‘The Pelvic Equilibrium Theory’ A New Paradigm Clifton Bradeley The IOCP 2018 National Podiatry & Associated Healthcare Conference
Introduction to the problem Sites of common overuse Injuries. 1. Foot & ankle. 2. Lower leg shank. 3. Knee & thigh. WHY? 4. Pelvis & SIJ. 5. Lower lumbar spine. The same common injuries. Very little has changed despite advances in technology. The injury patterns are also the same.
What are the common factors? Pain & Dysfunction u Pain; inflammation; dysfunction. Local Tissue Mechanical u Tissue stress. Stress Factors These do NOT u Medical & nutritional. Overuse explain the full u Overuse. injury mechanism of u Poor technique. u Poor footwear. injury! Medical & Body Type Nutritional u Sports surface issues etc. u Body mass issues. 3 Party Factors u Body type issues. u Local mechanical factors.
What are the temporal parameters of overuse injuries? End Tissue Stress Geophysics Overuse Injury Vestibular Balance Tissue adaptive syndrome Gravity. (TAS). Establish the Essential Pain. Newton’s 3 rd ; GRF . ‘T’. Overuse. Inflammation. CoM efficiency. Tissue cell damage. Dysfunction. Start Balance. Overload syndrome. Stable Sinusoidal Physiological changes etc. curves. Local Mechanical Foot & Ankle. Lower Shank. ‘Middle Knee & Thigh. Bit ?’ Pelvis & SIJ. Lower Lumbar.
Local Mechanical Local mechanical pathways Foot & Ankle. Lower Shank. to overuse injury: basic understanding. Knee & Thigh. Pelvis & SIJ. Lower Lumbar. u Excessive pronation - bilateral or unilateral u Under pronation/supination (bilat/unilat). This is taught at u Early or delayed heel lift (bilat/unilat). undergrad u Excessive internal or external rotations level (bilat/unilat). u Increased ankle, knee, hip or spinal flexion These are (bilat/unilat). local adaptations u Increased ankle, knee, hip or spinal extension (bilat/unilat). u Pelvic obliquity (frontal plane) & Leg length. u Adduction/abduction.
Local Mechanical Foot & Ankle. Local mechanical pathways Lower Shank. Knee & Thigh. to overuse injury: advanced understanding. Pelvis & SIJ. Lower Lumbar. u Pelvic/ sacral torsions (various axes). 1. They are u Hypo/hyper lordosis/kyphosis/ etc. all created u Anterior innominate orientation. by u Posterior innominate orientations. abnormal loading. u Displaced center of mass (CoM). 2. The u Sinusoidal curve pattern disturbance. loading starts u Sagittal plane facilitations/blockages. extrinsic to u Time:Pressure integral disturbance. the lower u Joint acceleration/decelerations. limb. u Asymmetrical Overload syndrome. u Fascial slings/ form & force closure issues.
‘X is the whole body Therefore, adaptations that include the local mechanical we are missing something! changes .’ There has to be a LINK & a MECHANISM Global Adaptation? that combines the x Local Overuse Geophysics Mechanical Geophysics Injury changes to the At Pelvic Level? local mechanical compensations/adaptations.
The LINK is the: Muscle-Tendon-Joint Engineering with the Myofascial slings assisting with a force vector ‘mesh’ that connects the whole kinetic chain.
Postural fascial slings Posterior oblique sling u Fascia delivers force throughout the whole network. These are fascial slings. & thoracolumbar fascia. u However, they are not the origin of the force. u This force is generated by the pelvis i.e. the fulcrum during adaptation to asymmetry. u The type of adaptation determines which structure is over loaded and therefore which overuse injury occurs. These global adaptations around the pelvis can create the local mechanical changes.
The MECHANISM is movement patterns (adaptations) adopted by the pelvis to deal with asymmetry.
So, why do adaptations occur?. u Postural adaptations allowed our ancestors to cope with the natural world during stand and gait. u Each of these adaptations were SHORT-LIVED & CONSTANTLY CHANGING as our ancestors moved around from surface to surface. u The extrinsic natural environment was the main driver for these adaptations. u Their aim was to achieve vestibular balance in the presence of gravity, GRF and natural asymmetry (internal & external) .
The ‘Essential T’ takes priority. u The geophysics has NOT changed. u Our ability to adapt has NOT changed. u The need to establish ‘The Essential T’ has G NOT changed. GRF
E Etc. D The asymmetrical load created by adaptation C determines the overuse B injury depending on: A A Body type • B Weight • Axes orientation • C Temporal parameters • + the third party factors already • discussed. D i.e. Muscle-Tendon-Joint Engineering. E Etc.
The Pelvic Equilibrium Theory . Hypothesis: that all ambulant humans appear to demonstrate one of four adaptations and that they may help to explain how overuse injuries occur throughout the whole kinetic chain.
Pelvic Adaptation to Asymmetry. 2. Double Femoral Pathway, 1. Single Femoral Pathway, PI ilium, Both Sides. PI ilium, Long Side. Posterior Posterior Adaptation Adaptation Rotation on Rotation on Long leg both sides. side.
Pelvic Adaptation to Asymmetry. 4. Single Femoral Pathway, 3. Single Femoral Pathway, PI ilium, Short Side. AS ilium, Short Side. Posterior Anterior Rotation Adaptation adaptation Rotation on on the Short leg side Short leg side
Posterior & anterior rotational lever arms. Facing this way Understanding this mechanism will be a key advancement to MSK medicine
This was an evolutionary adaptation to bipedalism Sacral base angle 30 to 40° Sacral base angle almost vertical
We measured 1000’s of pelvi & discovered the adaptation RULES of the pelvis. There are several rules & they are extremely useful clinically. E.g.’s
Motion palpation. This should match the numbers Sample pelvic behaviour as gathered from the pelvis. often as you can.
Our study. Cohort Methodology u Each patient underwent the same protocol. u N=118 consented. u Static trial: 8mm board. u 68m/50f u Dynamic trial: 8mm in-shoe raise platform. u Age (years) 17 to 76 u Innominate inclination was measured after u Average age = 44 each trial with a digital pelvic inclinometer. u All presented to an MSK center with at least one MSK overuse injury. u Sequential and prospective data collected after an independent reliability study. Beardsley, C., Egerton, T ., & Skinner, B. (2016). Test–re-test reliability and inter-rater reliability of a digital pelvic inclinometer in young, healthy males and females. PeerJ, 4, e1881.
10 2 8 9 10 1 -2 13 11 8 10 2 8 9 1 11 2 1 10 Single Femoral Pathway, PI ilium Long side
Figure 10 – Pelvic Inclination data showing measurements taken at different stages of the assessment grouped by pelvic adaptation
Our study. Results Conclusion. 1. Pelvic adaptation is extremely 1. Pelvic adaptation to asymmetry may common. have a great effect on the upper and lower kinetic chain. 2. Posterior & Anterior pelvic adaptation may to be a significant 2. Pelvic dysfunction may help us to explain factor in the formation of overuse localized mechanical dysfunction. injuries. 3. More research is needed in this area. 3. Specific injury patterns may be 4. As a profession we need to progress associated with certain pelvic beyond the lower limb and old adaptations. paradigms. 5. Innovate your ideas and ignore the Facebook trolls.
Thank you. Email: clifton@sub-4.co.uk
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