By Peter Carter, Osteopath, The Medical Sanctuary

The pelvis may be viewed as 3 separate bones having 2 possible fixation areas. The first in the in the pubic symphysis is the anterior and inferior end and the second is the sacro-illiac joints the posterior and superior ends.

Secondly it can be seen in walking illial rotation concurs with rotation of the public bones around a transverse axis through the symphysis pubis MMP Page 49. From this motion the interdependence of these 2 pelvic joints can be seen i.e. motion about 1 join occurs concurrently with motion about the other.

Distortion of the posterior articulation; the illio-sacral joint can occur in the 3 possible geometrical planes. In the sagittal plane superior or the inferior illum; transverse-illiac flares. It can be expected that the anterior articulation; the pubic symphysis, can likewise distort in 3 axis i.e. sagittal-superior or inferior pubis; transverse-anterior or posterior pubic and coronal-pubic flares. From my clinical experience it has been easy to recognise the superior-inferior and anterior-posterior patterns whereas pubic flares would seem to be non-existent and almost impossible to recognise. These distortions would almost certainly be recognised as iliac flares because of the difficulty of the pubic symphysis fibro-cartilage been able to make the necessary compressive and expensive accommodations to make this possible. The shape of the pubic articulation also makes this highly unlikely whereas it seems far more capable of accommodating a superior-inferior or anterior-posterior gliding motion occurs as secondary effect when the normal rotative action of the pubic bones is impaired.

The most commonly presentation pattern clinically is a combined inferior-anterior or superior-posterior pubis. This combination is what should be expected to occurs given the normal rotative action of the pubic bones. When this pattern presents clinically it is easily treated in the normal manner particularly when the practitioner keeps in mind the rotative action of the pubic bone and encourages this with a slightly rolling motion of their own.

However this combined pattern does not always present clinically where singular superior-inferior or anterior-posterior may occur or dual combinations of interior-posterior and superior-anterior may also occur seemingly contradictory to normal physiological motion. This I suspect occurs as mentioned before due to the possibility of binding at the pubic symphysis when there is a restriction of the normal rotative motion. Indeed this seems to be the pattern throughout the body where it will take any possible route of movement available to it once other directions of movement have been exhausted or restricted. Thus once normal rotative motion is restricted it can give rise to a range of other possible distortions in either one or two planes of motion.

The mechanism for producing the restriction of motion of pubic bones comes directly from its relationship to illial rotation during walking. Restriction of motion of the innomiate bones may occur at either the posterior articulation – the sacro-illiac joint or at the anterior articulation the pubic symphysis in a reverse interdependence. Restriction at the sacro-illiac joint restricts rolling motion of pubic bones which alters pubic symphysis movement. Pubic bone restrictions may be the primary underlining cause of iliac distortions.

The most common traumatically acquired pubic distortions result from childbirth. Here the pubic bones separate to allow passage of the emerging infant. Unfortunately the pubic bones do not always return to their previous relationship after child-birth. This particular event would be the most logical explanation for the much higher clinical occurrence of pubic distortions in women. I suspect it is al significant contribution factor to the high incidence of problems in their related urogenital viscera.

Diagnosis

SUPERIOR-INDERIOR

M.M.P page 199 201 describes the diagnosis of superior and inferior pubic distortion. This approach is adequate but a more complete picture can be obtained by using a slightly altered diagnostic grip. Instead of using 2 index finger points on the pubic tubercles the practitioner places 4 fingers of each hand on the superior margin of the pubic bones one hand on each side of the pubic symphysis and the rests the side of the thumbs on the mons pubis for stability. This gives a much clearer picture of the pubic bones location and feels far more comfortable for the patient than sticking a single finger points into the pubic area.

ANTERIOR-POSTERIOR

Using the diagnostic grip described above the hands now slide slightly downward onto the mons pubis, keeping on hand on either side of the mid-line. By keeping the fingers flat and pressing downwards towards the bench into the mons pubis it is much easier to accurately assess whether one pubic bone is more anterior or posterior than the after.

