The Muscle Energy Manual Evaluation and treatment of the pelvis and sacrum volume 3 BY Fred L. Mitchell

The Muscle Energy Manual VOLUME THREE Evaluation and Treatment of the Pelvis and Sacrum

ii THE MUSCLE ENERGY MANUAL

The Muscle Energy Manual VOLUME THREE Evaluation and Treatment of the Pelvis and Sacrum BY Fred L. Mitchell, Jr., D.O., F.A.A.O., F.C.A. Professor Emeritus of Osteopathic Manipulative Medicine College of Osteopathic Medicine Michigan State University East Lansing, Michigan AND P. Kai Galen Mitchell, B.A. .-&­ Second Edition MET Press East Lansing, Michigan 2001

iv THE MUSCLE ENERGY MANUAL Dedicated to my father1s memory. THE MUSCLE ENERGY MANUAL, VOLUME THREE, SECOND EorriON . Copyright© 2001 by Fred L. Mitchell, Jr. and P. Kai Galen Mitchell All rights reserved. This book is protected by copyright. No parr of this book may be used or translated or reproduced or transmitted in any manner or form whatsoever including photocopy, recording, or utilized by any information storage or retrieval system, without written permission from d1e copyright owners, except in the case of brief quotations embodied in critical articles and reviews. Inquiries and requests for permission to reproduce material from this work should be sent to MET Press, P.O. Box 4577, East L1nsing, Michigan 48826-4577. Fax: (517) 332-4196. Editm·s: P. Kai Galen Mitchell, Carol P. Mitchell, & Arm McGinthli•JWeller Desigr� ar�d Layout: 1� Kai Galm Mitchell Photogmphy: Marilyn Fox & P Kai Galm Mitchell Printed in the United States of America. Library of Congress Catalog Card Number: 95-77816 ISBN 0-9647250-1-0- PB (Volume One) ISBN 0-9647250-2-9- PB (Volume Two) ISBN 0-9647250-3-7- PB (Volume Three) Disclaimer: This bcK>k is intended to provide accurate information regarding the subject matter covered. However, it is impossible to ensure that the infor­ mation presented will be accurately interpreted and applied in all cases. Therefore, the authors and the publisher specifically disclaim any liability, loss, or risk , personal or otherwise, which is incurred as a consequence, directly or indirectly, of the usc and/or application of any of the contents of this book. MET Press, P.O. Box 4577, East Lansing, Michigan 48826-4577 • Fax: (517) 332-4196.

THE MUSCLE ENERGY MANUAL V Preface for The Muscle Energy Manual Series This series greatly expands upon the concepts presented in the first texts ever published on Muscle Energy (Mitchell, Jr., Moran, Pruzzo; 1973 and 1979). This current work is the culmination of more than thirty-five years of clinical practice, research, and teaching. Muscle Energy Technique (MET) was first introduced by the author into the curriculum of osteo­ pathic colleges in 1964 at the Kansas City College of Osteopathy and Surgery, following a four­ year postdoctoral joint practice with Fred L. Mitchell, Sr. ( 1960-64). Since that time, its concepts and methods have spread to osteopathic colleges in the USA, Canada, and overseas. Today, Muscle Energy is taught at all osteopathic colleges- and many other manual medicine and manu­ al therapy programs worldwide - making the need for an updated, comprehensive Muscle Energy text and manual even more urgent. Although the 1973 and 1979 Muscle Energy manuals were enthusiastically received at home and abroad, years of teaching have made it apparent that certain deficiencies of the earlier publications have led to incomplete understanding and misapplications of MET. The earlier works did not include sufficient explanation of physiological mechanisms, nor the anatomic detail necessary to provide a rationale for the procedures. Additionally, although some readers no doubt appreciated the brevity of the cookbook approach, the diagnostic and treatment procedure descriptions did not provide enough information for the procedures to be performed reliably and consistently. The new MET series was written to address these omissions. Possibly because of the name, Muscle Energy has often been perceived as solely a treatment modal­ ity for \"tight\" muscles. Far too often, MET treatment techniques have been taught without suffi­ cient reference to MET's distinctive diagnostic algorithms. MET is more than a method of treat­ ment or therapy; it is also a biomechanics-based analytic diagnostic system, using precisephysical diagnosis evaluation procedures designed to identifY and quantifY articular range-of-motion restriction. The unique MET method of evaluation and diagnosis is an essential part of MET, in that it provides the necessary information needed to apply MET correctly, and therefore effectively. Among the algo­ rithms presented in this text is new material on rib-based vertebral joint diagnosis. Expanded also is discussion of the biomechanics of non-neutral ERS and FRS segmental dysfunction. The series is intended as both a text- especially emphasizing the theory and systematic methods of MET diagnosis- and an evaluation and treatment manual. The Muscle Ene�y Manual, Volume One (1995), covers Muscle Energy concepts and mechanisms, the musculoskeletal screen, and cer­ vical region evaluation and treatment. Volume Two (1998) covers the evaluation and treatment of the thoracic spine, lumbar spine, and rib cage. Volume Three (1999) covers the evaluation and treatment of the pelvis and sacrum. Fred L. Mitchell, Jr., D.O., FAAO, FCA

