Hesch Institute Presents...What we see regarding bony landmark asymmetryof thepelvis isdueto: •...

CPTA Virtual Conference 2020 1

Hesch Method

Hesch Institute

Presents:

Hesch Method

TITLE OF WEBINAR

Is it time for a major shift in how we interpret

sacroiliac joint biomechanics, evaluation, and treatment?

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Website: HeschInstitute.com

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Yes, It is remarkably long overdue.

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QUOTATION

“Fortunately, biomechanical research into the pelvic girdle is increasing and, as new knowledge is acquired, the theoretical construct provided here may well need modification.”

Philip E. Greenman D.O.Hesch Method

Origins of the Sacroiliac Joint Dysfunction Model

The traditional physical therapy model of pelvic joint pathomechanics can be traced to a landmark 1958 article by Fred Mitchell, Sr, DO titled Structural Pelvic Function, in which he culled several disparate writings on the pelvic joints bringing them together into a cohesive whole.

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Origin of Muscle Energy Technique (MET)

Muscle Energy Technique (MET) writings of his son Fred Mitchell Jr. DO, whose first MET workbook was written in 1973 with Moran, & Pruzzo.

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This biomechanical model has infiltrated far and wide and is found in other osteopathic texts and physical therapy texts, articles and continuing education programs. Incredibly, much of the mythology from this work continues to infiltrate PT practice today.

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In standing and walking the sacroiliac joint (SIJ) assumes a stable position and very minimal movement occurs as has been validated with several stereophotogrammetry studies. Reality informs that in weight-bearing the entire movement of the pelvis occurs primarily with the articulation of the trunk including muscles, lumbar facets, disc, and ligaments, and with the pelvis as a unit moving symmetrically or asymmetrically on the femoral heads.

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The model taught by Hesch Institute negates three patterns in the traditional model as they are untenable:

• Unilateral sacral flexion

• Unilateral sacral extension

• Upper pubic rotation (axis on lower part of joint)

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The model taught by Hesch Institute recognizes 12 patterns of pelvic movement dysfunction which are not reported in the body of literature on the sacroiliac, pubic joint and sacrococcygeal joint.

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Advanced palpation is utilized, and treatment consists of a passive fulcrum with mild force application sustained for a minimum of 2‐minutes, sometimes 5‐minutes

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Every movement dysfunction has a self‐treatment technique such that the clinician does not have to perform passive care and by 2nd day the patient is independent in managing that aspect of their rehab.

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With standing trunk or hip flexion tests or sitting spine flexion tests the intrinsic SIJ movement is so negligible such that it cannot reasonably be perceived with visual observation, therefore, the positional and movement asymmetry has to be coming from somewhere else, such as asymmetrical muscle control, uneven movement in the hip joint or any lower extremity joint or the spine.

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It appears that knowledge regarding how the entire pelvis moves (absent movement occurring inside the SIJ) is absent or is minimally addressed in the education of physical therapists. A fundamental reinterpretation of lumbopelvic-hip biomechanics is encouraged.

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Multiple studies on SIJ movement using the standard of the industry which is stereophotogrammetry, including symptomatic populations has consistently demonstrated very minimal movement in the SIJ. Specifically, there is less than 2-degrees rotation and less than 2mm of glide in the frontal, sagittal and transverse planes.

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This small amount of movement cannot be objectively evaluated in the rehab setting, it cannot be quantified, and it is imperative that our language accurately reflects that reality and that nocebo messages are avoided regarding “joint dysfunction.” The rehab profession needs to embrace contemporary studies and the explanatory model for what we encounter and treat in the clinic needs to evolve.

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How Can We Improve Palpatory Accuracy?

Use minimal palpation in standing because standing has increase in muscle tone whereas sitting, prone and supine have less muscle contraction and less compensatory patterns.