Treatment

The possible distortion patterns can be rectified by adjustive procedures similar to those described in MMP pages 385 387

However I would not recommend the procedure on page 389 390 as these are in my opinion entirely non-specific and contra-indicated if there are any inguinal ligament neural entrapments or injuries to the tendons or muscles in the groin of other damage to other structures in or around the pelvic floor (particularly post-partum)

Firstly I would recommend the modification of all adjustive procedures to ensure that one monitoring hand is always placed by the practitioner upon the bone that is the process of being corrected.

Secondly some hand positions and directions of force would need to be altered to ensure the maximum effectiveness of the treatment and ease of the practitioner. I would recommend that the superior-inferior distortions be corrected first as these I consider to be the primary gravity distortions – as in the case of the sup-inf innominates.

SUPERIOR

The adjustive procedure for the superior pubic in MMP page 285 is used with the following modifications. Instead of the hand stabilizing the opposite ASIS it is used to monitor the pubic bone been corrected. The grip upon this bone is as previously described to palpate the pubic bone but the hand is slid slightly medially over the pubic symphysis to monitor changes in its position.

The other hand applies pressure down upon the leg as usual. This is done just to point of taking up any slack that is present in the thigh. The thigh is then extended and abducted or adducted until the pubic bone is felt to move inferiorally by the monitoring hand. The patient the gently flexes the thigh against the practitioners hand then relaxes. Upon relaxation the monitoring hand should feel the pubic bone move more inferiorally.

A little extra encouragement can be given by pulling slightly inferiorally upon the pubic bone with the monitoring hand or alternatively by using the breathing rhythm of the patient. The pubic bone is encouraged inferiorally on exhalation.

INFERIOR

The adjustive procedures in MMP page 287 for the inferior pubic is used with the following variations.

The practitioner stands on the side of the involved pubic bone. The hand that is normally used to hold the patients knee is used to monitor the pubic bone as describer before in the superior distortion. The other hand engages the ischial tuberosity and exerts a cephalad force.

The practitioner leans his/her chest against the patients knee. The practitioner then leans backwards and forwards flexing and extending the patients thigh till the monitoring hand feels the pubic bone move superiorally. The patient is asked to gently extend his/her thigh against the practitioners chest in a muscle-energy procedure. The pubic bone is guided in a cephal direction by the other hand. The patient then relaxes his/her contractive muscle force. This procedure is continued until the pubic bone is reluctant to continue its upwards path.

Then re-diagnose to determine if the pubii are now level.

POSTERIOR

The adjustive procedure used is the same as the superior method with the following modifications.

The monitoring hand is placed upon the pubic bone in the same manner as the described for the diagnosis of the anterior-posterior distortions. Pressure is applied downwards as in the normal procedure. The monitoring hand applies pressure posteriorally on the inferior edge of the pubic bone causing it to slide posteriorly (and the superior edge and to rotate anteriorly). The thigh is then lowered further and the procedure continued until correction occurs.

Then re-diagnose to assess the new pubii level.

ANTERIOR

The adjustive procedure is followed for the posterior pubic with the following modifications

The monitoring hand is placed upon the superior edge of the pubic bone. The other hand raised the leg on the involved side in a position similar to the inferior adjustment procedure. The thigh is flexed until the monitoring hand begins to feel the pubic bone move posteriorly. Pressure is then applied onto the pubic bone by the monitoring hand causing it to slide posteriorally (and the superior edge to rotate superiorly). The thigh is then raised further and the procedure continued till correction occurs.

Then re-diagnose to asses the new pubii levels.

REFERENCES

EVALUTIONS AND TREATMENT MANUAL OF OSTEROPATHIC MANIPULATIVE PROCEDURES

By Drs. Mitchell, Moran and Pruzzo, 1979

Mitchell, Moran and Pruzzo &Assoc.

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