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Role of Manual Therapy in the Evaluation and Treatment of a Surgically Stabilized Pelvis

Physical therapists face many challenges in the evaluation and treatment of the sacroiliac and pubic symphysis joint complex. Unfortunately, there is no agreement on a unified system of testing, interpreting, and treating the sacroiliac joint under normal or pathologic conditions. When trauma to the pelvis results in its surgical stabilization, therapists must be especially mindful of safety issues in developing treatment protocols.

Two approaches are commonly used to treat pelvic diastasis-fusion and stabilization. Fusion is the surgical formation of a bony ankylosis in a procedure involving resection of articular cartilage until subchondral bone is exposed. This is followed by apposition of bone surfaces and then immobilization using internal or external fixation techniques to achieve a bony fusion (arthrodesis). No motion is possible in a fused joint.

In the stabilization approach to treatment, Masacral lag screws and pubic symphysis plates are used co hold the sacroliliac joint in a fixed position.3' pitt,20-2' in studies of recurrent subluxation of the sacroiliac joint stabilized with iliosacral lag screws, states that fusion (ankylosis with internal devices or bone grafts) should not he used to treat sacroiliac hypermobility except in the most grossly unstable situations. He concludes that stabilization is a safe and effective way to manage a hyperrnobile sacroiliac joint by fixation (attachment) of the ilium to 'the sacrum; stabilization does not fuse the joint. Placement of a single iliosacral lag screw across the ligamentous portion (superior) of the sacroiliac joint will fixate and stabilize the hypermobile sacroiliac joint and will allow a small amount of rotational motion.2°21 Two lag screws will effectively stop rotational movement of the sacroiliac joint and are used if a single Lag screw does not provide sufficient stability).

Sacroiliac dysfunctions have been described in the literature and treatment interventions have been proposed, but no literature exists regarding mobilization of a surgically stabilized sacroiliac joint In this resident's case problem, we present a patient with a surgically stabilized pelvis who showed signs and symptoms of sacroiliac dysfunction. Manual therapy evaluation techniques are described that lead to a diagnosis that will guide physical therapy treatment, and mobilization is used to achieve am anatomic position, relieve pain, and allow sacroiliac joint motion as determined by clinical examination and testing.

HISTORY
A 31-year-old woman (weight, 59 kg, height 170 cm) was employed as a heavy equipment operator at a sand and gravel company when she was injured on September 8, 1997. She fell approximately 8 meters off a structure that tipped over while crushing stones. She sustained a L2 compression fracture, fracture of the right talus, fracture of the right sacral ala and,L5 transverse process, and a right sacroiliac and pubic symphysis diastasis. She had an open reduction internal fixation of the right talus the next day. One week later she underwent an open reduction internal fixation of the right sacroiliac joint and pubic symphysis. A pubic symphysis plate and screws and a single iliosacral lag screw were used to fix the sacroiliac joint into the body of S1 (Figure 1). She was immobilized its a thoracolunsbosacral orthosis, and an aircast on the right ankle with non-weight-bearing gait for approximately 4 months, In January 1998 she must account for the surgical stabilization and the strength of the lag screw. Forces on the sacroiliac joint during a manipulative thrust (Grade V) have been shown to be 328 N (SD 78 N) .17 Extraction strengths of iliosacral lag screws such as the one used in this patient have been studied by Kraemer16 and reflect the amount of resistance to vertical shear when a load is applied. Kraemer"' found that extraction strengths were 925 ± 498 N. Mobilization, Grade I through IV, as defined by Maitland are by definition of lessor force and amplitude than thrust (Grade V). Therefore, I concluded that mobilization (Grades I-IV) forces would not cause a safety problem. In the absence of absolute contraindications, increasing the mobility of the sacroiliac joint and achieving normal position was the goal of treatment, and mobilization was the logical approach to this goal.

Given the complex nature of the patient's injuries, aggressive strengthening was not appropriate in the early stages of rehabilitation. The general plan was to address the flexibility and weakness issues early with a home program, and then introduce mobilization procedures to relieve pain and restore functional sacroiliac and lumbar alignment and mobility. Concurrently, strengthening exercises would be introduced as pain levels decreased and impediments to normal function were eliminated.

