Continuing Education Activity

The pelvis contains a large number of muscles that allow the upper and lower body to function as one. When these muscles are not functioning optimally due to somatic dysfunctions, patients develop pain in various parts of their bodies. This activity reviews muscle energy for somatic dysfunctions of the pelvis and explains the role of the physician in evaluating and treating patients with these conditions.

Objectives:

• Outline how to diagnose pelvic dysfunctions.
• Describe the findings associated with the somatic dysfunctions of the pelvis.
• Explain how to treat somatic dysfunctions of the pelvis.
• Summarize the importance of improving care coordination amongst the interprofessional team to improve outcomes for patients affected by pelvic somatic dysfunctions.

Introduction

The pelvis is composed of various ligaments, muscles, bones, and other structures that connect the axial skeleton to the lower extremities. When dysfunctions occur in this important part of the body, patients may experience pain in a variety of muscles, abnormalities in gait, and viscerosomatic disturbances. Irritable bowel syndrome is a common functional problem that can be caused by the disturbance of either nerve in the pelvic area or due to psychosomatic issues.[1] 

Osteopathic manipulative treatment (OMT) techniques directed at treating the pelvis in this paper will focus on muscle energy (ME). ME is considered a direct technique, a form of treatment that engages the targeted muscles and stretches them towards their restrictive barrier. One of the aspects of ME is that it requires the patient to be able to understand and participate in the treatment; therefore, it requires clear communication between them and the physician. ME is an effective technique at treating pain in various parts of the body ranging from the pelvis to the neck and even the elbow.[2] 

The educational purpose of this paper will focus on how ME can treat different types of muscular and non-muscular pain in the pelvic area. 

Anatomy and Physiology

The main function of the pelvis is to allow for the transfer of weight from the torso to the lower body and proper ambulation.[3] Since the pelvis contains so many muscles, this article will look at the most important muscles involved in the dysfunctions and how to utilize those same muscles during treatment. The main flexors of the pelvis are, but not limited to, the iliacus, psoas, and rectus femoris, all of which receive blood supply from the abdominal aorta and the femoral artery [4]. Damage to the hip flexors is a common cause of acute groin pain.[5] The iliacus and psoas are innervated by lumbar plexus, while the femoral nerve innervates the rectus femoris.[6] 

The primary extensor of the pelvis is the gluteus maximus. It is supplied with blood by the superior and inferior gluteal artery and innervated by the inferior gluteal nerve.[7] The main adductors of the pelvis are the adductor magnus, longus, and brevis along with the pectineus. The main blood supply to this area is the obturator artery, which originates from the internal iliac artery.[8] There are a variety of nerves that supply this muscle group, but all of them originate from the lumbar and sacral plexus.[4] 

The final main muscle group of the pelvis is the hip abductors, those of which are the gluteus minimus and medius along with the tensor fascia lata. All of these muscles are supplied with blood mostly by the superior gluteal artery along with some branches from the inferior gluteal artery.[9] The nerve that innervates the hip abductors is the superior gluteal nerve.[10] These muscles are especially important because they have implications in the proper function and stability of the pelvis and appropriate ambulation.[11]

Indications

The indications to perform OMT on the pelvis vary greatly from but are not limited to sacroiliac, generalized hip, groin, low back, leg, to pelvic girdle pain.[12] Since ME is such a safe and effective technique, it is a common treatment modality by physicians. It is essential to keep in mind that ME requires the patient to understand and participate in the treatment process. 

Contraindications

Although OMT is generally safe, there are still minimal risks involved. ME should not be used if a patient is in too much pain to contract a muscle. Other contraindications include local fractures, unstable joints, and recent surgeries. 

Equipment

Equipment needed for this procedure includes:

• OMT Table
• Stool

Personnel

Only the clinician is required to perform ME.

Preparation

The physician should discuss the risks/benefits of the procedure with the patient. Prior to performing OMT, the physician needs to assess the pain scale from the patient to compare it after treatment.

Technique or Treatment

There are six main dysfunctions for which this section will discuss diagnosis and treatment. The first step in diagnosis is determining laterality. There are two possible tests, the Standing Flexion Test and the ASIS Compression Test. For the Standing Flexion Test, the patient must be standing and facing away from the physician. The physician then places both their thumbs on the patient's posterior superior iliac spines (PSIS) and then asks the patient to bend forward slowly. Laterality is determined by whichever PSIS travels a greater distance relative to its original position. That side's sacroiliac (SI) joint is dysfunctional. It is important to ask the patient to stretch their hamstrings before doing this test because tight hamstrings could lead to a false negative and not allow the dysfunctional SI joint to rise.

The ASIS compression test is done while the patient is supine, and the physician places both hands on the patient's anterior superior iliac spines (ASIS). The physician then applies pressure to each ASIS in a rocking motion, one side at a time. The side that shows greater resistance is positive. Next in diagnosis, the physician must determine the orientation of two different landmarks, the ASIS and PSIS, on the side that had the positive test of laterality relative to the other side. We will now discuss how to treat somatic dysfunctions of the pelvis. For the following examples, we will use the left side of the pelvis, but the treatments are the same for the right side, and when treating, you must use the corresponding side's muscles.

