musculoskeletal myths#7 pubic symphesitis (Full Version)

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ginger -> musculoskeletal myths#7 pubic symphesitis (August 23, 2005 5:37:00 PM)

Musculoskeletal myths #7 Pubic Symphesitis
Commonly ascribed to footballers and others playing running and kicking sports is the newest in high fashion designer diagnoses, pubic symphesitis. Characterised by a painful groin , sometimes on one side only, affecting the individuals ability to run and kick. Occasionaly with pain extending to the medial aspect of the thigh even as far as the knee. Made worse by exercise, by standing for long periods, constant pain may be felt in severe cases. Palpable tenderness elicited in the anterior hip joint area including the symphesis pubis, sometimes able to be elicited with full range hip flexion , extension and or ab/adduction.
This can be interpreted in one of two ways . In some cases there is a biomechanical disturbance to normal pelvic movements by loss of one or both sacroiliac joint movements. This leads to the torques and forces otherwise soaked up by the rearward movement of these large joints reaching the anterior aspect of the pelvis, giving rise to stress at the symphesis. It is little wonder then that occasionaly a painfull condition arises where forces sustained during rapid kicking movements are forced towards a joint which would not bear such forces when the SIJ's are fully functional. Restoration then of SIJ function is indicated . These joints ought to be able to rotate rearward from 6 to 8 degrees. Best observed by placing the thumbs on the PSIS's while the subject raises the ipsilateral knee towards the chest , to about pelvis height. In the fully mobile joint , the thumb connected to the ipsilateral psis will be seen to rotate and drop downwards . An immobile joint will see the thumbs remain at the same height or even the flexed side be raised slightly.
In cases where this is the primary cause of Inflammatory events at the symphesis , treatment to restore full range and freedom of the sij is sufficient to relieve the problem permanently . This is rarely seen however in isolation. As the disturbance to normal biomechanics of the pelvis hips and lumbar spine is such that protective responses will be initiated in the lumbar spine. This leads to inflammatory events of joints and nerves , with the likelihood then of referred pain arising from T12 , L1 and L2 joints and nerves .
It is therefore essential that attention be given to this area of the lumbar spine with appropriately and skillfully delivered mobilisation treatments. Tight dura of the femoral nerve may need to be stretched as well. The so called pubic symphesitis will quickly dissapear, once referred pain is brought under control. This is usually possible within one to three treatments. In my practice I have yet to see a case of pubic symphesitis that did not respond immediately and permanently to this combination. Any local treatments that go beyond the occasional use of the interfential device is in my view innapropriate. Until or unless the upper lumbar spine has been excluded as the cause of this problem (certainly including those who do not complain of lumbar pain )it is safe to assume a contribution from referred events arising from that area.



Synergy -> Re: musculoskeletal myths#7 pubic symphesitis (August 23, 2005 7:38:00 PM)

[QUOTE]These joints ought to be able to rotate rearward from 6 to 8 degrees.[/QUOTE]Ginger,

Do you have any documentation proving that amount of rotation? I was under the impression that yes...there is some mobility in the SI joints, but minimal at best and so minimal that it's extremely difficult to measure. Anyone have any articles that support SI joint motion...down to degrees of rotation?



ginger -> Re: musculoskeletal myths#7 pubic symphesitis (August 23, 2005 11:32:00 PM)

Looks to me like you are focusing on the leaves chris, step back and view the whole tree.



Sebastian Asselbergs -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 1:52:00 AM)

Ginger, that diagnosis is FAR from new - been used in sports medicine for over 25 years. And it does exist. And it IS misdiagnosed - yes. BTW, YOU are the one throwing out the "leaves": "6 to 8 degrees". Support that.



JLS_PT_OCS -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 2:59:00 AM)

Geoff/Ginger-
A good case series would be great. You could outline your approach to this often difficult problem to treat without having to devote a lot of time to research. Given your reported high clinical load, it should be rather easy to gather a few cases together and help some others of us learn a useful treatment regimen.

Treatment and even proving movement at the SIJ is very much a contentious issue in the literature, so I am surprised you seem so certain of it's motion.
Well, I guess not surprised at this point, but rather continually amused.