COURSE OF TREATMENT
The patient was created 3 times a week for 6 weeks, with 1 cancellation. Her treatment program is summarized in Table I. She received a written home program using the PTEX Home Exercise System version 4.0 (PTEX Systems, Wilbraham, Mass) computerized exercise program. The patient was also supplied with a 3-mm cork lift for her right shoe and a senurgid Freedom Aliplast XPE half sole (Alirned, Dedham, Mass) orthotic shell for both shoes, with a Nickleplast Lice (Ahmed) extrinsic medial arch sup= port on the right to provide some lift and support the relative supination on the right compared with the left. The rationale for the lift and orthotic was to help equalize the structural component of the leg length inequality, dampen excessive pronation, and attenuate the ground reaction forces "1 relieve pain and promote efficient ambulation. Visual inspection of the iliac crests for horizontal height was done to confirm improvement of the leg length inequality. The functional component of the leg length inequality would be addressed with the mobilization procedures described below and the stretching program for the hip flexcr/rectus femoris and lumbar musculature. In the clinic. the patient warmed up For 10 to 15 minutes on a recumbent bicycle, a stair climber, and an upper body ergometer and then began using the strengthening equipment listed in Table 2. The posterior rotation mobilization of the right in-nominate technique was applied using Grade I and II mobilizations for pain relief with oscillation at the rate of 1 to 2 oer second. The patient was placed in a left sidelying position and a force couple was applied with the right hand directed posterior and cranial and the left hand directed anterior and caudal, with mobilization performed S to 5 repetitions, 15 to 20 seconds of mobilization with each repetition (Figure 6). Reassessment showed no improvement after the first session, so on the next 2 visits Grade III mobilization was performed to the limit of the available range (up to the motion barrier), which was estimated to be two-thirds of the normal anatomic limit The patient reported decreasing pain, but no significant change was observed in the positional and function:al tests For the sacroiliac joint.

During this period the patient's lumbar spine was also mobilized into right rotation {Figure 7) by placing the patient in the left sidelying position and performing Grade I and II mobilizations for pain relief with oscillation at the rate of 1 to 2 per second, 3 to 5 repetitions, 15 to 20 seconds for each repetition.

No lasting relief was reported.

After 3 weeks, the patient's progress was reviewed. She'reporced a reduction of pain and the assessment of range of motion and Function showed improve ments. However, the sacroiliac positional and functional tests were still abnormal, and the patient's lumbar spine continued to show symptoms of dysfunction. A more aggressive approach was then considered. The previously mentioned study by Cibulka5 demonstrated that manipulation done on one sacroiliac joint affects the contralateral sacroiliac joint since the pelvis is a closed ring. I reasoned that such an indirect approach (mobilizing the left sacroiliac joint) might well be safer and a more appropriate plan.

Mobilization of the Opposite Sacroiliac Joint
On the ninth visit, the patient's left. sacroiliac joint was mobilized with a technique described by Cibuika4 and Stoddard.34 The patient was placed in the supine position with her hands crossed behind her neck and the operator on the right side. The pa-dent's lumbar spine was sidebent left and rotated right by threading the operators left arm through the patients crossed left arm, resting the operators left hand on the patients chest wall (Figure 8). The operator then places their right hand over the patient's left ASIS and delivered a graded mobilization force in a posterior and inferior direction (Figure 9). Initially, Grade II mobilizations were done and they were pain free. Progression was made to Grade El, and there was an audible pop on the first attempt. I could not determine from where the sound originated, but the patient said that she thought it came from the right sacroiliac joint. Origin from the lumbar spine or possible accessory sacroiliac joints can not be excluded. Immediate reassessment showed normalization of all sacroiliac joint functional tests and no pain in the posterior right hip or pubic syrnphysis area. The ASIS's were checked for horizontal height and the right was still somewhat lower than the left, but improved. No further sacroiliac joint mobilizations were given after this treatment session.

Grade III mobilization of the lumbar spine into right rotation was performed as described above on the next 2 visits. An audible pop occurred during the second session, and reassessment showed improvement in quality and quantity of trunk motion.