Discard the iliac crest based on multiple studies with low intertester reliability

Instead, palpate the rather flat anterior iliac shelf (flat portion just above the ASIS)

Palpate anterior upper, middle and lower pubic bone

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Palpation continued

Palpate the top of pubic bones when hips and knees are flexed (supine) to relax rectus abdominus and reduce false positives

• Palpate the flat portion of the ischium (prone)

• Palpate the medial aspect of the ischium

• Use the Rule of Thirds to improve accuracy

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Practice palpation skills

Form a palpatory practice group

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Books on Palpation

• Palpation and Assesment in Manual Therapy

• Palpation and Assesment in Manual Therapy

• Trail Guide of the Body

• Palpatory Literacy

• The Muscle and Bone Palpation Manual

• Palpation Technique

• Anatomical Landmark Palpation

• Clinical Guide to Musculoskeletal Palpation: A Clinical Guide

• Field's Anatomy, Palpation and Surface Markings

• Color Atlas of Skeletal Landmark Definitions E‐Book: Guidelines for Reproducible Manual and Virtual Palpations

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Is considerably greater than SIJ motion

Is measured in inches, or centimeters, of glide, i.e. side-bending (hip hiking and hip drop)

Is measured in large degrees of rotation, using double digits

MOTION OF THE BONY PELVIS

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Pelvis? Sacroiliac?

The bony pelvis is a separate structure from the sacroiliac joint

The bony pelvis has its own set of biomechanical rules

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• Many Professions Including Physical

Therapists confuse pelvic mechanics and ascribe pelvic pathomechanics to the sacroiliac joint.

• Linguistic problems regarding pelvicmotion versus purported SIJ motion.

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What we see regarding bony landmarkasymmetry of the pelvis is due to:

• Asymmetrical muscle control• Asymmetrical movement of the entire pelvis onthe femoral heads and movement with thefemeroacetabular joints

• Leg length asymmetry• Developmental asymmetry of the hip, pelvis,spine

• Developmental or movement asymmetry in anylower extremity joint

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NAVIGATING THE LINGUISTIC DIVIDE

Solution to the linguistic problems regarding pelvic motion versus purported SIJ motion.

Whenever possible clarify when there is objective evidence for pathological motion (x-ray, CT, MRI, fluroscopy, digitized x-ray, etc).

Otherwise, suggest general terminologies that express a system of integrated structures in which the pelvis itself, the SIJ, the pubic joint, the lumbar spine and the hip work in an integrated manner and isolation of a single part of the system is not clinically reliable (such as “the ilium is rotated on the sacrum, etc.” However, treating all components to the degree that is reasonable and appropriate should be the focus.

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Please remember that there are several patterns of symmetrical pelvic movement dysfunction.

Therefore, it is relevant to perform passive spring‐recoil testing on pelvises that appear to be in “correct alignment

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The Palpation Rule of 3’rds

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Standing spine flexion

Standing hip flexion

Seated flexion

Long sit

Prone knee bend

Research: Traditional Evaluation (Joint) False Tests

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Standing posture invokes compensation, whereas gravity‐reduced postures such as prone and supine more accurately represent what is actually happening, it gets to the core pattern without overlying obfuscation.

Standing posture does not predict mobility and stability.

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Don’t drink the

pelvic alignment

Kool aide!

We must follow the science and stop believing that we can palpate pelvic bony landmarks and ascertain 2mm of glide or 2‐degree of rotation inside the sacroiliac joint. We cannot.

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We cannot isolate motion INSIDE the SIJ by touching and observing pelvic bony landmarks in different postures and with movement of the spine or hips.

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Asymmetrical motion or asymmetrical position of pelvic landmarks only tells us the entire pelvis is asymmetrical, it cannot, it does not tell us about asymmetry INSIDE the SIJ!!!

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We can only discern motion that traverses THROUGH the SIJ determining hypmobility or hypermobility with passive spring‐recoil tests.

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Hesch Method utilizes 16 basic spring tests evaluate motion going THROUGH the sacroiliac joint.

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Passive Spring-Recoil Micromotion Testing

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The spring tests determine if the motion going THROUGH the SIJ, and if it is hypomobile or hypermobile, and guides appropriate treatment, and determines when stability and normal mobility are achieved therapeutically.

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These tests are very similar to ligament stress tests applied to other joints of the body. An arbitrary example would be the Lachman’s anterior drawer test used to test integrity of the ACL.

The primary purpose of the pelvic spring-recoil tests is to evaluate mobility, or lack of mobility or hypermobility.

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Please realize that these test do not, cannot validate a correctable shift inside the SIJ such as “the ilium rotated on the sacrum and got stuck. Motion being blocked from traversing through the SIJ is probably very oftentimes due to phenomenon extrinsic to the SIJ such as:

1. Altered hip, pelvis and lumbar posture

2. Alteration in muscle tone

Why is this a high probability as opposed to the traditional theory of a rotation intrinsic to the SIJ?

