Pubic instability

[OregonPT]

I could use a little advice. Have a rodeo cowboy who was referred to me for "abdominal and adductor strain" from an injury while he was riding a horse. Upon testing and reassessment, it was apparent he may have strained his arcuate ligament and has some pubic instability. Initial injury was over 6 weeks ago and the majority of the pain is subsided. However, he continues to have pubic instability unless wearing a SIJ belt. We've been working on pelvic stabilization, but he continues to pop and in VERY anxious to get back to roping. Any advice for specific pubic stabilization exercises?

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[jerryhesch]

By your description I assume that he is functional such as can walk ok, and does not likely have a complete diastasis. An x-ray would be nice to have. I am a big advocate of establishing normative positioning of the symphysis pubis before doing exercise or SI belt. Repositioning is easy, just takes about 5 minutes and can be repeated as needed, oftentimes repeat correction is NOT necessarily, the body prefers being in a corrected position, it easily relearns to stay etc.

If a pubic bone is in upslip it will lack inferior spring. Gently abduct and traction the leg for 2 to 5 minutes. Reassess. I much prefer this technique to the Muscle Energy Technique (MET)

If in downslip, the pubic bone will lack superior glide. Will ulnar border of your hand making as much contact as possible on the face of theinferior pubic bone or underneath it glide it superiorly for 2-5 minutes.
Oftentimes it takes 2 minutes to take the slack out and then you feel a very slow creep. Reassess.

If one pubic bone is in pure posterior glide, the entire length of the pubic bone will be posterior in relation to the opposite side, place a 3" diameter (7.5cm) firmly rolled towel of 10" (25cm) length placed horizontally just above the gluteal crease/topmost part of thigh such that it captures the ischium. client lies supine, legs in neutral for 5 minutes. Reassess. Then screen the ischia for P-A relationship and medial lateral positioning, do passive motion testing to theishcia if asymmetry present and if say the pubes are now equal but there is a paradoxical posterior andlateral ischium, do not be shocked. It is bizarre but is explained as an unusual rotation of the hemipelvis and is treated easily. Typically the upper pelvis is symmetrical (apparently close to the axis of rotation) and the sacrotuberous ligament is taut as is sacrospinous. It is effectively treated by - surprise - treating both sides of hip and pelvis. Stretch/mobilize into external rotation on the side in which the ischium is posterior and lateral, and then into internal rotation on the other hip (prone, knee flexed to 90 degrees) This in 2 minutes will resolve the poster positioning of the ischium proving that it is a rotational pattern (in spite of pubic bones being symmetrical). Then stretch/mobilize the lateral ischium and hip into adduction and the other side into abduction, for 2 minutes GENTLY. Retest. Viola better! I discovered this pattern about 14 years ago. It is rare.

Another pattern I discovered; when both pubic bones are symmetrical with respect to superior/inferior relation and same for A-P, but palpating across the bones the fibrocartilage is posterior-yes, posterior! A-P spring to the fibrocartilage is tender and feels hypermobile. Treat with rolled towels (described above) under each ischia placed horizontally with hips n knees in neutral for 5 minutes. This is VERY, VERY rare. Treated a PT student and she was able to resume running. May require a few repeat sessions of self treatment.

If you have a working knowledge of how postional and movement dysfunction of a joint can cause reflex inhibition of muscle function in addition to that caused by altered muscle length weel it makes perfect sense to seek symmetry of the structure in all 3 planes of the body prior to use of a stabilizing belt or exercise. Sometimesthe repositioning is the only treatmentthat works. Joint mechanoreceptors types 1, 3 and 4 are certainly relevant.

For an external support that can beworn on oneside or on both sides, have client flex trunk by 50% and tie a sheet under the pubic boneand around the trunk making a complete loop. When they stand up it should fit snugly and they shoiuld feel upward support and immediate pain relief (if inferior instability was an issue). IT shouuld be under the pube/ischia in the front and in the back under the ischial tuberosity. Sometimes just 5 minutes is long enough, it varies. Bilateral if instability is bilateral. Not for wearing in public!!!! You can then cross over so that the top is on the opposite shoulder and this changes the vector adding an oblique force. This is another approach I developed. I am writing this quickly and have the sense that there is more....

Of course the symphysis is intimate with the SI so you have to treat the whole pelvis. I never treat just one part of the pelvis, at the very least screen the whole structure.
jerry hesch mhs pt
www.heschmethod.com

[jjose_01]

I have a patient who had a road traffic accident (15 days) and he has diastasis symphysis pubis of more than 2.5cm, but the orthopedic surgeons are treating him conservatively (complete bed rest) and binder for L2 compression fracture, they adviced me to mobilize him but he has pain on the groin on weight bearing of the right leg. strength of both lower extremities are 3+/5 to 4/5. What should I do since I am not that skilled with your technique?