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

CHAPTER 7 � Subluxations in the Pelvis: Evaluation and Treatment 109 If the dislocation has occurred bilaterally, the landmark sacroiliac mobility. Refer to Chapter 6, Figures 6.23.A - findings may be symmetrical. To rule out bilateral disloca­ 6.25.G. tion one side must be treated experimentally, and the land­ marks reexamined. This procedure should be incorporated In the non-weight bearing supine dynamic leg length routinely into general physical examinations. In the class­ test, each side of the pelvis is subjected to controlled cir­ room or workshop situation students should practice the cumduction movements of the hip joint. These circum­ treatment procedure on seemingly \"normal\" classmates to ductions can be used to shorten the leg (with flexion, rule out bilateral dislocation. The treatment procedure is abduction, external rotation of the hip), and lengthen the nontraumatic, when performed with judicious force. There leg (with flexion, adduction, and internal rotation of the is no danger of producing a \"downslipped\" dislocation. hip). Pubic subluxation may or may not be present with The amount of leg length change on each side is com­ upslipped innominate, either on the same side or on the pared. With the supine dynamic leg length tests, a normal contralateral side. The etiology of pubic subluxation, how­ pelvis will permit the leg length to change 6 to 12 millime­ ever, is entirely different from the traumatic etiology of ters. A subluxated sacroiliac joint, because it is more hyper­ upslip. Pubic subluxation is caused by abdominal-thigh mobile under non-weight bearing conditions, will permit muscle imbalance. more than 12 millimeters. In contrast, a dysfunction due to restriction (i.e., sacroiliac or iliosacral dysfunction) will One expert in the field of manual medicine initially allow less than 6 millimeters' change in response to these believed that the upslipped innominate was an undiagnos­ tests. Thus, the supine dynamic leg length tests can pro­ able condition after X-raying a series of patients while his vide supportive evidence of the presence of subluxation, by thumbs were palpating the ischial tuberosities. It was then making more evident the degree of hypermobility on the discovered that an error in technique led to the thumbs side with the lesion. sometimes being positioned as far as two centimeters from the inferior surface of the ischium. The author, observing Note: Before measuring supine leg length it is customary to spring the the technique used, noticed that the palmar stereognostic legs into internal rotation - except when using leg length to diagnose approach was not employed in locating the inferior surfaces mobility asymmetry in the pelvis. Theoretically, the stork tests should of the ischial tuberosities, a common mistake of even high­ also demonstrate hypermobility of the dislocated side, but this has not ly skilled clinicians. Instead, the thumbs were simply yet been tested experimentally. Of course, recumbent leg length is pushed into the inferior gluteal fold. expected to be shortened on the side of the upslipped innominate. The change in prone leg length, before and after treatment, is an indicator Students should be taught to first palpate the inferior of treatment success and a measure of the severity of dislocation. gluteal folds with the palms of the hands, which are moved in small circular motions until the stereognostic sense iden­ Paradoxically, even though a subluxated joint is more tifies the precise location of the inferior surface of the hypermobile and tends toward instability, the standing and ischial tuberosity. The thumbs can then be placed precise­ seated flexion tests for pelvic joint mobility almost always ly on its inferior surfaces. In placing the thumbs, care must manifest restricted mobility of the subluxated side. The be taken to avoid pushing the thumbs against skin tension; most likely explanation for this paradox is that supporting skin slack can be created by pulling gluteal skin down with weight on the dislocated joint tends to jam or wedge the the thumbs. The preferred method of evaluating the ten­ sacrum onto the ilium. There are exceptions, however, but sion of the sacrotuberous ligaments also depends on know­ they can usually be accounted for by concomitant dysfunc­ ing precisely where those ischial tuberosity surfaces are. tions on the opposite side of the pelvis (which may actual­ ly be secondary lesions compensating for the dislocation). Using Mobility Tests for Lateralization and Confirmation of Upslipped Diagnosis Sometimes the wedging effect of the weight-bearing The use of a combination of flexion tests and the supine hypermobile sacroiliac joint does not sufficiently restrict Dynamic Leg Length Test of Pelvic Motion Symmetry can the mobility enough to affect the flexion test. In other provide supporting evidence of the diagnosis in question­ words, hypermobility may be demonstrated both standing able cases. The combination of standing mobility restric­ and supine. In this case, the flexion tests are not reliable to tion and ipsilateral supine hypermobility is persuasive evi­ discriminate upslipped innominate on one side versus dence of sacroiliac subluxation. A supine leg length chang­ downslipped innominate on the other. It is best to assume ing test is a reliable method of testing non-weight-bearing that the downslipped innominate is a fictional entity, and treat the superior innominate.