vi T H E M U S C L E E N E R G Y M A N U A L Volume Three Preface There is a widely shared and correct conviction that treatment of somatic dysfunctions of the pelvis and sacrum is complex and has a high priority clinically. In the early days of Muscle Energy Tutorials, in deference to its importance, evaluation and treatment of the pelvis and sacrum was presented first. The transition from pelvis to spine, ribs, and extremities, however, con­ stituted such giant conceptual leaps that the course sequence was changed in the 1980s to begin at the superior end of the axial skeleton. Conceptual development was smoother, advancing in smaller steps with a more logical sequence. Anticipating that some clinicians will choose to read Volume Three first, we have elected to pre­ sent, in the Introduction, a brief chronology and history of the development of the Muscle Energy concepts in order to clarity their relevance to pelvic evaluation and treatment. As with the previous volumes of The Muscle Energy Manual, the text begins with the relevant basic anatomy and physiology, proceeds to a general discussion of manipulable disorders, and con­ cludes with the details of clinical evaluation and treatment. Putting the Muscle Energy approach to evaluation and treatment of the pelvis into specific clin­ ical contexts could be the subject of an entire book. Such a book would discuss clinical applica­ tions in many more fields than low back pain management. Until such a book is written, we must trust that all types of clinicians, regardless of specialty, understand the relevance of posture, loco­ motion, viscerosomatic/somatovisceral reflexes, and microcirculation to their specific fields. Fred L. Mitchell, Jr., D.O., FAAO, FCA Acknmvledgements This book would probably have never seen print had it not been for the long and arduous efforts and questionings of my wife Carol and son Kai. Their commitment to this project kept me busy rewriting rewrites and reorganizing reorganized text, until all considered the final work ready for publication. As well as coauthoring, Kai Mitchell created many original graphics for the text, in addition to layout design, editing, and publishing. Many thanks also to Marilyn Fox for her photographic work, to Ann McGlothlin Weller for the precision of her editorial input, and to our loyal model,)ames Marlow. My sincere appreciation to Gary Ostrow, DO, FAAO for reading and commenting on the manuscript. As will be obvious to readers, gratin.de is also owed to Martin Beilke, DO, Angus G. Cathie, DO, Vladimir Janda, MD, Lawrence )ones, DO, Norman Larson, DO, Karel Lewit, MD, Kenneth Little, DO, Heinz-Dieter Neumann, MD, Charles Owens, DO, A. Hollis Wolf, DO, and). Gordon Zink, DO, tor many important insights and concepts. I owe my training in cranial osteopathy to the f.'1Ctllties of the Sutherland Teaching Foundation and the Cranial Academy, and especially to Thomas Schooley, DO, FAAO, FCA whose skilled hands and practical mind made cranial motion a reality for me. Most of all, gratitude is once again expressed to my father, Fred L. Mitchell, Sr., DO, FAAO who, through his teachings, provided me with a lifetime of valuable and knotty problems. F L. Mitchell, Jr.