RESULTS
The patient was reevaluated on April 7. 1998, 6 weeks after commencing physical therapy. Pain Questionnaires are summarized in Table 3, which includes a 3-monda follow-up. The most improvement in the right sacroiliac area occurred after the left sacroiliac joint was mobilized. The lumbar spine range of motion improved to forward bending with no limitations and with no deviation, backward bending restricted to approximately 30° with stiffness at end range and no deviation, right sidebending restrictedto approximately 20° with stiffness at end range, left sidebending restricted to approximately 25°, right rotation restricted to approximately 50°, and left rotation restricted to approximately 500. Pelvic landmarks were nearly equal (right ASIS and iliac crest slightly low; and all sacroiliac joint tests were negative. Thomas and Trendelenburg tests were negative on the right The patient had discarded the 3 mm lift and orthotic, reporting that they had helped initially but were not now needed. There did not appear to be any clinical reason to equalize the minimal leg length inequality with a lift, as the shortening did not adversely affect her pain, mobility, or gait. It has been reported that up to 6 nun of functional leg length inequality can be reversed with a change in innominate position"5 and reassessment showed near complete resolution of her leg length inequality Given the improvement in muscular flexibility and positional and functional sacroiliac joint tests, it is reasonable to assume that the mobilization of the sacroiliac joints and the stretching program played a significant role in the functional improvement in leg length inequality. Repeat radiographs done after discharge showed no change in the position of the pelvis or internal fixation devices (Figure 10). The patient returned to work full time for 3 months, during which she slowly developed increasing problems with right ankle pain and localized tenderness over the lag screw site. On July 22, 1998, she underwent ankle arthroscopy for removal of pins and loose bodies, and removal of the iliosacral lag screw, which had backed out approximately 2.5 cm at the time of removal. Subsequently, she returned to work full time with complete resolution of the pain at the lag screw site, and no further physical therapy was needed.

CONCLUSION
Evaluation and treatment of the sacroiliac joint remains controversial, and clinicians lack a "gold standard" to guide them through this complex subject In this case, a patient presenting injuries to the lumbar spine had internal fixation devices surgically placed in the pelvis. Decisions on the appropriateness and safety in the delivery of mobilization procedures for sacroiliac dysfunction were guided by reports in the literature. Although this type of patient is rarely seen in clinical practice, mobilization appeared to be an important part of this patients recovery. The evaluation and treatment of the patient emphasizes the functional interdependence of the sacroiliac joints and demonstrates how the evaluation of sacroiliac dysfunction can guide physical therapy intervention.

ACKNOWLEDGMENTS
I thank Marija Mikas-Shaw, PT, and Sandra L. Maes, MBA, for their support, recommendations, and patience in the preparation of this study.

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returned to work, operating a backboe and occasionally shoveling gravel for 20 hours a week_ By the third week she decreased her work hours because of increasing pain in the right low back and pelvis, and eventually returned to her orthopaedic surgeon when she could no longer work. She had no physical therapy until her referral and initial visit on February 26, 1998, A radiograph taken February 24, 1998, showed slight displacement and loosening of the iiiosacral lag screw and pubic syrnphysis plate; the pelvic and lumbar fractures were healed (Figure 2). The orthopaedic surgeon confirmed that the sacroiliac ' joint was not fused.

The patient had no history of musculoskeletal problems or systemic illnesses Her functional status had been that of a healthy, active woman employed in a heavy physical labor occupation. She worked 60-70 hours a week and her duties involved operating a backhoe and front end loader, and frequent manual shoveling of gravel. Workman's compensation covered the costs of her treatment, and no litigation wasfiled, Her goal was to return to full time work with full function and minimal-to-no pain.

On initial assessment, the patient completed a pain drawing and reported right side pain in the back, anterior and posterior ilium, and anterior and posterior ankle (Figure 3). Her reported pain levels were 2/10 on the best day. 10/10 on the worst day, and 6/10 at the initial assessment: The McGill Pain Questionnaire" total was 21. The Oswestry Low Bac. Pain Questionnaire" score was 34%, which is consid ered "moderate disability." Assessment of functional status at the initial interview revealed that the panel. experienced pain after sitting or standing for more than one-half hour, and while lifting, traveling. dres5 ing (especially when donning shoes and socks), walk ing more than 1 km, shoveling, stair climbing, and walking on uneven terrain. Sit to stand movements. supine to sit movements and reverse, transfers in an out of a car or bed, and supine sexual intercourse positions also caused pain. She presented with a complaint of general deconditioning and a weight gain of 7 kg since her injury. Pain was more pronounced in the morning and late afternoon and evening, and was lessened with activity at midday.

