacral

Superior / Inferior Shearing Referred to as an upslip or a downslip

Normal Mechanics Normal Mechanics

Sacroiliac = sacrum moving on the ilium

The ilia are the fixed points. Seated flexion and extension.

• Uni- and bilateral sacral extension and

flexion.

• Sacral torsions (rotation on an oblique axis).

Normal Mechanics Normal Mechanics

Sacroiliac

When the trunk

extends, the sacrum flexes.

When the trunk

flexes, the sacrum extends.

When the

sacrum rotates, L5 rotates in the

• pposite

direction.

Normal Mechanics Normal Mechanics

Sacroiliac

There are three

major axes of motion:

Horizontal = sacral

flexion and extension

Vertical = sacral

vertical shear

Oblique = sacral

torsion

Pathomechanics Pathomechanics

Once we understand, or at least agree, that

there is motion occurring at these joints, no matter how minimal, then we can understand or agree, that with pathology, these joints can become stuck, or dysfunctional.

Pathomechanics Pathomechanics

That being said, we can follow the

McKenzie model of dysfunction.

Pathology can occur when there is:

abnormal stress on normal tissue or normal stress on abnormal tissue.

Pathomechanics Pathomechanics

Abnormal stress on normal tissue

essentially involves some type and level of trauma.

Normal stress on abnormal tissue

essentially involves normal stresses on dysfunctional tissue.

Biomechanics of Walking Biomechanics of Walking

At heel strike, there is posterior ilial

rotation and a forward sacral torsion on the weight bearing side.

There is essentially no motion in the pelvis

• n the non-weight bearing side as the

ilium remains anteriorly rotated.

Biomechanics of Walking Biomechanics of Walking

At the mid-point of the cycle, the ilium on the

weight bearing side begins to move anteriorly, with the sacral torsion on that side at maximum.

There has still not been any change on the non-

weight bearing side.

As the opposite limb strikes the ground, the

• riginal weight bearing side changes from

posterior to anterior ilial rotation and sacral torsion is eliminated.

Biomechanics of Walking Biomechanics of Walking

As the opposite limb strikes the ground,

the original weight bearing side changes from posterior to anterior ilial rotation and sacral torsion is eliminated.

The new weight bearing side now

assumes the ilial and sacral changes previously mentioned.

Muscle Energy Muscle Energy

“Facilitates the correction of

biomechanical dysfunctions by normalizing neuromuscularskeletal balance”.

Any manipulative technique that involves

the voluntary use of the patient’s muscles.

Muscle Energy Muscle Energy

Hands on technique that stresses the

importance of a good biomechanical evaluation.

Must have a working knowledge of the

anatomy and biomechanics of the pelvis and low back.

Must understand that there is motion

• ccurring at the small joints of the pelvis

and spine.

Muscle Energy Muscle Energy

Must become adept at discerning subtle

changes in the biomechanics of movement and tissue texture.

Can be more difficult on some athletes

than others.

Muscle Energy Muscle Energy

Muscle Energy Muscle Energy

Look for “barriers” to motion. Recognize that dysfunctions and

corrections are found and treated in more than one plane.

Pain may remain for 24- 72 hours after the

correction is completed.

Muscle Energy Muscle Energy

This is not a technique that can be learned

from a book; it takes practice to be able to note the subtle changes of palpation and motion.

Must establish a rule for the number of

treatments before referral.

Adjunct Therapy Adjunct Therapy

Techniques utilized to eliminate muscle/ soft tissue barriers-

Myofascial Release; Strain- Counterstrain; Therapeutic Massage; Modalities- ice and/ or stim, hot packs, etc.

Adjunct Therapy Adjunct Therapy

Techniques utilized for diagnosis and

treatment-

McKenzie program; Mulligan Techniques (“NAGS”, “SNAGS”, and “MWMS”).

Differential Diagnosis Differential Diagnosis

Spondylosis:

Degeneration of the intervertebral disc

associated with reactive changes to the vertebral bodies above and below the derangement.

Differential Diagnosis Differential Diagnosis

Spondylolysis:

Uni- or bilateral stress fracture at the pars

interarticularis (isthmus) without vertebral slippage.

