SACRARTHROGENETIC TELALGIA - Fimnet

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SACRARTHROGENETICII.HORACEBYA STUDYC. PITKIN,Thisarticleis theanalysesrecordsof din regardextentornotis ionall kesmanipulatingbeenpartany1936ofclinicalto mobilityatthejoints,andweof abnormalmeasuretakenof acutepublishedwithof normaltheflexionunderwith the rroentgenogramsin thethesehavestudiesOf the other four articles,one has beenmainingthree are now in preparationand andstrain-thatsuchBrooke,others*VOL.6typeof the articularthatthe normalbeyondmeasurementsbut thesein hologicalnormalandroentgenographicin eandextension)movementsof the spineandthatitsin the cadaveris 4 degrees.Clinicalrecordsof sacroless easy to find.A few surgeons,like Ryerson,haveIt is npubis,not foundmotion.Osgood,littlesacrolumbarthebeenis demon-articulation.withthe shapewho osure.mobilityvaryauthoraddi-uponUniversityofof the uppervery90lumbaruponandto mustany,A.B.,as r(flexionaveragemobilityiliac entsto thedoubtfirstwe studiedthatof lationtheis to showtheyresembleof sacrolumbarbut we havefacets,whommayB.S.,It is based‘.in theexaminationsfor entranceis limitedto a studyof theto thevertebrae,theyof fiveusedstudentszygapophysesdorsalC. PHEASANT,CALIFORNIAwell as in autopsymaterial.the literature,we have encounteredIn reviewinguntilMOBILITYHOMERof a seriesits purposeassacrolumbarANDrecordsmalephysicalIts scopevivo,of opinion506normalSACRALFRANCISCO,secondof tandof therecumbenthyperextension,thesamephasestitleof the11;there-subject:365

H. C. PITKIN366thisbutmethodof normalTheparallelssuitableH. C. PHEASANTforrapidexaminationsof largegroupssubjects.axisof normaltheof theis notANDplanesecondof thesacralsacralmotionbaseof thevertebrain theusuallysacrumis describedandtransverseaspassesplanea linethatthebodythroughof ldbe formedbytheuppercontinuingarcof isareanalogoustoflexionand extensionof the spine.Despitethatthethefactsacrumis apartof the to takeandbendingex-part inlateralmovementsof the spine,we havenot foundany authorwhodescribestheseFIG.1Lateralviewof (rotation)sacraldenymo-shapestheofsacrum(lateralor OFBONEorofaboutthetheAntagonisticANDJOINTSURGERY

SACRARTHROGENETICmotionsof thiswhentheborneuponbonesthetypeis flexiontheof theinnominatehipcenterof thespine,checkedarebonessymphysisthiswouldof ghpositionandthatatby tinuallythanonlybodyinnominateIn thesetrunk,of ‘thea transversepossibleof theof tedbe bar*.of proximatethecenterthe rough1 and2).arc of theWe haveofmeas-anterolateralroentgenogramstakenwiththe tmethodmeasuringitmeansIposi-butwea nters2of continuallyplanebisectsof thearethesurfacemounted,spaceof ftheis parallelfrictioncalipers.to a linethatconnectsthe tips of the calipers.The examinerappliesone tip of the* Six musclesact directlyuponthe sacrum.All othersmustact throughthe mediaof the spine and innominatebones.The erector spinae, the multifidusspinae, and theiliacusact as fiexors.The gluteusmaximus,the piriformis, and the coccygeusact asextensors.Noneof thesemusclesarisesfromthe sacrumalone,buttionaland usuallya moreextensiveoriginfromthe contiguousilium.maximushas sufficientstrengthor leverageto overcomethe weightcause the sacrumto extend.act upon the uscles2,APRILIts leverageis enhancedsimultaneously1936is increasedenormouslyimmobilizeeachtakesan addiOnlythe gluteusof the trunkand toby flexion of the hips.Its power toby contractionof the flexors of thebothitsiliacoriginanditsfemoral

368H. C. PITKINANDH. C. tsthedegrees;anof theaverageright.,intactiliacxfromtheilaneangleof ectanteiliacanis inThis1)osition.atheangleincreaseswith flexionat the hipsanddecreaseswithextension.In our seriesof 144 protractor.definedstandingleft,itsthisandof tweenplate.of theThe.--;,,:.:pendu-freethe Planeis Perl)endidularmay. .fr/theprotractorof useof inclinationdegrees;ain eeswereIn.antagonisticof thethemoveanglesofinclination.A *geneticexampleThepositionsanglesaveragewere:ofof theone-halfanglestodegrees;is foundstudents.iliaplaceinthreehisrightandin ions.footinheight,right,in our series of cases that showed9.6 degrees;average,8.6 degrees.of inclination7.6ofof thesubjectinchesof motiongroupinclinationeachleft,typeof ourrequestedandtelalgiaof thisexaminationhima blocktoJOURNALOFBONEANDJOINTofextendsacrarthroThe rela-ilia are reversed.TilEcx-SURGERY

