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TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15-YEAR OLD TENNIS PLAYER ___________________________________________________________________________
A Case Report
Presented to
The Faculty ofMarieb College of Health and Human Services
Florida Gulf Coast University
In Partial Fulfillment
of the Requirement for the Degree of
Doctor of Physical Therapy
________________________________________________________________________
By
Mohammad Khan, SPT
2018
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD
APPROVAL SHEET
This case study is submitted in partial fulfillment of
the requirements for the degree of
Doctorate of Physical therapy
___________________________
Mohammad Khan
Approved: March 2018
Eric Shamus, PhD, DPT Committee Chair
Stephen Black, DSC, PT,ATC, CSCS Committee Member
The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the
above mentioned discipline
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD
Acknowledgements
I would like to thank all of my professors and instructors here at Florida Gulf Coast
University for providing me with the knowledge and skillset to treat patients and pursue a case
study using the treatments techniques I have learned. I would also like to thank my Clinical
instructors and their fellow staff for educating me and helping me along this journey ultimately
leading to this case report.
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD
4
Table of Contents
Abstract 5
Background/Purpose 6
Case Description: Patient History and Systems Review 7
Clinical Impression #1 7
Examination 8
Clinical Impression #2 9
Interventions 10
Outcome 11
Discussion 12
References 13
Appendices 15
Appendix A: Outcome Measures 15
Appendix B: Examination 16
Appendix C: Figures 17
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 5
Abstract
Background and purpose: Pelvic dysfunction is frequently reported in patients with low
back pain. The purpose of this case report is to identify the potential benefits of performing a
Muscle Energy Technique (MET) for a patient with pelvic dysfunction, specifically a left
anteriorly rotated innominate. MET’s have been widely used by manual therapists over the
years, but still have limited research validating its use and limited evidence to substantiate the
theories to explain its effects. Case Description: The patient is a 15-year old female tennis player
who reported having low back pain following several tennis practices. Her primary pain
symptoms were left pelvis. The patient described having 7/10 pain following her tennis
practices. Physical therapy evaluation revealed that the patient had an anteriorly rotated
innominate on her left side. She received outpatient physical therapy two times a week for 3
weeks. Her plan of care included manual therapy, MET, therapeutic activities, manual
stretching, flexibility, and stabilization exercises. Outcomes: Outcome measures included the
Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Improvements were
noted in all measured outcomes at discharge. Pain intensity decreased on a numeric pain scale
from 7/10 following activities to a 0/10 following activities. Her lumbosacral range of motion
improved from 50 to 100%. Her Oswestry disability score decreased from 21% disability to 0%
disability. Discussion: The combination of MET’s and other standard therapy treatments may be
beneficial for the treatment of low back pain associated with pelvic dysfunction for decreasing
pain and improving functional mobility. The patient appears to have benefited from the MET
followed by soft tissue normalization and core strengthening exercises.
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 6
Background/Purpose
The spinal alignment of the vertebral column including the sacrum and coccyx is
balanced by muscles and ligaments. Proper posture aids to maintain this balance. Postural
abnormalities can lead to changes in lumbosacral and hip mobility (McGill, 2002). Research
shows that pelvic alignment allows for efficient movements of the hip and allows for effective
muscle recruitment (Abutaleb et al, 2015). An anteriorly rotated innominate is a pelvic
abnormality that can alter the neutral position of the pelvis. This results in an imbalance
between the muscles, ligaments and fascia that effect the pelvic joints (Janda, 1983).
Pelvic dysfunction is estimated to be involved in 13 to30% of low back pain pathology
(Weksler et al, 2007). The pelvis is composed of the articulation between the sacrum and two
ilium surrounded by muscular and ligamentous support for stability. The pelvis functions to help
transfer weight and dissipate forces from the upper and lower extremities and has little
movement. Pelvic dysfunction can result from hyper or hypomobility and can cause changes
within functional movements usually leading to either an anterior or posterior dysfunction
(Goode et al, 2008).
