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Sacral torsion

 
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Sacral torsion - October 27, 2005 7:56:00 AM   
JSPT

 

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I am treating a 62 y/o male whom I suspect has a sacral torsion (L base and L ILA both don't move well with associted lumbar flexion and extension). His only complaint is of groin pain near the pubic symphysis and along the L inguinal ligament. I have treated him with strain/counterstrain, which gives relief for a few hours, but after 3-4 hours of standing, the pain returns.

There is no LLD, X-rays of the hip and pelvis were normal, there are no symptoms or movement dysfucntions in the lumbar spine, and no rotated innominates. I have tried direct mobilization of the sacrum with modest results. I know that there are some muscle energy techniques for this dysfunction, but I have only used MET for the spine. Does anyone have any insight?

Thanks in advance.

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Re: Sacral torsion - October 27, 2005 9:15:00 AM   
Diane

 

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If it's anterior torsion, use the same technique as for ERL on the same side. If it's posterior torsion, use the same technique as for FRL on the same side. (That's how I remember all that stuff.)

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Re: Sacral torsion - October 27, 2005 11:27:00 AM   
Shill

 

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JSPT,
What else provokes symptoms? Is standing 3-4 hours really the only thing that hurts? Has inguinal hernia been ruled out? I only have questions at the moment, sorry for the lack of insight.

Steve

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Re: Sacral torsion - October 27, 2005 1:13:00 PM   
JLS_PT_OCS

 

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In an elderly man with groin pain, I would think "sacral torsion" would be the last thing on our list.
The "movement problems" you've mentioned, are they related to his current pain? How can we tell?

I think his hip exam might be helpful. I agree with Steve in that we need more info.
Thanks.
J

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Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
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www.silvernailstudios.com
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Re: Sacral torsion - October 28, 2005 8:10:00 AM   
JSPT

 

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Ok. Now I have a free moment to elaborate. Mechanism of injury was shoveling dirt about 4 weeks ago. Main complaint was of burning in the L SI area and radiating burning from there around the front of the hip to proximal anterior thigh.

Both my self and the patient's DO found no evidence for a hernia (he is stumped). Hip x-rays were negative for lumbar spine degeneration or hip degeneration. Quadrant and grind tests of the hip are negative. Faber test is negative. Decreased L innominate rotation noted with stork test. No pain with P-A glide of any lumbar vertebrae. Movements of the lumbar vertebrae are otherwise normal in all planes. Compression of the spine does not increase pain.

C/c is deep groin pain after standing for more than 1-2 hours. Lying prone increases pain in the groin, and passive extension of the hip does so as well. Anterior mobilization of the L femoral head greatly increases pain (makes me think of a capsular issue). L ER is limited by about 10 degrees as compared to the R. IR is normal.

I apprecite the help. The patient is my wife's grade school teacher. He is one of the "healthy and fit" elderly. He works on a golf course doing maintenance work.

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Re: Sacral torsion - October 28, 2005 8:48:00 AM   
ehanso

 

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I would refer you to [URL=http://www.kalindra.com/sacroiliac]www.kalindra.com/sacroiliac[/URL] for a good baseline in SI evaluation and treatment including MET. Which SCS technique as used? What does the pubic symphasis feel like? Does he have hip flexor weakness on the painful side? Even though is leg length may be equal he may still be having dysfunction at the SIJ. Ed

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Re: Sacral torsion - October 28, 2005 8:52:00 AM   
ehanso

 

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Sorry it should be [URL=http://www.kalindra.com/sacroiliac.htm]www.kalindra.com/sacroiliac.htm[/URL]

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Re: Sacral torsion - October 28, 2005 9:31:00 AM   
JLS_PT_OCS

 

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How does he respond to manual therapy of the lower lumbar spine?
How about hip mobilizations?

