00:00
Now, we're going to start
going through the tests.
00:02
You'll have a
separate video,
a very short 30 seconds to
a minute on each test.
00:08
Hip drop test, the patient is instructed
to bend one knee
while keeping both feet flat on
the ground. That's it.
00:16
You look at the curvature in the back
and you look at the level.
00:19
So the physician should take note
of the fluidity of the motion,
the amount of motion, as well as motion
of the lumbar spine curve
whether it gets more lateral or whether
the muscles are tight
and they're not moving
at all.
00:33
Do you see compensatory movement
or smooth fluid movement
or are you noticing some area
that your eye is pulled to
because the pelvis isn't moving right
or isn't moving at all?
Notice which side. Is it the bent-knee
side or the other side
where you're noticing the abnormality?
That's the hip drop test.
00:54
We'll do a short video
on that.
00:56
So note the amount of drop of the iliac crest
and repeat on both sides.
01:02
Compare the right and the
left side and note
the bending of the lumbar spine and
whether or not it is equal.
01:09
The iliac crest that drops more is the
side of restricted side-bending.
01:14
The Adams forward bending test,
I call this the scoliosis screen.
01:19
We do this for most kids. It's
looking whether or not
the student or the person
has a curve of the spine
and what happens
when they bend over.
01:29
This can be done from behind or
from in front of the patient.
01:32
We're saying for this test and for
conformity, we want to do it
in front and have them
bend forward
and you look at both sides
for symmetry.
01:45
The patient will bend forward
and you'll notice
whether or not they have a hump
forming on one side
or if they had an apparent curvature
if it goes away.
01:54
Again, you're looking to see if
there's a difference
between the right and left side
in the area of the rib cage.
01:59
You're looking for a rib hump,
and you're looking to see
how the body responds
to motion.
02:05
So if a patient has what
looks like a twisting
and maybe a small
curvature of the spine,
having him bend forward will tell
you if it's structural
and not going away and the body
is going to have a hump,
or whether it's functional and it goes
away when they move
and bend because the patient
is just a little twisted,
maybe a little weak, maybe
a little tired
and it is not a chronic
scoliosis pattern.
02:32
So with the scoliosis screen,
observe the gait and the stance
in horizontal planes, observe
the standing flexion test.
02:40
You can do a seated flexion test
as well to confirm
and to take the sacrum out so the
patient can't compensate
or hide something by doing
something themselves
to their functioning
or their motion.
02:54
The osteopathic diagnosis here is
first check the pelvis
and to take the pelvis out of the equation
by having him seated.
03:03
You may want to check the medial
malleoli length as well,
the iliac crest length. Check the ASI levels,
the pubic symphysis levels
and the tibial and femoral
length differentials.
03:15
This will tell you whether the issue
is going to be pelvis
or whether you have a
spinal scoliosis.
03:22
You want to put them prone.
Again, you are checking
the pelvis and sacrum here. You check
the spring test of the sacrum.
03:29
Then you have them get up on their elbows
to check the sphinx test.
03:33
You want to check levels of the
posterior superior iliac spine.
03:36
You want to check the sacral sulci for
deepness and equality.
03:42
You want to check the ilias, the bone hips,
and check the lumbar spine.
03:48
I usually touch the spinous processes
when generally not tender.
03:52
It's a good start and
less sensitive.
03:54
Then I go to the transverse processes
to check for motion,
tenderness, bogginess, tonicity
of the muscles.
04:01
If there are abnormalities here,
you may want to consider
a muscle energy treatment
of the pelvis
in order to take the pelvis out
and get back to evaluating
each area of the
body individually.
04:15
Muscle energy of the pelvis here could be
the anterior iliac dysfunction.
04:22
It could be posterior iliac innominate
pelvic dysfunction.
04:25
You could have abnormality
of the pubes.
04:30
You can have a pubic
shear or discrepancy
in the two sides of the
pubic bone.
04:36
You can have a pubic ramus
that's elevated,
or you can have a superior iliac
innominate pelvic shear as well,
or a lumbar mechanical
abnormality.