Spondylolisthesis:

Bilateral stress fracture at the pars resulting

in anterior slippage of the superior vertebra

• n the inferior.

Differential Diagnosis Differential Diagnosis

Netter, Ciba Clinical Symposia, Vol. 32, No. 6, 1980

Differential Diagnosis Differential Diagnosis

Spondylitis:

• Degenerative

hypertrophy (osteoarthritis); may be associated with any of the aforementioned conditions.

Netter, Ciba Clinical Symposia, Vol. 32, No. 6, 1980

Differential Diagnosis Differential Diagnosis

Posterior Lateral Disc Derangement

Usually unilateral. Neurological S & S’s Decrease strength, reflex, etc. Eliminate as diagnosis prior to treating w/

ME.

Special testing/ imaging to confirm.

Differential Diagnosis Differential Diagnosis

Central Disc Derangement

Present with mid- line back pain. Usually no neurological S & S’s. May or may not present with signs of dysfunction. Special testing/ imaging to confirm. Usually do well. Rowing.

Differential Diagnosis Differential Diagnosis

Osteitis Pubes

Pain in groin or hip flexor area. May have symptoms uni- or bilaterally. Usually have associated dysfunctions, which may

be different day- to- day.

Referral and special testing/ imaging. Good luck!!!

Differential Diagnosis Differential Diagnosis

Harris and Murray, British Medical Journal, 1974, 4, 211- 216

Differential Diagnosis Differential Diagnosis

ASIS Avulsion Fracture

Pavlov, Clinics in Sports Medicine,

• Vol. 6, No. 4, October, 1987

Differential Diagnosis Differential Diagnosis

Tumor Pubic Stress Fracture Facet Joint Inflammation Hip Joint (Acetabulum) Pathology All of the Hernia’s (Gilmore’s Groin, Sportsman’s

Hernia, Athletic Pubalgia)

Differential Diagnosis Differential Diagnosis

Transitional

vertebrae (variation)

Sacralization

• f L5

Fusion of L5

with sacrum

Differential Diagnosis Differential Diagnosis

Transitional

Vertebrae (variation)

Lumbarization

• f S1

Resulting in a

sixth lumbar vertebrae, and

• nly four sacral

vertebrae.

Barrier Concept Barrier Concept

Point beyond which a joint will not move

Types:

Physiological- limit of active range Anatomical- limit of passive range

Going beyond anatomical barrier results

in joint disruption

Barrier Concept Barrier Concept

Types (cont.) Restrictive- point in the range of motion

where all of the slack is taken out.

• Muscle- spasm can be a cause or an

effect of biomechanical changes

Barrier Concept Barrier Concept

ANATOMICAL LIMITS TOTAL RANGE OF MOTION MIDLINE

Barrier Concept Barrier Concept

ACTIVE RANGE OF MOTION MIDLINE

P R O M P R O M

PHYSIOLOGICAL LIMITS ANATOMICAL LIMITS

Barrier Concept Barrier Concept

ACTIVE RANGE OF MOTION

OLD MIDLINE

PROM

PHYSIOLOGICAL LIMITS

MOTION LOSS

NEW MIDLINE

ANATOMICAL LIMITS

RESTRICTIVE BARRIER

Leg Length Discrepancies Leg Length Discrepancies

Do not underestimate the effect of small

differences in leg length.

Use of good heel lifts can be very effective at

correcting leg length discrepancies and eliminating muscle barriers.

Felt or cork lifts will only last a short time,

especially in a heavier athletes.

Leg Length Discrepancies Leg Length Discrepancies

Leg Length Discrepancies Leg Length Discrepancies

Evaluate in

supine with knees bent, feet aligned from side and front views.

Eliminates

muscle barrier discrepancies.

Leg Length Discrepancies Leg Length Discrepancies

http://www.bmlbasic.com/ Heel lifts; 3 mm, 5 mm, 7 mm, 9 mm, 12

mm

Select “D 60” (Red Brown)

Biomechanical Evaluation Biomechanical Evaluation

History- key component Inspection- dominant eye Palpation- subtle changes Functional movement- normal

biomechanics

History History

What are

your motion limitations?