The concept of Muscle Energy Technique (MET) relies on active patient effort through
muscular contraction (Wilson, Payton, Donegan-Shoaf & Dec, 2003). It focuses on the joint,
muscle, fascia relationship and the effect of muscle contraction on manipulating joint function.
Muscle Energy Technique relies on isometric contractions leading to post isometric relaxation of
the muscles. When using MET’s the contraction level is low and may represent only 10% max
when using it to make pelvic joint modifications (Shamus & Van Duijin, 2016). MET is
considered a direct manipulative technique where the joint or muscle is taken to the restrictive
barrier to motion or the right muscles to the elongation barrier (stretch point). Then the patient
contracts away from the restrictive barrier (Shamus & Van Duijin, 2016). In regards to the
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 7
innominate, MET techniques are used by targeting a contraction of the hamstring, quadriceps or
hip flexors to movie the innominate in the corrected position (Selkow et al, 2009).
The purpose of this case report is to determine the effects of using MET’s alongside with
standard physical therapy interventions on a youth female tennis player to determine its effects
on pain level, pelvic alignment and functional mobility.
Case Description: Patient History and Systems Review
The patient was a 15-year old female high school tennis player. She reported having low
back pain following tennis practice for the last 2 weeks. Despite her low back pain she was going
to tennis practice every day. She was referred by her physician to outpatient physical therapy
for treatment. After further questioning, the patient revealed that she had just started training
for her tennis season and has been working out for several hours every day and continued to
play while having pain.
The patient reported a 0/10 pain in resting, but 7/10 pain on the Numeric Pain Rating
Scale (NPRS) following her tennis workouts. She described the location of her pain in her left
lower back surrounding her Posterior Superior Iliac Spine (PSIS) and upper left gluteal region.
The patient reported no radicular type of pain. She reported that she was taking Aleve to help
alleviate her pain. Her chief complaint was left sided low back pain. Besides the patient’s chief
complaints she was otherwise healthy and had no other comorbidities, and no previous surgical
history. The patient’s and her family’s goals were to decrease the patient's pain so that she can
return to playing tennis as quickly as possible, for an upcoming tournament.
Clinical Impression #1
Based on the subjective information that the patient provided, there were various
pathologies that the patient could have been presenting with. Further examination was required
to screen the hip, pelvis and lumbar spine. Radiculopathy was ruled out due to the patient not
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 8
having any neurological symptoms. Pelvis, hip and lumbar spine dysfunction including lumbar
facet and musculoskeletal pathologies were considered due to patient’s presentation.
After review of the patient’s subjective symptoms due to the location of the pain,
pelvic dysfunction was the principal hypothesis. Although presentation of pelvic dysfunction can
vary among individuals, there have been many prevalent referring pain patterns in the literature
which include pain surrounding the PSIS and gluteal region on the affected side of the pelvis
(Slipman et al, 2000). Pain is most often reported below the 5th lumbar vertebrae (Dreyfuss,
Dreyer, Cole & Mayo, 2004). A comprehensive examination was performed which included
postural analysis, sensation testing, bilateral hip ROM, lumbar mobility, lower extremity
strength testing and special tests to determine a clinical diagnosis and to determine
interventions and create a plan of care. Further testing was done to determine whether the
patient would be appropriate to perform MET’s.
Examination
Postural examination and observation were key in identifying the patient’s pathology.
Upon, postural analysis the patient presented with slight forward head posture, lumbar lordosis,
and asymmetrical pelvic landmarks. Postural examination revealed that the left ASIS was shifted
down and the left PSIS was shifted up relative to the right side. Following the postural analysis a
leg length discrepancy test or the long sitting test was performed. In the supine position the
patient’s left medial malleolus was slightly longer than the right and upon going into the long
sitting position the left malleolus shortened indicating that there is malalignment of the pelvis.
The long sitting test is commonly used as an indicator for pelvic dysfunction (Bemis & Daniel,
1987).