04:51
Other ways of treating the
issue would be
a facilitated positional release with a
lumbar superficial muscle
that's hypertonic being relaxed. You may
want to extend the lumbar spine
and treat the somatic
dysfunction,
or you want to treat lumbar
flexion somatic dysfunction.
05:10
FPR is one way of positioning a person,
giving them time
to reset their proprioceptive sense
and their use of the muscle.
05:20
Now, we're going to go into the
causes of short leg syndrome.
05:24
We've already said that short leg syndrome
is not a short leg.
05:28
It's a disorder of the
sacrum or the pelvis.
05:30
It's usually a mechanical disorientation,
disuse, or just not working right.
05:38
So we're going to go through
them one by one.
05:40
One common reason for a
short leg syndrome
is when you have the anterior
innominate rotated.
05:47
To diagnose an anterior
innominate rotation
you want to do a standing
flexion test.
05:53
You can have them drop a hip and
you see if the curve is good
or changes, and what happens
to the PSIS.
05:59
If you want to make the diagnosis though,
you lay them supine
and you check the ASIS
on both sides.
06:05
You see how much
motion you have,
how free the motion is if things
are moving right.
06:11
Then, you'll check the medial
malleoli and see
if the side where you have the
ASIS abnormality is equal
or if it's lower on
that side.
06:22
You want to see if the leg on
the other side
is compensated,
if it's shorter.
06:27
If you have the right side of the innominate
moving forward,
the left side of the innominate
would move backward,
the left leg would be shorter
or apparently shorter
and the right leg would be longer.
That's the diagnosis.
06:38
The treatment of an
anterior innominate
is to put the
person prone.
06:45
Then to find the hip motion,
move the hip slightly
off the table on the same side
of the dysfunction,
monitor the ilio-sacral junction
or the sacroiliac junction
and move the thigh. Check the
motion. Spring the sacrum
and see if you can return the
motion that way.
07:09
By using gravity and having
the patient's weight
pulled down and holding
the sacrum,
you're going to help create
motion and move things.
07:20
Use your monitoring hand to
support the patient's knee.
07:25
Have the patient push
their foot forward
to fatigue some of the muscles
and to ease motions.
07:32
So when you're talking
about the flexors,
you're talking about
the rectus femoris,
the lateral, intermediate, and medial
muscles of the hip flexors
as well as the iliopsoas.
Use those muscles,
provide some support, and monitor
the sacrum as you do it.
07:50
Repeat several times. I usually go three
to five seconds each time.
07:54
Make sure that you get some stretch
or additional motion each time.
07:58
Then you recheck to make sure
that you have returned
the leg to the proper orientation. You now
have equal leg lengths.
08:07
So for the anterior innominate rotation,
to continue the treatment,
the patient can be supine as well.
You want to get on
the side of the dysfunction,
the side that isn't moving.
08:19
You can rock it, monitor it by putting
your hand medial to the PSIS
so you're not causing tenderness because
the posterior superior
iliac spine is going to be somewhat tender.
There's a problem there.
08:31
It's not moving. That's got
an abnormality.
08:34
You see how far
you can move it.
08:36
When you hit the barrier and
it can't move anymore,
that's where you're going to
start the treatment.
08:42
Ask the patient to push against you
using their own muscles.
08:46
Again, this would be
the opposite now.
08:48
So now you're using the hip extensors.
The semimembranosus,
the semitendinosus, the
gluteus maximus
are all going to be engaged
to extend and to help
bring the leg back to
equal leg lengths.
09:02
Have the person push for
three to five seconds.
09:06
Repeat several times. As long
as you continue
to get increased motion, increased
activity, you're doing well.
09:14
So that is the first. That's anterior
innominate rotation.
09:21
Other causes for apparent
short leg syndrome.
09:26
This is number two. You can have
a posterior innominate.
09:30
We're seeing which one is stuck,
which one isn't moving.
09:34
So if you have the right innominate
moving forward
and the left one moving posteriorly,
both of those are problems.