What are

your activity limitations?

History History

How does this affect the rest of your

activities? Sitting in class? Riding in a car?

Does the pain interrupt your sleep? Is

sleep position affected or changed?

Any other related previous injury? Lower

leg fracture?

Inspection Inspection

View from front, back, and each side Begin with static standing Looking for anatomical differences

between each side

Begins at the feet and ends at the head

Inspection Inspection

Static Standing

Anterior View Lateral View Posterior View

Inspection Inspection

Static Standing

Inspection Inspection

Observe for

tibial bowing unilaterally

• r

bilaterally.

Observe

stance pattern.

Static Standing Static Standing

Observe

height

• f popliteal

lines.

Static Standing Static Standing

Observe height

• f gluteal folds.

Static Standing Static Standing

Observe height of both PSIS.

Static Standing Static Standing

Observe height of both ASIS.

Static Standing Static Standing

Observe height of both Iliac Crests.

Spinal Alignment Spinal Alignment

Spinal alignment in extension and flexion. Shoulder height. Discernable “C” curve or “S” curve.

Standing Motion Standing Motion

Repeated flexion x ten.

Standing Motion Standing Motion

Repeated Extension x ten.

Standing Motion Standing Motion

Does either motion :

increase pain? decrease pain? have no effect on pain?

Part of the McKenzie Approach Exam.

Standing Motion Standing Motion

Ask athlete to

flex the trunk while you have your thumbs at each PSIS/ sulcus.

You should see

& palpate symmetrical motion at your thumbs.

Standing Motion Standing Motion

Ask the athlete

to perform a “stork stand”.

You should

• bserve

symmetrical motion at your thumbs.

Standing Motion Standing Motion

Repeat this test

with hip extension.

You should

• bserve

symmetrical motion at your thumbs.

Seated Flexion and Extension Seated Flexion and Extension

Same procedure

as standing motion tests. Observe for symmetrical motion.

Supine Supine

Anatomical symmetry

• f pubic rami.

Allow the athlete to

perform this test by themselves.

Do not perform in

private office without

• bserver (coach,

another ATC, etc.).

Supine Supine

Place each thumb

• n the

corresponding ASIS.

Looking for the

involved side to be either more anterior and medial or posterior and lateral.

Supine Supine

Place each thumb

• n the

corresponding ASIS.

Looking for the

involved side to be either more anterior and medial or posterior and lateral.

Supine Supine

Place each

thumb on the correspondin g ASIS.

Looking for

the involved side to be either more superior or inferior.

Supine Supine

Perform other traditional hip and

sacroiliac joint tests:

Patrick or Fabere Test. Hip Scour. R/O hip/ acetabular pathology.

Long Sit Test Long Sit Test

Perform long sit test

Initially observe for symmetry of medial

malleoli.

Ask athlete to sit and touch their toes. Observe for any changes in leg length. Not consistent w/ rules that appear in

textbooks.

Long Sit Test Long Sit Test

Long Sit Test Long Sit Test

Pelvic Rock Test Pelvic Rock Test

Pelvic rock and long

leg traction to look

• for. restrictions in

movement.

Used to confirm

finding of dysfunction.

Long Leg Traction Long Leg Traction

Pelvic rock and

long leg traction to look for restrictions in movement.

Used to confirm

finding of dysfunction.

Prone Prone-

• Spring Test

Spring Test

Used to check the

mobility of the spine.

Place one hand on

top of the other and press down into the spine.

Work your way up

the spine.

Prone Prone

Use your

fingertips to check sulcus, which is just medial to the PSIS, depth in neutral (flexion) and in extension (sphinx position).

Prone Prone

Use finger tips

to assess the levels of the R and L transverse processes of each lumbar vertebrae.

Muscle Energy Muscle Energy

The painful side is the dysfunctional side. Be sure to rule out underlying condition. Use muscle energy once per day. Retest motion after each Muscle Energy

Correction.

Muscle Energy Muscle Energy

Establish a rule for the number of

treatments performed before referral.