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Because the author has seen many, many x‐rays showing pelvic asymmetry and in the MRI, there was perfect congruency inside the SIJ in all images in the frontal, sagittal and transverse planes.

Also, research has shown in several studies that treatment does not alter the position within the SIJ, and the same is true of extremes of posture and again, motion in the joints, even in symptomatic population is negligible, typically less than 2mm of glide and 2‐degrees of rotation. There are exceptions such as severe trauma and this population is not ambulatory.

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How to Perform a Spring-Recoil Test

Take up slack pushing on the pelvis in a specific direction using an average of 15 lbs

Keep the slack taken up throughout the test

Perform a forward spring which takes less than a second

Pay attention to the amount of forward movement and pay attention to the recoil

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INSERT VIDEO ON SPRING‐RECOIL TEST TECHNIQUE AND DESCRIBE

1. Normal test

2. Able to take up slack but no spring motion interpreted as hypomobile (blocked motion)

3. Unable to take up slack (blocked motion)

4. It takes longer to take up the slack and forward spring and recoil take longer and are weak. This hypermobility can be positional and corrects with treatment, also can be due to muscle inhibition ndis rarely due to ligament damage

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These passive spring‐recoil tests are much more relevant than simply looking at alignment, whether in static or dynamic contexts.

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This model DOES thoroughly correct alignment but goes much further than that in improving joint function. It seeks to normalize both mobility through the pelvis and also improves stability through a variety of mechanisms.

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This model also screens for developmental asymmetry which appears to be significantly under-represented in the traditional model.

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GOOD NEWS!!!Traditional model of manual therapy uses a

six-point mobility scale and it gets dubious with the use of +/- or ++/- -

oHesch model greatly simplifies mobility testing with dichotomous scale of:

oMobile/Normal, Hypomobile (blocked mobility), or Hypermobile, which is easily discerned and avoids subtlety

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The traditional model of manual therapy uses a six-point mobility scale and it gets dubious with the use of +/- or ++/- -

Hesch model greatly simplifies mobility testing with interpretation being Mobile/Normal, Hypomobile (blocked mobility), or Hypermobile. These are easily discerned, and avoids subtlety, greatly enhancing confidence of the clinician

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Treating the direction of blocked mobility/hypomobility gives “the biggest bang for your buck”, is much more efficient and efficacious than chasing subtleties.

It is a much simpler model and has greater intra and inter tester reliability and greatly enhances confidence of the clinician

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Sacroiliac Pain Provocation Tests

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What do they really tell us?

• Thigh thrust (force goes through the hip), only with careful positioning is the posterior SIJ ligamentous complex isolated. It is unknown whether or not the include the lumbar spine, truly isolate the SIJ, and force certainly traverses the hip

• PA spring on sacrum (initially isolates L5‐S1 facets)

False Tests: Pain Provocation

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• Distraction/compression (rarely positive)

• Patrick Faber (force initially goes through hip). Does it truly isolate the SIJ and hip or does some force traverse the lumbar spine?

• Gaenslen’s (force initially goes through hip) ). Does it truly isolate the SIJ and hip or does some force traverse the lumbar spine?

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If three or more tests are positive (produce pain) it predicts a positive response to intraarticular SIJ injection, typically performed under fluoroscopy. We will elaborate on injection when we discuss pain, especially concerns regarding specificity.

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We do not need to produce pain in order to be given permission to treat a symptomatic or an asymptomatice biomechanical dysfunction of the lumbopelvic‐hip complex.

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Validity of Physical Exam Maneuvers in the Diagnosis of Sacroiliac Joint Pathology

“In this cohort, patient physical exam maneuvers to identify intra-articular SIJ pain did not demonstrate diagnostic value when compared with the reference standard of an intra-articular anesthetic block.”

Schneider BJ, Ehsanian R, Rosati R, et al. 2019

• Exercise

• Pelvic Support,

• General Intervention

PUBIC JOINT DYSFUNCTION, SEPERATION/DIASTASIS

Placement of sacroiliac low at the level of the trochanters is a standard of care which has good research support in cases of pubic seperation.

Bonner TJ, Eardley WG, Newell N, Masouros S, Matthews JJ, Gibb I, Clasper JC. Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring. J Bone Joint Surg Br. 2011 Nov;93(11):1524-8.

PELVIC SUPPORT

• Some studies support high position some studies support low position at level of trochanters in which 40% greater joint compression was achieved.