Impression From Patient's History
This patient had significant traumatic injuries and a 5-month period of immobilization that resulted in a chronic and stable dysunctional status. My working hypothesis was (I) pelvic innominate dysfunction secondary to fracture and surgical stabilization with prolonged non-weight-bearing gait, and (2) lumbar movement dysfunction secondary to L2 compression fracture. Possible contraindication to physical therapy treatment was primarily the surgical stabilization of the sacroiliac joint and pubic syrriphysis.

PHYSICAL EXAMINATION
The examination and treatment of the right ankle will not be described in detail in this report. The en tire evaluation was videotaped using a VHS paha-icorder, and video stills were produced using the ATI Modular Video Driver (ATI Technologies, Thornhill, Ontario, Canada) and the Computer Coach Version 3.0 program (Golf Training Systems, Duluth, Ga). The line drawings and measurements were created from the video stills.

Static standing posture was evaluated from behind and showed that the iliac crest was lower on the right side, and the lumbar spine was mildly sidebent to the left. From a lateral view her pelvic inclination angles were- measured, adapting an inclinometer method described by Cibuika5 and Crowell et al.' A video still photograph of the patient in a standing, relaxed position was used, aligning the horizontal arm of the goniometer through the postcrosuperior iliac spine (PSIS) and parallel to the floor, and measuring the angle through the anterior superior iliac spine (ASIS), An imaginary horizontal line drawn through the PSIS and ASIS was considered zero. Positive values indicate an anterior innornin2.te alignment and negative values indicate a posterior innom Mate. The measurement was plus 9° on the right and plus 5° on the left (Figure 4), indicating that both innominates were in an anterior position, with the right more anterior than the left. Reliability of this method has not been established, however, intratester reliability of the inclinometer method has been established.5o7 In the standing position pelvic landmarks were palpated for horizontal height, with the thumbs inferior to the ASIS; the right ASIS inferior compared with the left ASIS (Figure 5). Similarly, the PSIS's were assessed for horizontal height and appeared level. Care was taken to place the examiner's thumbs inferior to the ASIS and PSIS and pressure was exerted in a cranial direction to come into firm contact with the inferior aspect of the bone.

Visual inspection of active spinal range of motion was done for gross quality and quantity of Movement and to determine which movements produced pain. The patient performed forward bending and came within 3 inches of the floor with her knees extended, but with, slight deviation to the left and incomplete reversal of the lumbar lordosis. She had pain with backward bending, with deviation to the left at, approximately 10°. Right sidebending was reported painful at approximately 5°. Left sidebending was restricted to approximately 15°. Right rotation was restricted to approximately 30°, and left rotation was restricted to approximately 45°. Repeated backward bending and right sidebending exacerbated the pain, which she felt at the end of the available range of motion.

Right hip active range of motion in the supine position was: flexion 105° with pain in the low back area; abduction 40° with pain in the pubic area; adduction 20°; internal rotation (hip at 90° of flexion) 20° and tight at end range; external rotation (hip at 90° of flexion) 45°. Hip extension in the prone position was 5°. Thomas test was positive for tightness of the right hip flexor and rectos lemons. Straight leg raise was limited to 70° on the right. Care was taken to stabilize the lumbar spine and sacroiliac joints during the range of motion evaluation by observing the motion at the hip joint only and by hand placement on the ASIS when possible to see when motion occurred at the pelvis. The right ralf was tight, allowing dorsiflexion to plus 5'. The left calf showed no limitations of range of motion.

Passive mobility testing of the lumbar spine was done with the patient in the sidelying and sitting positions and palpating segments Ll through L5. There was tenderness to palpation over the spinous process of L3. The patient reported tenderness when the right lumbar paraspirsal muscles were palpated. Using the grading scale developed by Gonnella and Paris's with 3 being normal, 2 being slight restriction. and 1 being considerable restriction, the most sigruficant finding was that at L2/L3, sidebending right was graded 1 and rotation right was graded 1. In this system, the examiner palpates the interspinous space at L2/L3 by taking up the slack from below by flexing the hips and knees and then introducing rotation or sidebending and grading accordingly. lntratester reliability has been demonstrated with this system, but intertester reliability is not considered dependable."