SACRARTHROGENETICbothknees.the rightfollowing1.Thelatterinstructionpreventedthe left.The pelvis2.as a wholea pointmidwaybetweenshorteningof the longof the shortleft leg.3.Theleftwasinnominateboneinclinationing of theon the left and a tendencyshortleft leg by tionpelvisof avingnotedthehadexaminerbothfeetwaselevateda whole,left.wastoand relativelengtheningforwardaboutin ncreased.abductionof was3 degrees.Theextra-articular,totalof sely,axisof theinofgrouptwoiliailiaof oundposition,andthebeto19 degrees,wassacro-ischialthe case ofsymphysis,themeasurementswhenthe subjectwhenthe subject’sleft foot ationmobilityspreadfanwiselaterallyto respondingon the floor and, thein mpletedbones,wererotatedtheanto be rotatedhipwas is6.totalflexionpubis.of thebodiesthetowarda furtherof the left sacro-iliacsymphysistowardtowardThisboneof dductionabductionand relativewasaxis4.of theshiftedthe heels.rightleg andtransversehip,compensationknee.Examinationof the subjectsin this positiondisclosedchangesin the relationsof the skeleton:The rightacetabulumwasraised,-thatis, the cligamentsligamentsunilateralaverage1 1 degrees;iliacligamentsligaandopposeopposemotionon thatsacralaboutside* Thisspinal rotationis due in part to the forwardinclinationof the sacrumandoccurseven when both sacro-iliacjoints are solidly ankylosed.If the sacrumwere vertical, all of the pelvic tilt would be transmittedto the last lumbarvertebraas lateralbending towardthe side of the shorterleg.Because the sacrum normallyis inclinedforwardat an angle of 60 degrees with relation to the horizon, only two-thirdsof the pelvic tilt istransmittedto the last lumbarvertebraas lateralbending;one-thirdof the tilt is transmittedas rotationof the body of the last lumbarvertebratowardthe side of the longerleg.VOL.XVIII,NO.2, APRIL1936

-ischialflexionof ptrotateforwardligamentsmobilityandto; extensionof theupperthetheiliumiliaoccurs,it thussimultaneously;is beingthatrotatedis beingtrunktendsto holdof our therelaxwillandHowever,allowthethe sacroWhenan-backward.createsa needforandsacruma needforobviouslyit canextendof inclination,inclination,side.Thecannotandjoint8.a decrease.ligamentsandsacrumiliacflexangleto rotateof the sacrumon the side of increasingextensionof the sacrumon the decreasingand the weightof thenotedin the summarysacralopposesacro-iliacofthetwoof ntsligamentssacrumwillC.do onlyoneflexionof theseacts,it in flexion.Thus,as we haveof normalmales,the ilium thata greaterexcursionincreasedlumbarincreasedflexionof the sacrum.Whenan ilium rotatesforwardaboutthe symphysisits articularsurface,whichis slightlybehindthe centerthanlordosistheonereflectstheon a risingarc and is carriedsomewhatilarly,rotationof the iliumbackwardtranslatedbackwardand downward.upward,causesWhenpubisas a center,of motion,travelsas well as forward.Simthe articularsurfaceto beantagonisticiliac mobilityoccurs,the sacrumcannotremainsuspendedin mid-air,but is forcedbygravityto followany downwardor forwardmotionof the iia.Therefore,the articularsurfaceof the sacrum,on the side of the thumthat is rotatingTHEJOURNALOFBONEANDJOINTSURGERY

LALGIAsurfaceoppositeof thatsideiliumthattendsis causedto bendof theto rotatelaterallyiliumin its forwardsacrum,in a likebackwardand to rotateandmanner,anddownward.awayfrom theside on whichthe angleof inclinationis increasing.Theantagonisticmovementsof the ilia and the associatedmovementsof the sacrumcanbe demonstratedquiteeasilyby measurementsof resbyit is ngin whichtheiliaandthatrotationin thisbendinganddoes not differthe mpensationtestsTheiliaconeforofwhenbothto date.typeofsacro-iliacmotionand rotatorymovementselementis greaterin thesea lengthenedleg,perhapsand otherregularlyac-of the roblemjoint,normallyrespectthe rest of the presacralvertebrae,We have found,by inclinometric.forrotation,fromaxis.companiesall lateralbendingI)Becausethe volitionalthemo-fixed.membersand the sacrumfollowspassively.It shouldbe emphasizedthatlateralbendingnot occur alone,but as measuringseparatelyjointsIn casesarethemovable,of feitherbeanthesacroinsolublemeasurementsof iliac mobilityregularlyhaveshownless than2.0 degreesof totalantagonism(whichestablishesthe maximumerror inherentin this method).In cases of yof the woofwashandwe mademadethegroupof the dominantWhenstudents,ourrecordssides,ornormal4.8 degrees,andeyetomales,havethewhileto iliacmobilitydifferedaveragethatbyan-of theis interestingrightandmeasurementsofof iliac mobffityin the group ofhandednessand eyednessby Quinan’stheirand discoveredthe followingfacts:1. The dominanteye, primarily,and the dominanthand, secondarily,a decreasein the iliac inclinationon the same side in normalstance.‘2.stance,beof the doublyb.Theside whenthatc.less mobiledoubledominancedominantlargestis sionofonewith:thetwoto showtheusuallyilium,are associatedanglesof inclinationsmallerangle;the one on thein normaldoublydominantside is lowered;largestnet changefrequentlyfollowsTheiliumin the inclinationof the pelvis as a whole,sincetheratherthan opposesthe motionof the more mobileone.twovidual3. Right-eyednessilia.4. Left-handednessisexcursionsof the5.The largestnettwowiththe smallestVOL.XVIII,NO.istotal2, APRILwith the largest total antagonistic mobilityassociatedthe largestdiscrepancybetweenthe mdi-ha.changeantagonistic1936withassociatedof theintheinclinationmobilityof thepelvisas a wholeof the two ilia, and viceversa.is associated