• Try both positions!

• Shifting the medial compression force of 100N in steps of 10N to the greater trochanter did not change the muscle activation pattern but further increased SIJ compression force by 40% compared to coxalcompression.

• Pel JJ, Spoor CW, Goossens RH, Pool-Goudzwaard AL. Biomechanical model study of pelvic belt influence on muscle and ligament forces. J Biomech. 2008;41(9):1878-84. doi: 10.1016/j.jbiomech.2008.04.002

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• Pelvic belts alter sacroiliac joint motion and provide partial relief of ligament strain that is subjectively marked, although minimal in absolute terms. These findings confirm theories that besides being mechanical stabilizers, the sacroiliac joint ligaments are likely involved in neuromuscular feedback mechanisms.

• Sichting F1, Rossol J, Soisson O, Klima S, Milani T, Hammer N. Pain Physician. Pelvic belt effects on sacroiliac joint ligaments: a computational approach to understand therapeutic effects of pelvic belts. 2014;17(1):43-51.

Recommendations include rest and pelvic supports as basic treatments. Additionally, the few clinical trials reported recommended additional physiotherapy, including strengthening and stabilizing exercises, to reduce SPD symptoms.Urraca-Gesto MA1, Plaza-Manzano G, Ferragut-Garcías A, Pecos-Martín D, Gallego-IzquierdoT, Romero-Franco N. Diastasis of symphysis pubis and labor: Systematic review. J Rehabil Res Dev. 2015;52(6):629-40. doi: 10.1682/JRRD.2014.12.0302.

We recommend a combination of specific stabilizing exercises, nonelastic SI belt in the high position, and ergonomic education as the most beneficial interventions in the management of SIJD/posterior pelvic pain for pregnant individuals (with SIJD). There is little evidence to support specific intervention recommendations for SIJD in those who are nonpregnant individuals.Sharma, A, Sharma, S, Steiner, LA, Brudvig, TJ. Identification and Effectiveness of Physical Therapy Interventions for Sacroiliac Joint Dysfunction in Pregnant and Nonpregnant Adults: A Systematic Review. J Women's Health PT. 2014;38(3):110–117. doi: 10.1097/JWH.0000000000000015

•Hip and Knee Relation to Sacroiliac

•The following study supports the evaluation of hip rotation as part of a thorough SIJ evaluation. Although research is lacking, hip motion also includes the evaluation of hip extension.

• Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998, 1;23(9):1009-15.

A significant number of patients meeting strict diagnostic criteria for SI joint pain had radiographic evidence of femoroacetabularimpingement (FAI) and hip arthrosis. The clinician should maintain FAI in the differential diagnosis when investigating patients with buttock pain.

Morgan PM1, Anderson AW, Swiontkowski MF.Symptomatic sacroiliac joint disease and radiographic evidence of femoroacetabular impingement. Hip Int. 2013 Mar-Apr;23(2):212-7. doi: 10.5301/HIP.2013.10729.

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• The results of this case series support the use of gluteus maximus strengthening exercises in those with persistent lumbopelvic pain and clinical tests positive for SI joint dysfunction.

• Added MAN, de Freitas DG, Kasawara KT, Martin RL, Fukuda TY.

Strengthening The Gluteus Maximus In Subjects With Sacroiliac Dysfunction. Int J Sports Phys Ther. 2018 Feb;13(1):114-120.

SIGNS AND SYMPTOMS

• Lumbar dysfunction

• Pelvic dysfunction

Subjects: 24 healthy pregnant women

Age 20-38 years

Visual analogue scale for pain

Number of visits: 3-6

NEW RESEARCH

ADL’s

• Function

• Sports/Recreation

• Rx: Hesch only

RESULTS

Parameter Initial Discharge

Pain 7.3 1.9

ADL’s 62.7% 76.1%

Work 60.7% 80.3%

Sports/Rec 51.8% 78.7%

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Traditional method of evaluation has poor intra-rater and inter-rater reliability

Hesch research

Olson 70% intratester reliability

Showed pain relief after one visit-study by Olson

RESEARCHOLSON MASTER’S THESIS

• ESTABLISHING THE RELIABILITY OF THE HESCH METHOD’S SPRING AND POSITIONAL TESTS IN PATIENTS WITH LOW BACK PAIN.

• Olson, L. TJ; Finch University of Health Sciences: Chicago Medical School, Chicago, IL, USA.