I would mobilize his Lx spine, and try to mob his hip into extension if he could tolerate it.
J

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Re: Sacral torsion - October 28, 2005 9:37:00 AM   
Yogi

 

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http://www.physsportsmed.com/issues/1998/04apr/ruane.htm

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Re: Sacral torsion - October 28, 2005 9:41:00 AM   
Yogi

 

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http://www.physsportsmed.com/issues/2000/01_00/lacroix.htm

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Re: Sacral torsion - October 28, 2005 10:22:00 AM   
JSPT

 

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MET of the lumbar spine was well tolerated, as was P-A glides. I did these during our first session to alleviate some of the L SI symptoms. He absolutely cannot tolerated mobs of the hip into extension.

I used the Jones S/CS techniques for the pubic symphysis and inguinal pain. These provided relief for about 4-5 hours, but then the pain returns. I have only seen him 4 times over 3 weeks, so perhaps things will start to move in the right direction once they settle down. I plan to reassess lumbar and sacral alignment and movement next visit. I'm wondering if a stress fracture along the pubic ramus is another possibility. I believe that could be missed on an x-ray if it is a recent injury.

Thanks for the references, Yogi. A good reminder of how many things could be at work in this region.

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Re: Sacral torsion - October 28, 2005 1:01:00 PM   
Shill

 

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JSPT,
Your wife is in grade school? Just kidding.

This is a case where I would evaluate with repeated lumbar movements, likely into extension (with prone pressups), as that is just the way I do it. With the mechanism of injury being loaded flexion (basically), I would try unloaded extension. His pain with lying prone (which amounts to slight extension) may change for the better with repeated extension, one only knows after trying. If no pain changes occurred with this, for perhaps 5 sets of 10 reps, or prone on elbows for a few sets of 1-3 minutes resting in this position, I would try extension with a shift, closing down the left side by shifting the pelvis to the right while he does a few sets of prone pressups. If no changes for the better occur here, (remembering that a change for the better could be a slight worsening of central pain), I would try prone over one pillow, prone over two pillows, to see if this allows him relief. Whichever happened to help, he would be asked to unload his spine every 2-3 hours during the day, as his pain with standing 1-2 hours is an indication of the need to unload. If worsened by standing flexion, morning dressing routine, he would be asked to dress (pants, underwear, socks, shoes) while lying supine, due to the lessening of the load with this position. If he has trouble with lying down on the job to unload, just tell him to pretend he is looking for gophers.

Hope this helps.

Steve Hill

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Steve Hill PT

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Re: Sacral torsion - October 28, 2005 4:43:00 PM   
JSPT

 

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Thanks, Steve. I'll give that a shot next week if the sacral mobs didn't work. I'm sure there are some pretty creative ways he could work that into his substitute-teaching day with high school students....

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Re: Sacral torsion - October 29, 2005 11:32:00 PM   
physiosteve

 

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JS,
Thinking a bit outside the "arthrogenic" box, have you assessed some of the myofascial components? For example, taking the view that the hip rotators work much as the rotator cuff of the shoulder, uneven tension in those may lead to limitations in the hip joint, mimicking a "capsular" presentation. How are his piriformis, obturators/gemelli, and quadratus femoris? How about the TFL (influence on apparent innominate mobility/motion by reversal of origin and insertion) and the adductors? If these muscles are dysfunctional, could it be possible that there is some spinal segmental facilitation here? If so, anywhere from L2 to L5/S1 could be implicated. That burning pain on initial injury/irritation could indicate a peripheral nerve irritation, no? If so, there could be a spinal link.
Just musing on a Saturday night.... Look forward to reading what you find with this guy.

Steve.

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Re: Sacral torsion - October 30, 2005 9:39:00 AM   
Alex Brenner PT MPT OCS

 

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Right on Jason.

I would highly suspect the hip to be the source of pain. As I gain more experience I seem to be drifting further and further away from the SI as being much of a "player" in low back or hip pain. I don't believe in sacral torsions or sacral obliquities any more although I do recognize the SI can sometimes be a source of pain.