I think you are working on your career in humor as well, yes?
:)
J



SJBird55 -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 3:47:00 AM)

Oh, I'm sure there's movement at the SIJ. It isn't fused, so logically there is movement. The degree of the movement is what is difficult to measure. There is very low inter-examiner reliability in measuring motion at the SIJ manually. The other aspect to consider is that the SIJ is 3-dimensional - in a regular clinic, we don't have anything to capture and measure 3-D movement. In my mind, it's a technological issue - for some reason we don't have the technology or if we do have the technology in some other field, it isn't being put to use to answer SIJ movement questions. And the other aspect that makes measurement difficult is the lack of symmetry between sides and the variability between individuals.

In ginger's defense, he may be accurate in the 6-8 degree number... I do remember reading something (can't remember what but a few years back) on some numbers in that range... could have been like 3-8 degrees? I just remember it was a very low number of degrees.

Do a search for Bobcat and some of the things discussed a few years back.



Sebastian Asselbergs -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 5:59:00 AM)

SJ, the literature in past threads here was very controversial with regards to actual motion ranges at the SI joints. From as much as 16 degrees to as little as 3. I appreciate the points Ginger makes about looking beyond the local issues in the tissues, but there are so many problems with the reliability and variety and intertester and intratester reliability of the testing and treatments of SI and lumbopelvic joints, that stating his case as strongly as he has, he is bound to get some flack. After all, there are many here who have taken osteopathic, MET, Cyriax, Kaltenborn, Maitland, Janda, Butler etc etc courses, and have found them all to be of some value, but not to everything....



SJBird55 -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 6:23:00 AM)

From Cleland's book on the review of literature... I just read the one aspect yesterday in regard to SIJ and I am terrible at memorizing...

If I remember correctly, someone did a study that if a discogenic problem was ruled out using McKenzie (10 repetitions of standing flexion, standing extension, standing side glide left and right, and lying flexion and lying extension - noting centralization or peripheralization).. then I think if 4 of 5 sacroiliac tests were positive there was a higher probability that the problem would be sacroiliac related. Now if I can remember the tests at the top of my head... thigh thrust, gaenslen's, I want to say compression test... and I obviously didn't retain what I read because everything is fuzzy in my head now. I don't believe the tests that indicated a higher probability of sacroiliac dysfunction were actually related to motion palpation but instead pain provocation.

I don't think the test ginger is referred to was one of the 5... AND ginger believe it or not, there is very low inter-examiner reliability in that test.

This is where I am having difficulty in our profession and in how we make decisions... in regard to the manual aspect of what we measure and test, there is amazingly very low inter-examiner reliability. That means, that if I were a gambling person, I'd tend to bet that on the exact same patient with the exact same information doing the exact same test that with two therapists involved, I would always bet that the manual findings would be slightly different. How can that be? Something like that seems like it should be so black and white... but it's not. Why is there so much variation?

And ginger, it just blows my mind... how can you always be focused on the spine? How do you rule out that the periphery is cleared and that that spinal mobilization is the answer? At what time frame are you seeing these patients post onset of condition? I can't decide if you're just tossing crap out there to get some arguments going or if you are really being serious.

When we make our clinical decisions there has to be something somewhere somehow that triggers our approach. At least logically, I'd think that. Is it what a patient says, is it how a patient moves, is it what we observe, is it what we feel with our hands... but my head tells me for success it has to be a combination of all of that information. Maybe I make things more difficult than they really are?



steve -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 7:09:00 AM)

SJ,

There have been two different studies using nerve block and examining sensitivity/specificity of sacroiliac provocation testing. The ones I use are:

Thigh thrust
distraction
compression
Fabers
Sacral shear.

Off the top of my head 4/5 correlates with an 80% probability that a patient will have pain relief with SI injection. I'll try and look up the source.

How are you enjoying Josh Cleland's book?

Steve



JLS_PT_OCS -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 7:21:00 AM)

SJ-
I think your concerns about those issues are understandable, and we all wrestle with those issues.
I think you are correct in that our eventual course of action is a combination of clinical experience, exam findings, subjective reports, and our personal 'gestalt' on the patient at the time.
I'm not sure that's a bad thing. I'm all for trying to generally standardize our practices, but I'm not sure anyone seriously thinks that many of those manual tests have any chance of a good interrater reliability.
Even basic orhthopedic tests such as knee ligament testing I am sure has a degree of unreliability to it.
Perhaps Josh covers that in the book as well?