Neurologic screening assessed muscle contraction and muscle strength of the major myotomes of each lower extremity, using a grading system of 0 = no contraction, 1 = trace, 2 poor, 3 = fair, 4 = good, 5 = normal. The score for all muscles on the left was 5/5. On the right, the muscles were scored as follows: Li/L2 (hip flexor): 4+/5; L3 (quadriceps): 5/ 5; L4 (tibialis anterior): 5/5: L5 (extensor hallucis long-us): 5/5; Si (gastrocnemius and coleus): 5/5; S2 (hamstrings): 5/5. I thought that the hip flexor weakness was related to the pelvic fractures, the prolonged immobilization, and the patient's apprehension about contracting the muscle. The scores for the right hip abductors, extensors and adductors were 4/5. Right ankle invertors and evertors were 4+/5 and this was believed to relate to deconclitioning related to the ankle fracture- Reflexes were tested using a grading system of 0 absent, 1+ = diminished, 2+ = normal, 3+ = increased, and 4+ = clonus. The scores at the patellar tendon and achilles tendon were 2+ bilaterally. Slump testing's was performed with the patient in the sitting position with the knee fully extended, the ankle fully dorsiflexed and the patient flexing her spine and head to the maximum extent possible. The test was scored as negative bilaterally, and the patient did not report any sensory disturbances. She also demonstrated a mildly positive Trendelenburg sign on the right and had difficulty maintaining balance with a right single leg stand, which suggested weakness of the right gluteus edius. The reliability of individual sacroiliac joint tests is considered to be poor by many authors. Stretching for lumbar spine flexion and extension, hamstrings, calf, quadriceps, and hip flexorrectus fernoris. Strengthening for abdominals, back extensors, hip flexors, hip extensors, hip abductors, quadriceps, and calf.

Manual stretches of hamstrings, calf, and hip flexors.

Strengthening exercises on Cybex and Biodex equipment.

Three millimeter cork lift in right shoe, semirigic orthctics. Right extrinsic post in arch for increased suoport and lift. used to diagnose sacroiliac joint dysfunction. According to Cibulka,4 a finding of sacroiliac dysfunction can be reliably made when 3 of 4 tests are positive (standing flexion test, prone knee flexion test, supine to long sit test, and abnormal sitting PSIS position). Descriptions of these tests can be found in the literature-5,6 and will riot be presented here. In this patient, the standing flexion rest was deemed abnormal on the right as the right PSIS had greater excursion at the end range of flexion than the left PSIS. The prone knee flexion test was also positive on the right side, as the right medial malleolus appeared shorter at 900 of flexion compared to full extension. The supine to long sit test was also positive on the right as the right lower extremity appeared to get shorter in the long sitting position compared with the supine position. The position of the PSIS's did not appear to be abnormal. In the left sidelying position, passive movement testing of the right innominate was performed manually with 1 hand touching the iliac crest and the other hand touching the ischium; an anterior rotation movement was reported as painful. Passive movement testing of the right innominate was also performed manually with 1 hand touching the ASIS and the other hand touching the ischiurn. A posterior rotation movement was possible through a partial range of motion and was reported to relieve posterior right pelvic pain. The end feel of this movement was an abrupt stop before coming to another barrier to motion. Continued gentle force yielded a slight incremental increase in motion. Reliability for the above tests has not been established, but they provided additional clinical evidence to suggest the hypothesis of hypomobility of the right innominate.

Position of the sacrum was evaluated by palpation of the sacral sulci and inferior lateral angles in the prone neutral position and was not found to be deviated. The position of L5 relative to the sacrum was assessed by palpation of the transverse processes of L5 and was in normal alignment. There is n.0 established reliability of these tests; however, I assessed the above landmarks for asymmetry to arrive at a positional diagnosis and plan an appropriate intervention.

The patient had clinical evidence of both structural and functional leg length inequality. In the standing position the iliac crest and greater trochanter were obviously lower on the right. A 6-rrun wooden block was placed under her right foot, but the ASIS and iliac crest on the right were still slightly low on visual assessment. The iliac crests were palpated with the patient sitting; the right was slightly lower than the left, but not as obviously as when the patient was standing, indicating that there was likely structural shortening in both the pelvis and lower extremity. However, no specific conclusion could be reached as to the structural origin of the short right leg withoutradiographic studies with the patient in the standing position. Other possible structural explanations for the short right leg include preinjury structural shortening, shortening resulting from compression of the right ankle and pelvic area because of the neauma, a small hemipelvis, asymmetrical femoral neck angles, length of osseous structures, and sagittal and frontal plane abnormalities of the knees and feet.