DETAILS

PURPOSE: A long-term controversy exists regarding the influences of pelvic joints on low back pain (LBP). The purposes of this study were to: 1) assess the intratester reliability of the Spring tests utilized in the Hesch method, and 2) to determine the intratester reliability of the 15 positional tests of the Hesch method.

RELEVANCE: Pursuing clinical success in reducing LBP symptoms has often served as an impetus to deliver treatments directed to the pelvic joints. However, determining reliable and useful pelvic mobility evaluation and treatment techniques remains largely unexplored and underreported.

SUBJECTS: Twenty-eight subjects (ages 25-67) volunteered to participate in this study. All subjects were recently diagnosed as having mechanical low back pain of possible SIJD origin. The lottery technique randomly assigned subjects to either the experimental or control groups.

METHODS: A pilot study was employed to determine the reliability of force delivery during treatment. Two steps were involved: a positional exam and pelvic Spring tests. Data was collected 3 times: prior to treatment, immediately post treatment, and 2 weeks post treatment. Treatment for the experimental group consisted of gentle mobilizations; for the control group, mock treatments involving appropriate hand placement but no force.

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ANALYSES: Cohen’s weighted Kappa was used to assess intratester reliability of both Spring and Positional tests. The Spring tests were evaluated to be hypermobile, normal, or hypomobile. The positional tests were also evaluated on a 3-point scale although the labels varied depending on the area assessed.

RESULTS: Only 6 of the 10 Spring tests demonstrating fair to good reliability (Kappa = .441.666). Seven of the 10 Spring tests demonstrated better than 70% agreement. Of the 15 Positional tests, 3 demonstrated excellent reliability (Kappa = .781-.868) with 4 indicating fair to good reliability (Kappa = .429-.639). No single test had less than 60% agreement and 12 of the 15 positional tests demonstrated better than 70% agreement.

OLSON MASTER’S THESIS

CONCLUSIONS: Seven out of ten Spring tests and twelve out of fifteen positional tests demonstrated clinical usefulness. Potter and Rothstein used 70% agreement as criteria for acceptance of clinical tests used to evaluate pelvic dysfunction.

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PAIN

FUNCTION AND DYSFUNCTION AND THE NERVOUS SYSTEM

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NERVOUS SYSTEM

SIJ Innervation Spans L2‐S2

Joint mechanoreceptors type 1, 3, 4

Sympathetic nerves, parasympathetic in close proximity

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Table 1. CLASSIFICATION OF ARTICULAR RECEPTORS / MECHANORECEPTORS

Type IType IIType IIIType IV

Wyke, also Sakomoto, and others, 1972, 2010

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PELVIC JOINT RECEPTORS

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SI Ligaments :

97% nociceptors

3% proprioceptors(Sakamoto 2001)

Histologic Study on Nerves(Szadek 2009)

PELVIC JOINT RECEPTORS

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Ligament – Muscle

Muscle – Ligament

Clinical Gem: Treat Both!

PELVIC LIGAMENT-MUSCLEFUNCTION PARADOX


Pudendal,

Ilioinjuinal,

Iliohypogastric,

Genital Portion: Genito-Femoral

•(Becker 2010)

SYMPHYSIS INNERVATION

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R. Maigne (Paris 2006)

A)Distribution of the spinal nerves T12 and L11. Anterior ramus2. Posterior ramus3. Perforating lateral cutaneous branch

B)Referred pain from the TLJ is felt in the cutaneous distribution of these nerves; the skin and subcutaneous tissues are the site of reflex cellulalgia. However, the pain is felt as deep pain.1. Low back pain (posterior ramus)2. Pseudovisceral pain and groin pain (anterior ramus)3. Pseudotrochanteric pain (lateral perforating branch)Usually, the cause is painful minor intervertebral dysfunction of a TLJ segment.

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Are SIJD pain patterns unique?

No! they are very similar to low back, gluteal, hip, abdominal pain patterns

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CONTINUED

Some suggest that sij mediated pain is drawn below the waist

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CONTINUED

unlike lumbosacral pain which is at the waist and above

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CONT.CONTINUED

Oftentimes pain of sij original refers to buttock, hip (anterior, lateral, posterior), inguinal area involving the iliacus or psoas, and the lower extremity.

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Continued

Oftentimes pain of sij original refers to buttock, hip (anterior, lateral, posterior), inguinal area involving the iliacus or psoas, and the lower extremity.

