TREATMENT OF AN ANTERIORLY ROTATED INNOMINATE IN …

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


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


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.


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.


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


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


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


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


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).


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


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.


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 lumbopelvic-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


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


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


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


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)


Appendix C: Figures (Continued)

Figure 4. HEP: Transverse abdominus contractions for 10 second holds and 10 repetitions 3 times a day (CMomFit,2018)

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