Other examination tests included the Gillet or Stork test which was positive-the left PSIS
did not move down as the patient performed standing unilateral hip flexion, which is a positive
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 9
test for indicating pelvic hypomobility (Lee, 2004). A cluster of sacral provocation tests were
performed including the sacral compression, sacral gapping, Gaenslen’s, sacral thrust and thigh
thrust test. Of these tests the sacral compression, sacral thrust and the thigh thrust test were
positive. Research indicates that sacral cluster tests are reliable in identifying pelvic dysfunction
(Laslett, 2008).
Neurological screen was negative, and the patient did not have any strength deficits in
her lower extremities. The patient demonstrated slight ROM deficits in left hip extension and
left hip external rotation. Flexibility testing showed tightness in patient’s hip flexors in the
Thomas test.
Palpation and joint play revealed slight hypomobility in lumbar spine. Tenderness was
also noted along the left side of the patient’s sacrum.
This patient was a good candidate for the use of Muscle Energy Technique based on her
examination findings. She reports having low back pain, more on her left side. Postural analysis
reveals an anteriorly rotated innominate. Other examinations findings include decreased lumbar
extension and left hip range of motion.
Clinical Impression #2
Succeeding the patient’s examination the patient presented with signs and symptoms of
pelvic dysfunction with an anteriorly rotated left innominate or ilium. Upon testing, the patient
had asymmetrical pelvic landmarks, pain with sacral provocation testing, tenderness with
palpation to the left side of the patient’s sacrum and left glutes, slight hypomobility with lumbar
passive intervertebral motion testing, decreased flexibility of her hip flexors, and slight deficits
in hip range of motion.
Based on these findings, it was concluded that the patient would benefit from
performing an MET to restore pelvic alignment. As an MET can be employed to reposition a
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 10
dysfunctional joint and treat the affected musculature (Wilson et al, 2003). To determine the
success of the outcome of the MET performed, pelvic landmarks will be assessed to determine
alignment. Pelvic joint provocation tests would be performed as a posttest after treatment. Hip
range of motion would be examined. Post treatment pain would be determined using NPRS and
comparison will be made in the Oswestry disability outcome measure.
In theory if the interventions performed were successful, the patient would have
normalized pelvic bony landmarks, decrease in pain, range of motion improvement, an
improvement in the Oswestry disability index, and the ability to return to playing tennis.
Interventions
The patient was seen in physical therapy twice a week for 3 weeks. During the patient’s
initial evaluation MET’s were performed. After assessment it was determined that the patient
had a left anteriorly rotated innominate. First the MET was performed to realign the pubic
symphysis. Following the pubic symphysis technique, MET to correct the anteriorly rotated
innominate was performed. Pelvic landmarks were reassessed and MET’s were performed one
more time to correct alignment.
For the pubic symphysis technique the patient was lying supine hook lying with feet
shoulder width apart. The patient was asked to abduct against resistance for 10 seconds three
times following this the patient adducted against resistance for 10 seconds. The MET to correct
the anteriorly rotated innominate, the patient was side lying with her left side facing up with
her knee bent and hip flexed until tissue resistance. Her opposite innominate was stabilized.
Patient performed an isometric contraction of her left hip by contracting her glutes and
hamstrings into hip extension for 10 seconds as her motion was resisted. A posterior
mobilization force was given to bring the left innominate into neutral alignment (shown in
appendix figure 1).
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 11
After the initial evaluation, the patient was given a Home Exercise Program (HEP) to
perform Transverse Abdominal (TA) contractions:10 reps of 10 second holds three times per day
(attached in appendix). More advanced strengthening exercises were performed in the patients
following visits, which included supine single/double knees to chest, planks, bridges, resisted hip
abduction, and resisted cable trunk rotations.
For the remainder of the patient’s physical therapy visits, the patient began each session
with a warm up on the bike for 10 minutes. Following the warm up, the patient’s pelvic
alignment was assessed and an MET was performed if necessary. Soft tissue mobilizations
consisting of effleurage, skin rolling, and foam rolling were performed to the patient’s lower
back, gluteal and hip flexors. Hip joint mobilizations were performed to help improve range of
motion. The patient then performed therapeutic exercises targeting core musculature.