In patients that have a left anterior rotation, the test of laterality will have been positive on the left, and the left ASIS would be lower than the right ASIS, and the left PSIS would be higher than the right PSIS. To treat a left anterior rotation, the patient is supine on the table, and the physician flexes the patient's left knee and hip until it is to a barrier. The physician will then hold this position and provide isometric force while the patient uses their hip extensors to push against the physician for three to five seconds. Once the patient has finished pushing, the physician will flex the hip again to a new restrictive barrier and repeat the process for another two to four times or until there is no more restrictive barrier. After completing this process, the physician will check the ASIS and PSIS heights to determine if there is a resolution of the somatic dysfunction.

In patients that have a left posterior rotation, the test of laterality will have been positive on the left, and the left ASIS would be higher than the right ASIS, and the left PSIS would be lower than the right PSIS. To treat a left posterior rotation, the patient is supine, and the physician will drop the patient's left leg off the table and push down the knee until it is at a barrier. The physician will then hold this position and provide isometric force while the patient uses their hip flexors to push against the physician for three to five seconds. Once the patient has finished pushing, the physician will extend the patient's hip more to a new restrictive barrier using the knee and repeat the whole process for another two to four times or until there is no more restrictive barrier. After completing this process, the physician will check the ASIS and PSIS heights to determine if there is a resolution of the somatic dysfunction.

Physicians should use the umbilicus as a landmark to determine how far the ASIS and PSIS are from the midline. In patients that have a left inflare, the test of laterality will have been positive on the left, and the left ASIS would be closer to the midline than the right ASIS, and the left PSIS is farther from midline than the right PSIS. To treat a left inflare, the patient is supine and must arrange their left lower extremity into a "figure four" position. The physician then pushes towards the ground on the patient's knee until they feel a restrictive barrier. Then the patient will use their adductors and push upwards against the physician for three to five seconds. Once the patient has finished pushing, the physician will push down on the patient's knee again until it is at a new restrictive barrier and repeat the whole process for another two to four times or until there is no more restrictive barrier. After completing this process, the physician will check the ASIS and PSIS heights to determine if there is a resolution of the somatic dysfunction.

In patients that have a left outflare, the test of laterality will have been positive on the left, and the left ASIS would be farther from midline than the right ASIS, and the left PSIS would be closer to the midline than the right PSIS. To treat a left outflare, the patient is supine and must flex their hip to 90 degrees. The physician will then push the patient's knee medially until they feel a restrictive barrier. Then the patient will use their abductors to push laterally against the physician for three to five seconds. Once the patient has finished pushing, the physician will flex the patient's hip to 90 degrees again and push the patient's knee medially to the new restrictive barrier and repeat the whole process for another two to four times or until there is no more restrictive barrier. After completing this process, the physician will check the ASIS and PSIS heights to determine if there is a resolution of the somatic dysfunction.

For the next two somatic dysfunctions, there are no ME techniques. Instead, we will include how to treat them for completeness' sake. In patients that have a left superior shear, the test of laterality will have been positive on the left, and the left ASIS would be higher than the right ASIS, and the left PSIS will be higher than the right ASIS. To treat a left superior shear, the patient is supine and holding firmly onto the table. The physician grasps the patient's left ankle with both hands while adding traction and slight internal rotation. Next, the patient takes a deep breath in, and on exhalation, the physician pulls quickly and firmly on the ankle in the caudad direction. This technique is called high velocity, low amplitude (HVLA). After completing this process, the physician will check the ASIS and PSIS heights to determine if there is a resolution of the somatic dysfunction.

In patients that have a left inferior shear, the test of laterality will have been positive on the left, and the left ASIS would be lower than the right ASIS, and the left PSIS would be lower than the right PSIS. To treat a left inferior shear, the patient must hop on their left leg for 10 to 15 seconds. After completing this process, the physician will check the ASIS and PSIS heights to determine if there is a resolution of the somatic dysfunction.

Complications

The physician should warn their patient of soreness after the treatment. This soreness will subside in 24 to 48 hours.

Clinical Significance

Somatic dysfunctions of the pelvis can manifest in a variety of ways, the most concerning of those being a pain in the groin and lower back. It is important to be able to diagnose and treat these dysfunctions so that patients do not have to undergo invasive procedures, imaging, or starting unnecessary medications. OMT can be done by in the office and by any osteopathic physician. If properly trained to spot these dysfunctions, the physician would save patients time and money while also improving the quality of life. 

Enhancing Healthcare Team Outcomes

OMT is typically only done by the physician. Since no other healthcare providers are required, but there needs to be increased communication between MDs and DOs because a large number of patient complaints could find relief with OMT as opposed to conventional treatments. It is essential to educate healthcare professionals of all levels to direct patients to the most cost-effective and safe treatments. This approach is especially crucial for patients who are not candidates for medications or surgery. OMT provides a non-invasive treatment method that can be very beneficial for patients.