Initiate exercise for maintaining correction

and/ or preventing reoccurrence:

Flexibility. Core Stability.

Pubic Dysfunctions Pubic Dysfunctions

Pubes are the “keystone” for all other

pelvic dysfunctions.

Must be corrected for other pelvic

dysfunction corrections to remain corrected.

Always consider the possibility of a pubic

dysfunction with groin pain.

Pubic Dysfunctions Pubic Dysfunctions

Signs &

Symptoms

uni- or bilateral

groin pain.

extended period of

groin pain.

(+) bony

palpation.

R/O osteitis pubis,

hernia, genito- urinary conditions. Cephalic Pubes Caudad Pubes

Iliosacral Iliosacral Dysfunctions Dysfunctions

Ilium moving on the sacrum. Sacrum is the fixed point. Anterior and posterior rotation, superior

• r inferior shear, and internal and external

caliper motion (flaring).

Inflares Inflares and and Outflares Outflares

Inflares present

with the ASIS more medial and anterior while lying supine.

Complaint of

“hip flexor” pain. Outflares present with the ASIS more lateral and posterior while lying supine.

• Complaint of “hip

flexor” pain.

Up Slips and Down Slips Up Slips and Down Slips

Up slips (most

common) present with the ASIS, Iliac Crest, and PSIS all high.

Usually results

from a forceful landing on involved foot.

Up Slips and Down Slips Up Slips and Down Slips

Down slips (rare)

present with the ASIS, Iliac Crest, and PSIS all low.

Usually results

from a long traction mechanism (leg tackle, fall from a horse).

Anterior and Posterior Anterior and Posterior Innominate Innominate Rotations Rotations

Anterior

Innominate presents with a superior PSIS, an inferior Iliac Crest, and an inferior ASIS.

Long sit test would

demonstrate asymmetry with the malleoli.

Anterior and Posterior Anterior and Posterior Innominate Innominate Rotations Rotations

Posterior

Innominate presents with an inferior PSIS, a superior Iliac Crest, and a superior ASIS.

Long sit test

would demonstrate asymmetry of the malleoli.

Sacroiliac Dysfunctions Sacroiliac Dysfunctions

Sacrum is moving

• n the ilia.

Ilia are the fixed

points.

Three axes of

rotation- horizontal, vertical and oblique.

Extended or Flexed Sacrum Extended or Flexed Sacrum

Sacrum can get

stuck in the flexed position, unilaterally or bilaterally.

One or both

sacral sulci will appear deep on palpation . Sacrum can get stuck in the extended position, unilaterally or bilaterally. One or both sacral sulci will appear shallow on palpation.

Vertical Shear Vertical Shear

Sacrum can rotate either

to the right or the left on the vertical axis.

Sulcus and ILA on the

involved side will both be deep compare to the uninvolved side.

Not very common in my

experience.

Sacral Torsions Sacral Torsions

Rotations about

an oblique axis result in sacral torsions.

Sacral Torsions

When found in flexion, the sacrum will be

rotated to the same side as the axis it is rotating on (R on R or L on L).

When found in extension, the sacrum is

rotated to the opposite side as the axis (R on L or L on R).

When dysfunction is found in extension you

will treat in extension and if found in flexion, treat in flexion.

Sacral Torsions Sacral Torsions

Move to flexed

position and then the extended position (“sphinx position”).

Compare the

depths of the ILA’s and the two sulci.

Sacral Torsions Sacral Torsions

If the R sulcus is deep, the L ILA

will be posterior/ inferior.

At the same time, the L sulcus

will be shallow and the R ILA will be anterior/ superior.

Prevention/ Correction Prevention/ Correction

Utilize Flexibility Programs and Core

Stability Programs as preventative and corrective measures.

Many questions of “chicken and the egg”!

Conclusion Conclusion

Work on the evaluation process first. Start by looking at the feet and working

your way up.

What is happening through the kinetic

chain that can effect the back, hips, or groin?

Conclusion Conclusion

Evaluation process takes some time to

become proficient- be patient.

Take the book out while examining/

treating an athlete.

Thank You!! Thank You!!