J



SJBird55 -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 7:52:00 AM)

Steve... lots of numbers in that book. LOL I had a goal of reviewing literature for the special tests that I use to learn more regarding the sensitivity and specificity of them, but geesh, I didn't have the resources or time to do that and do it well. Josh saved me a ton of time with what he put together. I'd love to ask him how he chose the literature that he chose... I'm assuming he did broad searches in databases. We really don't have a ton of research regarding our special tests and examination procedures. And then when there are multiple studies done by different researchers, the numbers in the columns aren't in a nice tight group - there's still quite a bit of variability. I don't know if I "enjoy" the book... I'd prefer some murder or CSI or some smut to read in the "enjoy" category... but it is very thought provoking. His book is something I have to put down quite frequently and leave for a bit.... if I don't concentrate and think while I'm reading, well, it could put me to sleep. LOL If I ever meet Josh, I'll suggest that every once in a while he should have left a page here and a page there throughout the book with say a picture of George Clooney or Matt Damon or Kevin Costner or Brad Pitt... you know, keep our attention for the majority of us in the profession (I'm pretty sure it's the female gender) reading and turning the pages.

LOL Jason... I'm sure Josh does. I'm not to the knee quite yet though. That is further in the book than I've read. I'm seeing a pattern though that manually there is very little inter-examiner reliability. (I think I've only read up to chapter 3 or 4?). I haven't read that section yet, but with a lot of the tests in which you come up with a positive or a negative response, he's generally listing the sensitivity and the specificity and likelihood ratios and probably with the knee ligaments, the literature would use arthroscopy as the determination of the accuracy? That's just me guessing though.

I'm not really looking at it from a standardize our practice kind of view. I'm looking at it more from maybe the clinical decision making aspect. Maybe more like how much weight to we put on the different things we find upon our examination? It's quite unsettling for me and mind boggling to see that our hands and our palpation skills we think hold quite a bit of weight to what we do... but the inter-examiner reliability is so terrible. What does that mean?

And the other thing... when you read about direct access and you listen to those in our profession here in the states that are the huge advocates... something else that is bothersome for me. There is a decent amount of stress of how well we as physical therapists capture subjective information. Which then leads to statements of the simple fact that all the expensive diagnostic testing isn't always necessary because we snag so much from the subjective portion of our exam. I do tend to believe that what the patient tells us does have some substantial weight... but interestingly, Josh didn't compile as much as I would have expected in the literature from the "history examination."

I believe our course of action is a combination but in saying that, I also think that each variable in the combination holds a particular weight or value to our decision-making process... but without really seeing supporting literature/research in black and white how do I know that I'm placing the value of whatever entitiy in the correct perspective of it's true worth within the combination of variables being considered.



jma -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 3:51:00 PM)

Interesting book. I will see if the hospital library has it. If not, then they will get it in.



karmzack -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 4:26:00 PM)

SJ I don't own Josh's book, but I saw a chapter on the Netter website. It looks like the book is more of a reference than a cover to cover read. I see how it would make you sleepy!



certMDT -> Re: musculoskeletal myths#7 pubic symphesitis (August 24, 2005 5:01:00 PM)

You guys are referring to the work of Mark Laslett, Sharon Young, and Charles Aprill. The criteria for clinical diagnosis of SI joint pain as clarified by SI injection are (in order, as this is an algorithm):

1. Inability to centralize the pain with MDT (McKenzie) evaluation.
2. No reproduction of SI pain with P-A pressure on lumbar vertebrae.
3. No pain with resisted hip external rotation.
4. No pain with passive hip rotation (specifically external, if I remember correctly).
5. Pain with 3/6 stress tests (all of which have been found to have good to excellent reliability for pain reproduction) - iliac compression, iliac distraction, Gaenslen's right and left, thigh thrust, P-A on sacrum.

They have done excellent and really admirable studies correlating their clinical findings to discogram and SI and facet injections. A recent article indicated that if all tests are negative, the patient does not have SI joint pain (as confirmed by injection, which can be debated).

I can give anyone the articles for this if they want them.