Common causes of functional leg length inequality include sagittal plane rotations of the innominates (anterior and posterior), soft tissue contracture, and asymmetrical subtalar joint function (pronation and supination).2-25-52-55 The physical examination of this patient demonstrated an anterior rotation position on the right and a posterior rotation position on the left, relative to the right_ Also, there was soft tissue tightness in the right hip flexors and rectus femoris. Examination of the subtalar joint in the neutral position with the patient prone demonstrated rearfoot varus of approximately 5' bilaterally, and forefoot Carus of approximately 10' bilaterally. Video of tile patient's gait revealed excessive pronation on the right of approximately 100 and on the left of approximately 15°. The sacroiliac joint problem was believed to have played a role in the leg length inequality as it has been shown that an anterior innominate rotation is a compensation for an imposed short leg (an attempt to lengthen the short lower extremity), and a posterior innominate rotation is a compensation for an imposed long leg."6.29 There is no consensus in the literature on this point, however, be-cause others have reported posterior rotation on the side of the shorter limb.1 A tight right rectus femoris would be consistent with a right anterior innominate rotation because it would tend to rotate the ASIS anteriorly and inferiorly it may have also bad a role in the functional shortening of the right lower extremity. Subtalar joint pronation is considered to be an adaptation to a long leg (functional shortening),"' and in this patient the left (long) side exhibited the most pronation. My conclusion was that there was functional and structural leg length inequality, with the injury to the right lower extremity resulting in an anatomic shortening with functional compensation (lengthening) at the foot (supination relative to the ,left), and anterior rotation of the innominate. I believe that on the left side there was functional compensation (shortening) at the foot (pronation relative to the right) and posterior rotation on the in-nominate (relative to the tight).

Impression From The Physical Examination
The history and physical examination of this patient art consistent with a working hypothesis (physical therapy diagnosis) of (1) tightness in the right lumbar area and decreased mobility of the lumbar spine, especially L2/L3, and (2) hypornobile sacroiliac joint with anterior innominate dysfunction on the right side. Clinical evidence to support a diagnosis of right anterior innominate position alteration is as follows: (1) ASIS inferior on the right with respect to the left ASIS; (2) pelvic inclination angle of 9° on the right; (3) tight rectus fernoris on the right; (4) positive standing flexion test on the right; (5) positive prone knee flexion test on the right; (6) positive supine to long sit test on the right; and (7) relief of pain reported with passive motion of the right in-nominate in a posterior rotation direction.

The leg length inequality' complicated the analysis of the patient's sacroiliac joint dysfunction, and had implications for the selection of the proper treatment, especially whether a shoe lift should be used. A lift would be appropriate for a structural shortening, but could perpetuate a functional shortening resulting in continuing dysfunction, It seems plausible that multiple factors, both structural and functional, influenced the leg length inequality in this patient. How does one clarify the various factors that influence leg length discrepancies? This is a difficult task even in seemingly simple situations, as reliability and validity studies are sparse and demonstrate unacceptable results with clinical assessment.'' Cummings ccal," using blocks under the feet of noninipaired subjects to impose a leg length inequality, reported that posterior innominate rotation occurs on the side of the lengthened limb (functional shortening), and anterior rotation (functional lengthening) occurs on the side of the shorter limb. The inference is that leg length inequality would result in the same changes in symptomatic patients; however, this has not been definitively demonstrated in the literature and some disagreement exists as to the exact relationsbip."-26'29 In summary, my conclusion was that the patient had a structurally short right leg primarily, and functional compensation occurred at the subtalar and sacroiliac joints, thus, contributing to the perpetuation of the anterior innominate rotation on the 'right.'

There were no contraindications to mobilizing the pelvis, however, it was my opinion that Grade V mobilization to the pelvic joints was nor advisable because of safety issues related to the surgical stabilization. There does not appear to be any literature about contraindications in the above conditions although Lippitt'° suggests that vigorous activity should be avoided for 2 months after the placement of an ilioSacra; lag screw. There were no contraindications listed on the referral from this patient's surgeon.