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CONT.

SIJD does not cause severe lancinating sciatica below the popliteal space, in spite of any belief otherwise.

Again, discerning between sij mediated pain and lumbar mediated pain is difficult, except that sciatica below the knee is attributable to lumbar spine.

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Continued

SIJD does not cause severe lancinating sciatica below the popliteal space, in spite of any belief otherwise.

Again, discerning between sij mediated pain and lumbar mediated pain is difficult, except that sciatica below the knee is attributable to lumbar spine.

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Continued

Hesch method respects pain and is primarily a biomechanical model

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PAIN PROVOCATION TESTS

are they a necessary permission‐granting process in order to treat?

no, not in a preventative and biomechanical model

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PAIN PROVOCATION TESTS

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Furthermore, caution is urged and pain provocation tests directed to the SIJ Are the same as

Hip (femeroacetabular) pain provocation tests!

This yields considerable room for thought, dialogue, cautious interpretation and further research

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ANTERIOR SIJ COMPRESSION TEST

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COMPRESSION IN SIDE LYING

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ANTERIOR SIJ DISTRACTION

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THIGH THRUST

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HESCH MODIFIED THIGH THRUST

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FABER TEST

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GAENSLEN’S

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Finally, a pain provocation that is directed to the sacrum/sij, although, it also affects the lumbosacral articulations. Caution urged!

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SACRAL THRUST

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the pelvis

sacroiliac

symphysis pubis

hip

lumbar spine

INNOVATIVE AND EFFECTIVE TREATMENT TO RESTORE NORMATIVE

FUNCTION IN:

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to the traditional model, providing a logical, integrative system:

which quickly and efficiently improves patient outcomes.

A CONTEMPORARY ALTERNATIVE

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The Hesch Method vs. Traditional Methods

More palpation

Most palpation on stable surfaces

Separates pelvic biomechanics from sacroiliac biomechanics

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Less reliance on pain provocation tests

Less trust of standing presentation

Distrust of gross SI motion tests

CONTINUED

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CONTINUED

Passive motion testing to grade mobility

Less reliance on pain in general

Reinterprets some fundamental biomechanics

Clearer language

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CONTINUED

Treatment approach is very unique using low‐load, long‐duration force application

Heavy on self‐treatment

Manual techniques only performed on initial 1 to 2 to 3 visits

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Assessing Hesch Technique for your patient

You should know if this approach is working in 1‐3 visits.

It works It works if combined with other PT approaches

It works if combined with other medical or alternative approaches

It doesn’t work

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TREATMENTS

External Force to correct

Viscoelastic nature of corrective tissue

Creep, (deformation over time)

Workbook indicates when HEP is needed

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Contraindications from Grieve (1976)

Stoddard’s Warning Signs (1980)

Patient rapport

Patient response

Poor response after 3 treatments

Treat in pain‐relieving direction

INDICATIONS AND CONTRAINDICATIONS FOR TREATMENT

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Evaluation

and

Treatment

Demonstration

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BEFORE THE MOST COMMON PATTERN YOU MUST SCREEN

Hip Internal Rotation

Hip Extension

Pelvic Side-glide

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Hip Internal Rotation Restriction

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Research versus clinical relevance: Do we do what the literature dictates or do we use our intelligence?

Good intra-tester reliability with prone testing of hip IR

Piriformis syndrome proposes prone testing of hip IR

Many clients have normal prone hip IR but restricted supine hip IR.

Supine IR testing addresses all external rotators.

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Hip Extension Restriction

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Sometimes clients compensate efficiently and lack of extension is not visualized with posture and gait analysis.

Therefore, you must always specifically test hip extension, always.

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Limited hip extension creates false-positive traditional sacroiliac tests.

Note: Thomas test does not clear hip extension, it is only a muscle length test. You still must test prone extension.

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Hip: Limited Extension

SUPINE

Femoral head in posterior glide and flexion

Anterior mid and distal femur will be prominent

Femur lacks A-P spring

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Hip Limited Extension: Supine

Patella will not lift

Prone-Post glided femoral head

Limited PROM: extension (prone)

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Screen for Pelvic Side Glide

Treat

Still RestrictedFixed Deformity

Re-treat

CorrectedStill Restricted

(very rare)

NormalRestricted

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Pelvic Side-glide Restriction

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The MOST COMMON PATTERN LUMBOPELVIC MOTION DYSFUNCTION

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The Most Common Pattern

Physiological versus non-physiological joint movement dysfunction

Physiologic: Can move farther into the pattern. Example: Anterior Ilium

Non physiologic: Cannot move further into the pattern. Example: Upslip Ilium.