I would not suspect a pubic ramus stress fracture after one day of exertion and I would probably concentrate my efforts at the hip and lumbar spine.

Good luck, keep us updated.

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Alex Brenner, PT, MPT, OCS

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Re: Sacral torsion - October 31, 2005 7:11:00 AM   
JSPT

 

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Thanks for the weekend feedback, gentlemen. If the sacral mobs did not help from last Thursday, I will check the hip and lumbar spine more tomorrow morning. I'll keep you posted, and really appreciate the voices of experience.

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JS

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Re: Sacral torsion - November 1, 2005 7:30:00 AM   
JSPT

 

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Ok, just saw my patient. Pain continues to worsen only with standing more than 2 hours. Lifting, bending, sitting, squatting, etc. do not increase symptoms. After sacral mobs and MET of lumbar spine, pain stayed away for all of Thursday and returned after 3 hrs standing Friday.

Sacral torsion has resolved and sacrum is moving normally. Found restricted L facet opening from L1-5, which resolved 100% with MET. Passive hip extension in prone did not produce pain today, and greatly proudced pain last Thursday.

Repeated prone extension did produce pain in the L groin, after 5 reps. Prone extension combined with L SB (press-up with L deviation of shoulders) drastically increased L groin pain. Symptoms disappeared when the patient retured to prone. Prone extension with R SB did not produce symptoms.

All musculature of the hip and low back is symmetrical and WNL. Note decreased multifidi firing, but this did improve with BP cuff ex for TA contraction.

Any thoughts? Shill: I'm not familiar with the technique you described; does this mean he should be doing press-ups to the R every 1-2 hours or PRN to relieve symptoms?

So, after my 4th session with this guy, he is leaving Thursday for a month to stay with a sick relative. I will see him Thursday morning before he leaves, so any additional input would be appreciated.

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Re: Sacral torsion - November 1, 2005 9:11:00 AM   
eam

 

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Hi JS-
Just a couple of thoughts (I quickly read the post). Have you tried the PKB to check out the femoral nerve? If that is not tolerable try the PKB with a slump component in s/l.
Keep us posted. Interesting case!
Erica

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Re: Sacral torsion - November 1, 2005 9:54:00 AM   
JSPT

 

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Sorry, eam; PKB isn't registering. What is it?

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Re: Sacral torsion - November 1, 2005 1:22:00 PM   
Shill

 

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JS,
It sounds like the pain is present during prone extension with SB (L), but not as a result of the movement. This is OK, as it does not make him worse. With more repetitions, the pain during may actually improve as well. You can find out in the clinic by doing the old 3 sets of 10 thing. You can also experiment by having him move only through half range. The intent of this at this point is giving him pain control, not necessarily restoring ROM.
If there is truly NO pain during all of the times he is not standing, then this will not be all that dramatic. I would be surprised if he was completely pain free during all of these other tasks, but I have been surprised before. (What is he doing that subjects him to standing for such long durations, and, does he need to stand for this?)
However, if there is minor pain during sitting, etc, which is often ignored, as it is so much better than the intense pain, this unloading exercise routine could help him feel more in control of the pain, as he will be able to take care of it on his own, especially over the next month. This is how you could convince him that the pain during is worth it, provided he is truly better as a result of the motion. He will likely need to know that returning to loaded bending this soon is likely to contribute to perpetuation of symptoms, given that not enough time has elapsed for actual tissue healing to take place. Careful movements during the next 4-6 weeks are a must for tissue protection, but he should return to see you after this time, so that you can help him restore movements once the tissue has healed. This instruction should help to avoid fear avoidance behaviors as well.

Obviously, if standing more than two hours is the only time he ever has any pain whatsoever , he needs to stand about an hour and 50 minutes, and then unload by lying prone, and/or doing some extensions as well. You can allow him to do whichever extension or other unloaded motion brings about the longest duration of relief as a result of the movement.
As I explain this, I question whether it makes sense to someone other than me.

Let me know.

Steve

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