Therapeutic Exercises consisted of abdominal planks, bridges, supine knee to chest, and glute
medius walkouts. Therapeutic exercises were followed by long duration low intensity stretching
of her hip flexors. Before cessation of treatment, the patient had practiced tennis like activities
in the clinic such as running, jumping, and cutting.
Outcome
The patient had 6 physical therapy visits over three weeks and was able to perform
progressive resistance exercises without aggravating her symptoms. The patient showed
improved postural alignment with her pelvic landmarks, following the use of MET’s. Subjectively
the patient reported that her pain significantly decrease after the initial evaluation and she felt
like she was progressing.
Significant improvement was made on the NPRS as the patient’s pain level following
activity went from 7/10 to 0/10. Research shows that the NPRS is a valid and reliable tool for
determining clinical change for patients with low back pain (Childs, Piva & Fritz,2005). The
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 12
patient had significant improvements in her ODI improving from 21% which indicates moderate
disability to 0% disability. The ODI is a well-accepted measure of disability in patients with back
pain and has been used in many studies (Fairbank & Pynsent 2000). The ODI is also proven to be
a valid instrument to measure of change in the SIJ health (Copay et al, 2016).
Discussion
The purpose of this case study was to describe outcomes after performing MET’s along
with standard physical therapy interventions in a youth female tennis player who was diagnosed
with pelvic dysfunction. The interventions were chosen to reduce the patient’s pain, improve
her pelvic alignment and to restore the patient’s ability to play tennis. The patient received soft
tissue mobilizations, joint mobilizations and progressive therapeutic exercises targeting her core
and tennis activities in conjunction with the MET’s.
The MET’s utilized as interventions for this patient were chosen based on the patient’s
presentation. As previously reported MET’s are a common conservative treatment for
lumbopelvic pain and are technique used to correct an asymmetry by targeting specific
contractions of muscles and manually moving the joint into the correct alignment. Research
shows that MET’s can help to alleviate low back pain (Selkow et al,2009). Based on this
information the patient in this case study received MET’s as an intervention.
The MET’s used in this case report along with the soft tissue mobilization and exercises
demonstrated positive clinical outcomes for a young female tennis athlete. It is difficult to
isolate a specific intervention within a comprehensive treatment plan.
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 13
References
Abutaleb, Eldesoky, M., Rasol, S. (2015). 'Effect of Muscle Energy Technique on Anterior Pelvic Tilt in Lumbar Spondylosis Patients'. World Academy of Science, Engineering and Technology, International Science Index 104, International Journal of Medical, Health, Biomedical, Bioengineering and Pharmaceutical Engineering, 9(8), 651 - 655.
Bemis, T., & Daniel, M. (1987). Validation of the Long Sitting Test on Subjects With Iliosacral Dysfunction. Journal Of Orthopaedic & Sports Physical Therapy, 8(7), 336-345. http://dx.doi.org/10.2519/jospt.1987.8.7.336
Childs, J., Piva, S., & Fritz, J. (2005). Responsiveness of the Numeric Pain Rating Scale in Patients with Low Back Pain. Spine, 30(11), 1331-1334. http://dx.doi.org/10.1097/01.brs.0000164099.92112.29
CMomFit. (2018). Transverse Abdominis Contractions. Retrieved from http://www.cmomfit.com/deep-core.php Copay, A., & Cher, D. (2015). Is the Oswestry Disability Index a valid measure of response to sacroiliac joint treatment?. Quality Of Life Research, 25(2), 283-292. http://dx.doi.org/10.1007/s11136-015-1095-3
Dreyfuss, P., Dreyer, S., Cole, A., & Mayo, K. (2004). Sacroiliac Joint Pain. Journal Of The American Academy Of Orthopaedic Surgeons, 12(4), 255-265. http://dx.doi.org/10.5435/00124635-200407000-00006
Fairbank, J., & Pynsent, P. (2000). The Oswestry Disability Index. Spine, 25(22), 2940-2953. http://dx.doi.org/10.1097/00007632-200011150-00017
Goode, A., Hegedus, E., Sizer, P., Brismee, J., Linberg, A., & Cook, C. (2008). Three-Dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. Journal Of Manual & Manipulative Therapy, 16(1), 25-38. http://dx.doi.org/10.1179/106698108790818639
Janda, V. (1983). On the Concept of Postural Muscles and Posture in Man. Australian Journal Of Physiotherapy, 29(3), 83-84. http://dx.doi.org/10.1016/s0004-9514(14)60665-6
Laslett, M. (2008). Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. Journal Of Manual & Manipulative Therapy, 16(3), 142-152. http://dx.doi.org/10.1179/jmt.2008.16.3.142
Lee D. (2004). The pelvic girdle: an approach to the examination and treatment of the lumbo- pelvic-hip region. 3rd ed. Edinburgh: Churchill Livingstone. pp. 52-53,130.