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Left Posterior Pubic Bone Definite step-off going right to left

across fibrocartilage, mutable. More common in the female population.

80% are not a true posterior fixation, there is no step-off.

Spring Tests: only in Advanced Hesch method.

Create a postural fixation with towel roll under left ilium, placed vertically

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Left Sacral Rotation

True joint fixation is probably very rare.

Muscle tone is increased on one side.

Usually motion is blocked, and left side prominent due to spasm or guarding of the segmentally innervated Multifidi and Erector Spinae muscles.

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Palpate S1-S2-S3-S4 bilaterally, 1” away from midline

Spring Tests

Create a postural restriction by placing a towel roll under the left ilium in prone.

Continued, Left Sacral Rotation

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Left Sacral Side Bending

Landmarks: Entire left side prominent

Spring Tests: Ulnar border of 5th

metacarpal on left side. Mid metacarpal medial to PSIS, so you spring above and below, thus encompassing S1-S2-S3

Create a postural fixation; have partner hip-hike (ilium) on right side in prone

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RIGHT ANTERIOR ILIUM

Landmarks

Spring Tests

Create a postural fixation by placing a towel roll horizontally across the right posterior iliac shelf (above PSIS) in supine

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Left Posterior Ilium

Landmarks

Spring Tests

Create a postural fixation by placing a towel roll horizontally under the left ASIS in prone.

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Right Type 1 Inflare/ Left Type 1 Outflare

Landmarks

Spring Tests

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CAUTION: springing in supine is very unreliable.

Always do Springing with Awareness in prone for inflare/outflare.

To create a postural fixation, place a towel roll vertically under the left ilium (ASIS) in prone.

Inflare Outflare

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TYPE 2 LUMBAR FLEXION DYSFUNCTION

Landmarks

Tests

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SACRAL TORSION

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Name That Axis

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Sacral Torsion

SI joint encompasses S1 to S3

Axis passes diagonally from the anterior portion of S1, thru midline, to the posterior portion of the opposite S3

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LEFT RIGHT

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Sacral Torsion

SI joint encompasses S1 to S3.

Axis passes diagonally from the anterior portion of S1, thru midline, to the posterior portion of the opposite S3.


Hesch Method

Sacral torsion: side bending and rotation occur in same direction or in opposite direction.

You do not have to memorize the ways in which side-bending and rotation couple for each of 4 types of sacral torsion.

Why? Because when you resolve the rotational restriction the side-bending automatically resolves.

Hesch Method

New way to name torsion example: Left Lower Quadrant Prominent and Stuck

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UPSLIP AND DOWNSLIP

If either is present, it must be treated first, before any other ilium dysfunction

Downslip usually causes severe pain, perhaps tractioning or compressing the lumbosacral plexus.

UPSLIP

Very stable dysfunction

Evaluation

Treatment

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Hesch Method

POSTERIOR GLIDE SACRUM WEIGHT SHIFT

Hesch Method

Birth And Trauma Related Instability, Symphyseal Diastasis

Orthopedic Trauma Literature

Older Tile Pelvic Fracture Scale (includes pubic separation

Newer Young-Burgess

Hesch Method

Pelvic Fracture / Symphyseal Diastasis

APC‐I AP‐C II, AP‐C III

Hesch Method

ACUTE TREATMENT WITH SLING

Hesch Method

Severe unstable obstetric

symphyseal diastasis of 4.7 cm. Kowalk (1996)

Hesch Method

SIJD WITH SEVERE SYMPHYSEAL DIASTASIS

Hesch model of posterior glide of ilia along plane of SIJ, a component of cam motion is supported by this image. Kowalk (1996)

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Hesch Method

Pelvic Belt AKA SI Belt or Trochanter Belt

Hesch Method

Hesch Method

Release The Pattern Of Injury Removing The Neural Inhibition,

Then Pursue Comprehensive Rehabilitation

Hesch Method

ADL’S

AutomobileSittingStanding, TwistingSquatReach

AUDIENCE:

THANK YOU

VERY MUCH!

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Hesch Institute Presents...What we see regarding bony landmark asymmetryof thepelvis isdueto: •...

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