THE MUSCLE ENERGY MANUAL vii Brief Contents Preface for the Muscle Energy Manual Series v Preface for Volume Three and Acknowledgements vt Brief Contents vii List of Tables viii List of Line Art Illustrations ix List of Procedures x Detailed Table of Contents xi Historical Chronology of Muscle Energy Technique xvt Introduction xvii History of the Development ofMuscle Energy Concepts xvii Diagnostic Concepts xviii Psychophysics ofPhysical Diagnosis xzx Treatment Concepts xxi A Short History of the Pelvic Axes xxm Some Frequently Asked Questions xxiii CHAPTER 1 RELEVANT PELVIC ANATOMY 1 •Osteology •Pelvic Landmarks •Pelvic Ligaments •Muscles of the Pelvis •Myofascial Influences CHAPTER 2 NoRMAL SAGITTAL PLANE MOTIONS IN THE PELVISACRAL JoiNTS 21 •Weight-bearing and Non-weight-bearing Sagittal Movements of the Sacrum •Transverse Instantaneous Axes of the Pelvis •Sagittal Plane Sacroiliac Motion- Nutation and Counternutation •Paradoxical Sacral Motion •Sacral Flexion vesus Sacral Shear •Iliosacral Motion and lnterinnominate Rotation CHAPTER 3 NoRMAL COUPLED MOTIONS IN THE SACROILIAC JOINTS: TORSION AND UNILATERAL SACRAL FLEXION 33 •Sacral Torsion and the Oblique Axes •The Walking Cycle and the Pelvis •Unilateral Sacral Flexion Movement •Lumbosacral Mechanics •Intrapelvic Adaptive Mechanics •The Sacral Base/ILA Paradox CHAPTER 4 OVERVIEW OF MANIPULABLE DISORDERS OF THE PELVIS 53 •Subluxations of the Pelvis •Sacroiliac Dysfunctions •Iliosacral Dysfunctions •Manipulable Muscle Imbalance •Breathing Movement Impairments •Craniosacral Dysfunction CHAPTER 5 INTRODUCTION TO EVALUATION AND TREATMENT OF THE PELVIS AND SACRUM 71 CHAPTER 6 SCREENING AND LATERALIZATION TESTS FOR THE PELVIS 75 •Relative Leg Length •Iliac Crest Heights Tests •Flexion Tests for Pelvisacral Mobility •Other Pelvisacral Mobility Screening Tests CHAPTER 7 SUBLUXATIONS AND DISLOCATIONS OF THE PELVIS: EVALUATION AND TREATMENT 101 •Subluxations of the Pubic Symphysis •Upslipped Innominate Lesions •Inflared and Outflared Innominate CHAPTER 8 EVALUATION AND TREATMENT OF PELVIC ARTICULAR DYSFUNCTION 121 •Diagnosis and Treatment of Sacroiliac and Iliosacral Dysfunctions APPENDIX: Patient Instructions for Sacroiliac Belt 159 BIBLIOGRAPHY and RECOMMENDED READING 162 INDEX 168

viii THE MUSCLE ENERGY MANUAL List of Tables Table 1.A. Pelvic Landmarks for Structural Diagnosis in the Mitchell Model 3 15 Table 1.8. Summary of Muscles Related to the Pelvis: Muscles Attached to the Sacrum Table 1.C. Table 1.0. Summary of Muscles Related to the Pelvis: Muscles Attached to the lnnominates from Above 16 18 Summary of Muscles Related to the Pelvis: Muscles Attached to the lnnominates from Below Table 4.A. T he Six Types of Manipulable Pelvic Disorders, with Possible Variants for Each 54 Table 5.A. Flow Chart for Evaluation and Treatment Sequence of Manipulable Pelvic Disorders 73 Table 6.A. Summary of Lateralization and Screening Evaluation Tests for the Pelvis 76 Table 6.8. Flexion Test Results and Probable Diagnoses 89 Table 7.A. Age and Sex Distribution of Patients Diagnosed with Upslipped Innominate 108 Table B.A. Treatment Sequence for Addressing Pelvic Dysfunction 122 Table 8.8. Pelvic Diagnosis Table 157