McCormack, R. (2012). Shotgun Technique. Retrieved from https://www.youtube.com/watch?v=BJkYRgptHKc
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 14
McGill, S. (2002). Low back disorders. Evidence-based prevention and rehabilitation, Human Kinetics, Champaign, IL, pp. 94-95.
Physical Therapy Nation. (2013). Shotgun Technique for Pubic Symphysis. Retrieved from https://www.youtube.com/watch?v=FDo-sA29SZI Physiopedia. (2018). Muscle Energy Technique to Correct an Anteriorly Rotated Innominate. Retrieved from https://www.physio-pedia.com/Low_Back_Pain_and_Pregnancy Selkow, N.M., Grindstaff, T.L., Cross, K.M., Pugh, K., Hertel, J. and Saliba, S. (2009) ‘Short-term effect of muscle energy technique on pain in individuals with non-specific Lumbopelvic pain: A pilot study’, Journal of Manual & Manipulative Therapy, 17(1), pp. 14E–18E. doi: 10.1179/jmt.2009.17.1.14e.
Shamus, E. and Van Duijn, A.J. (2016) Manual Therapy of the extremities. United States: Jones and Bartlett Publishers. pp. 6-11.
Slipman, C., Jackson, H., Lipetz, J., Chan, K., Lenrow, D., & Vresilovic, E. (2000). Sacroiliac joint pain referral zones. Archives Of Physical Medicine And Rehabilitation, 81(3), 334-338. http://dx.doi.org/10.1053/apmr.2000.0810334
Weksler, N., Velan, G., Semionov, M., Gurevitch, B., Klein, M., Rozentsveig, V., & Rudich, T. (2007). The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right. Archives Of Orthopaedic And Trauma Surgery, 127(10), 885- 888. http://dx.doi.org/10.1007/s00402-007-0420-x
Wilson, E., Payton, O., Donegan-Shoaf, L., & Dec, K. (2003). Muscle Energy Technique in Patients With Acute Low Back Pain: A Pilot Clinical Trial. Journal Of Orthopaedic & Sports Physical Therapy, 33(9), 502-512. http://dx.doi.org/10.2519/jospt.2003.33.9.502
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 15
Appendix A: Outcome Measures
Outcome Measure Before Treatment After Treatment
NPRS 7/10 following tennis workouts 0/10 following activity
ODI 21% disability 0% disability
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 16
Appendix B: Examination
Examination Initial After treatment
Posture L PSIS elevated L ASIS depressed
L & R ASIS and PSIS level
Long Sit Test + -
Gillet’s Test + -
Sacral special tests Sacral Thrust + Sacral compression + Thigh Thrust + Sacral gapping - Gaenslen’s Test -
Sacral Thrust - Sacral compression - Thigh Thrust - Sacral gapping - Gaenslen’s Test -
ROM Slightly Limited L hip ER Slightly limited L hip Extension
L hip ROM WNL
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 17
Appendix C: Figures
Figure 1. Image of MET for correction of anteriorly rotated innominate (Physiopedia, 2018)
Figure 2. Shotgun technique for pubic symphysis (Physical Therapy Nation, 2013)
Figure 3. Shotgun Technique (Mccormack,2012)
TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN A 15- YEAR OLD 18
Appendix C: Figures (Continued)
Figure 4. HEP: Transverse abdominus contractions for 10 second holds and 10 repetitions 3 times a day (CMomFit,2018)