09:40
Which one is the restriction that needs
to be evaluated on exam?
If you do a standing flexion
test and you noticed
that the posterior is the
one not moving,
that's the one that's going
to be treated
and that's what
you're diagnosing.
09:56
In the supine position, you'll
notice the ASIS
is going to be superior
and posterior.
10:02
You'll notice that the medial malleolus
on the same side
is going to be higher. On the opposite side,
it's going to be lower.
10:10
The short leg is going to be on the
side of the problem.
10:15
So the leg on the same side
is going to be shorter.
10:18
Again, the treatment now for the
posterior innominate.
10:23
We're going to put the person prone
and lie on their stomach.
10:26
You're going to go in the opposite
side of the problem
and use your weight and gravity
to help induce motion.
10:34
You're going to use your
hand to monitor
the posterior superior
iliac spine.
10:40
Again, you go a little bit off
of it because
you don't want to
hurt the patient
and they're going to be tender
right over it.
10:44
You check the
iliosacral motion.
10:48
Once you get some motion and you
could do that with rocking,
you could do that with
gentle easing,
That's when you know you're
getting some response.
10:56
So the doctor's hand is supposed
to be on the anterior thigh
supporting the leg and on the
sacroiliac junction.
11:06
Bring the thigh up, extending
the leg in order to help
fatigue the muscles. Use the muscles
to help induce motion.
11:15
You may have the patient push down
for three to five seconds
getting increased motion and
increased extension each time,
getting the 10 to 30 degrees
of extension of the thigh.
11:28
Repeat several times. As long
as you're getting
an increase in motion,
keep going.
11:32
Another way of treating this is to
put the patient supine.
11:36
I often use where the patient
is most comfortable,
what they tolerate, and
what they'll let you do.
11:43
If a patient is uncomfortable lying
on their stomach
and they start grimacing,
put them on their back.
11:48
Monitor the PSIS
on the same side
and the ASIS on the
opposite side.
11:55
That's the normal rocking
motion of the pelvis
and that's the motion
you want to see.
12:00
Bring the patient's leg off the table.
Hang it off the table
in order to use gravity and
to help induce
the extension of the
hip muscles.
12:10
Then have the
patient push up
trying to bring the pelvis back
into alignment.
12:16
Repeat several times until
you have a return
of leg length equality and
leg length motion.
12:23
Other ways of doing this, you can
have the patient supine.
12:27
Instead of doing
extension,
you can use a flexion
technique
where you will put your
hand on the ASIS
because you are now having
the patient supine
and put this on the ASIS of the
dysfunctional side.
12:44
Have the patient flex the
knee for comfort
and to see what kind of motion.
By flexing the knee,
you're taking the lower leg
muscles out of it.
12:52
They're not going to have this
easier time compensating
or using their body to
hide the problem.
12:59
Monitor the motion and the
progress of motion
in the hip, sacrum,
and pelvis.
13:05
You may want to flex the knee
against your shoulder
so you have more leverage
and you can push.
13:12
You can have the patient
push against you.
13:15
As long as they are using
their extensor muscles,
you're going to get some benefit
and some loosening.
13:21
You do three to five seconds
each time
as a normal muscle energy
procedure.
13:25
As long as you get increased motion,
you keep going.
13:31
Here's an extensive review of the
findings you may have
and how you can think about
what's going on.
13:39
A lot of what we want to instill in
people is the ability to think.
13:43
If you have the right side of the
pelvis move forward,
what happens to the left? What happens
to the leg length?
How does this affect
the sacrum?
So checking the PSIS, ASIS, sacrum,
all those levels put together
should give you a clear, coherent
picture of what's going on
in the skeleton and how one
part is affecting the other.
14:06
Then it's very biomechanical. If you
have the right side
of the pelvis pushed forward and you
want to do a direct technique,
you push the right side of the
pelvis backward
and go where they can't go to make
sure you get it treated.
14:20
So take a second, look at the test,
look at the findings,
and figure out the potential changes and
the normal functioning
and normal mechanics
of the skeleton.