Design of Plan of Care
The safety and appropriateness of using mobilization techniques for a surgically stabilized pelvis were considered before treatment was started. The sacroiliac joint was stabilized, not fused, and the sacral ala fracture was healed. It had been 5 and one-half months since the surgical stabilization and the radiogi aph taken just before physical therapy was started showed that die lag screw was backing out of the ilium, and the pubic syrnphysis had slightly widened (Figure 2). Screw loosening is believed to depend on many factors, including bone density, mechanical forces, screw placement, infection and bone micro-cracking around screw threads. My conclusion was that the normal mechanical forces of cyclic loading with ambulation and the resulting small motions of the sacroiliac joints caused the screw to loosen. This patient was very active, and because of her occupation, she was subjected to significant vibratory stresses and heavy loads across the low back and pelvis. Therefore, it appeared to me that while she was at work significant forces had already been transmitted through the sacroiliac and pubic symphysis joint complex without damage to the structures, and clinical mobilization forces were unlikely to exceed those she had already experienced.

The next step in making a clinical decision was to consider the possible uses of manual therapy to restore motion and position. The appropriate use of mobilization implies that a suitable condition exists (hypomobility), and a technique can be safely applied with a reasonable expectation of success. Greenmartm states that the pelvic girdle functions as an integrated unit with all 3 bones moving at all 3 joints, influenced by the lower extremities below and the vertebral, column and trunk above, Lee" states that the pelvic girdle is a closed osteoarticular ring supporting the abdomen and providing a dynamic link between the vertebral column and the lower limbs. The sacroiliac joints are bicondylar joints with 2. degrees of freedom, resulting in 2 structurally separate joints, but 1 joint functionally.'2 In other words, the sacroiliac joints are functionally interdependent, for the left sacroiliac joint cannot move without the right sacroiliac joint also moving." Since the pelvis is a closed ring with right and left paired innorninates connected via the pubic symphysis and the sacrum to form a functional unit to transfer load during the gait cycle, moving one sacroiliac joint will also move the opposite side. Cibulka et a1,5 demonstrated that a manipulative technique specific to one sacroiliac joint created a significant change in in-nominate tilt (anterior or posterior rotation) on the opposite side. Their work did not confirm that the manipulative technique they used is specific to the side manipulated, and can serve as a basis for clinical decision making concerning alternate approaches to direct contact with a surgically stabilized site. My conclusion was that mobilizing a nonsyrnptornadc sacroiliac joint would effect the opposite symptomatic sacroiliac joint_ Mobilization to the sacroiliac joints might adversely affect the pubic syrnphysis stabilization. However, Simonian33 showed that the sacroiliac joint and pubic symphysis act independently of each other when sectioned (ie, fixation of the pubic syrnphysis decreases pubic symphysis motion, but does not affect sacroiliac joint motion). Therefore, it appeared that mobilization of the sacroiliac joint was possible. since the joint was not fused, and passive motion was unlikely o to adversely affect the pubic symphysis stabilization.

Various authors have reported that the axis of rotation for anterior and posterior rotation of the in-nominate goes through the pubic symphysis. hg." This raises the possibility that a rotational mobilization could harm the pubic symphysis stabilization. There is no agreement, however, on the axis of rotation inthe pelvis,16".3"6 and clinical testing demonstrated posterior rotational motion about the right sacroiliac joint without pain in the pubic symphysis area.

The existence and extent of motion available in the sacroiliac joint is controYersial,lo1s,2'-'33.3035 however, Walker," in a review of nonimpaired sacroiliac joints, suggests that there is 1 to 3 degrees of rotation and 1 to 3 mm of translatory motion available at the sacroiliac joint. Sirxionian" reports that stabilization with an iliosacral lag screw and pubic symphysis . plate such as were used in this patient will decrease, but not totally eliminate, motion. Lippittl"' present ed a series of patients with hyperrnobile sacroiliac joints stabilized 1,,ith an iliosacral lag screw, 2 of which required a second screw later when the pelvis began to rotate around the screw. He stated that he routinely uses 2 screws now to firmly stabilize the sacroiliac joint. and prevent the return of innominate rotation and symptoms of hypermobility. Therefore, I reasoned that a small amount of "play" existed in my patient's sacroiliac joint and that the single lag screw was in one of the planes of motion and could allow the innominate to safely rotate around it to be repositioned correctly.

In this patient, it was clear that the innominate on the right must be rotated posteriorly to reach a normal position.