Charlie



SJBird55 -> Re: musculoskeletal myths#7 pubic symphesitis (August 25, 2005 1:34:00 AM)

Zack, you do have a point... but if I put it on a shelf looking all pretty and don't open it up and read it then I wouldn't be any closer to my goals of clinical decision making in the assessment area using literature to support my decisions more than my intuition. So... cover to cover it is. LOL

Charlie... yep, Laslett is was. I remember 1, don't recall 2, 3, or 4.... and 5 was what I was trying to remember. LOL My focus is in remembering what is relevant to help drive my assessment process. I'll post what the Cleland book had in regard to #5.



certMDT -> Re: musculoskeletal myths#7 pubic symphesitis (August 25, 2005 2:44:00 AM)

SJ -

3 and 4 are part of Cyriax's hip exam, which Laslett still references. The P-A pressure (along with the hip exam) are specifically described by Laslett in an early article (it's meant to further rule out lumbar involvement), and it is still taught that way on the McKenzie courses.

Charlie



JLS_PT_OCS -> Re: musculoskeletal myths#7 pubic symphesitis (August 25, 2005 3:27:00 AM)

Can someone clarify the "thigh thrust" test?
Is this the same as the Posterior Shear/POSH test?

J



SJBird55 -> Re: musculoskeletal myths#7 pubic symphesitis (August 25, 2005 5:13:00 AM)

Charlie, you are awesome. LOL The tests that needed to be positive to indicate SIJ dyfunction were: Distraction, thigh thrust, Gaenslen test, sacral thrust and compression. Charlie, could you look up how many of the tests need to be positive to indicate SIJ dysfunction? Josh has 3 out of 4... but there are 5 tests.

Jas, the thigh thrust is the same as the posterior shear test, yes. Pt in supine position, 90 degrees hip flexion with hip adducted and the examiner directs a posterior force through the femur at different angles of adduction/abduction.

Ginger.. the inter-examiner reliability for the Gillett test has a range from -.05 to .56 kappa value. Inter-examiner agreement is from 47% to 65%. I know I shouldn't joke in the written form, but that kind of range of agreement reminds me back in the day in microbiology lab.... I was holding a slide up to the ceiling under a light and telling my lab partner that it looked gram-positive to me. No need to pull out the microscope today. LOL Ummm... I got caught and questioned by the prof because to find out he was RIGHT behind me when I determined positiveness of the slide.



SJBird55 -> Re: musculoskeletal myths#7 pubic symphesitis (August 25, 2005 6:38:00 AM)

Jas, I just finished the knee chapter.

Inter-examiner reliability for range of motion measurements is good.
Inter-examiner reliability for determining end feel is poor.

This blows my mind... our ability to assess the cardinal signs of inflammation is terrible! (Fritz did this study)
The inter-examiner reliability:
fluctuation test: .37
patellar tap test: .21
palpation for warmth: .66 (THAT'S cause our hands are ALWAYS cold LOL)
visual inspection for redness: .21 YIKES that is terrible!!!

You asked about the inter-examiner reliability of the special tests...
depending on the test, but pretty much a range of -.08 to .66. Patellar orientation inter-examiner reliability was basically in the .02-.5 range.

Exceptions:
Posterior drawer test: .82
Lateral instability test 0 degrees flexion: .88

Can I ask why we even document any of our palpatory assessment findings? It's not like anyone else can pick up the written eval and agree with us. Definitely makes me think and wonder... AND, in the cases that the intra-examiner reliability is listed for the manually assessed stuff - there is a large range there too as to whether we are reliable with ourselves. I can see myself in court... "I'm sorry, Judge, reproducibility of my findings is very low."



JLS_PT_OCS -> Re: musculoskeletal myths#7 pubic symphesitis (August 25, 2005 10:44:00 AM)

Wow.
I think you would get some complaint from some groups with this data. I dare you to take it to our Orthopedic colleagues and say you're not sure about his read of a patient's Lachman test b/c the reliability of the test is only...
Now that would be fun.

I think Rob Wainner wrote a good editorial for JOSPT a while ago entitled "Reliability of the clinical exam, how close is close enough?" and I think Jules Rothstein also addressed it in an editorial called "The reliability journal?" or something like that.
They are both available at JOSPT.org.
They are good discussions of the pertinence and use of measures that can be unreliable and provides a good rational for why they are necessary in making clinical decisions anyway.
Good stuff, I thought.
J



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