RSSPubic Symphysis Dysfunction
August 24, 2009 by David Fitzgerald
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Filed under Groin, Physiotherapy Blog
Following on from our introduction to groin dysfunction we’ll now take a closer look at Pubic Symphysis dysfunction.
Osteitis Pubis is the most widely recognized pathology in this region with the spectrum of pathology ranging from….
joint strains.
Pubic Symphysis mal-alignment
Osteitis Pubis.
Mechanism of Pubic Symphysis Dysfunction
Shear stresses acting across the symphysis as a result of repetitive contractions of the adductors in sporting activities has been indicated as a likely factor in the development of osteitis pubis. This can be associated with pubic bone marrow oedema evident on MRI – also suggestive of a stress injury to the pubic bone.
Given the evidence in the literature showing a relationship between the movements of the lumbar spine and hip and the association of low back pain with both SIJ symptoms and hip joint dysfunction , it may be acceptable to consider the hip musculature from the perspective of deep local stabilizing muscles and more superficial global stabilising muscles as previously discussed for the spinal musculature
Review of Hip Muscle Anatomy
A biomechanical model of gluteus medius consisting of three segments each with a separate innervations has been proposed. It is suggested that the main function of the posterior gluteus medius and all of gluteus minimus is to stabilize the head of the femur in the acetabulum during the gait cycle. In a dissection study of gluteus minimus in twenty cadaver hips reported a deep muscular attachment to the capsule in all specimens and suggested a similar role for gluteus minimus as that of the rotator cuff of the shoulder due to its capsular attachment. These findings are suggestive of a stability role gluteus minimus and the posterior part of gluteus medius in the hip.
The deep external rotators of the hip namely…
Obturator internus
Gemelli
Quadratus femoris
have been described as a functional unit. In an anatomical and histological study of these muscles in cats the muscle fibers were found to be short with small fiber length:muscle length ratios and low angles of pinnation which the authors suggest is the optimal design for hip stability In the same study the deep hip muscles were found to contain a high percentage of type 1 slow fibers again suggestive of a stability role.
Psoas
Psoas has been proposed as a contributor to lumbar stability due to it attachments to the lumbar vertebrae and intervertebral discs particularly in upright stance.
All of the above evidence regarding the potential stability role of the deep external rotators, gluteus minimus, posterior part of gluteus medius and psoas major is anatomical and biomechanical in nature and lacks clinical studies to support or refute the hypotheses of deep local muscle motor control at the hip. However taken on its merits and in combination with the concept of motor control, it may be valid clinically as part of a clinical reasoning approach to consider specific deep muscle activation in the hip region as part of an early motor control program for the hip, SIJ and lumbar region.
1. Evaluate hip function in the context of pelvic stability during applied load.
2. Evaluate specific hip muscle control in multiple planes
3. Identify specific “plane of motion” dysfunction
4. Determine mechanical restrictive components
5. Determine muscle control deficits
6. Identify movement pattern breakdown
7. Prioritise treatment targets
8. Define progression markers
9. Identify potential bottlenecks
10. Quantify relevant outcome measures.
Enjoy the clinical challenge
David