)C)S0-‘2SL’0., .5SbC-SbS.5,C)‘--eSBSBBHI’B’C)L’S.-“-00 -‘2-:-B‘oBL’, .‘‘sI;’0B,-uSSB 2 #{149}I00bCC)bS.-U 0S.C)-C)S40B BL’ L’ .5bCV,5,SbCvi,SbOSbS ,S,S-BE-L’0,‘-.- .- 0L’U5,UI’L’L’BB,B-.L- 5,,bS‘-, ,.,bCbC‘-?-S.-zRBb,L’SC).i.)0S-0--uRB llC)C)61,.0L’B L’ ,S L’I0,B.S.L’C). 0.-BBSS000S0WIRIS.0.L’C). S00.t OINTSURGERY

SACRARTHROGENETICilium11.0was 6.2degrees.gia,thedegrees.In ourThisrepresentsgroupof cases um,and thegroupsshowsmobilitythatthethatof theof tnessof thewastobemobilityoftelal-increased; itsilium,7.6 degreesfor theA comparisonof the two‘.telalgia2.2degrees,theor 46.0averagepercent.;1 .4 degrees,or 23.0 per cent.by 3.6 degrees,or 33.0 perof 33.0familiar,abnormalpermobilityof maximumin mobilityfoundleftbyof an increaseis hrogeneticincreasedmobility,increasethanwithsideor a decreasedhaincreasedbywas increasedthe effectwhichheof itiesof thea totalshowed7.0 degreesfor thewas 14.6 degreesin theleftIf one will imagineof any jointwiththewastotal373TELALGIAwhenof theleftcent.in the mobilityhe will recognizetheentails.painbut,; andcent.mayshowwe consideriliumwasanthat23.0increasedin thispercent.seriesgreaterof the right,the acro-iliacligamentswas 14.0 per cent. more frequentleft side thanon the right.Thepatientscomplainedof telalgiatheoriginatingright.in iacjoint17.0 per cent.more oftenthan in theflexion‘#{176}wasmorelimitedon the left side 37.0 firstarticleof thisseries,weshowedthatsacrarthrogenetictelalgiain the lowerextremitiesis causedby pathologicaltensionof the extra-articularligamentsof the uppersacraltime we omittedall considerationof sacro-iliacmobility.betweenthe ilia,thethe incidenceof sacrarthrogenetictendernessof the sacro-iliacsourceof his pain,andthe tensionof thefeel thatabnormalsacro-iliacsacro-iiacbutcausealsoa potentsacrarthrogenetictheof thechangesin thejoints.At thatThe parallelismtelalgia,abnormalligaments,the patient’sresultsof thoseligamentsmobilitytestswhichis too strikingis not onlyabnormalmobilityopiniontendofofto increaseto be fortuitous.a itycanof the ilia.In the standingposition,be ghtheandextension,all motionsmovementsof the iliacenterof the symphysisVOL.mobilityXVIII.in f theare* Onlythe males were consideredin computingfigures more accuratelycomparable.The averagewas considerablygreaterthanin the normalgroup,thein vivobeentrunk,associateda transversethisby measuringwiththewithunpaired,axisaverage,in orderage of the individualsso that, all other factorsthegreater.thethatexceppassesto makethein this groupbeingequal,

ateralas correlatedof the EASANTof thethatantagonisticperH.sacrumarenormallydo notcoincidentaltoof the ilia in normalstance,as wellby the dominanteye and hand.average33.0ANDmotionsThe positionsare affected5.PITKINof the malein thosesubjectsnormalas theirrelativeilia is foundto bewho .Abnormalligamentoustensionsacro-iiacmobilityis a potentthatproducessacrarthrogeneticcauseof thetelalgia.abnormalREFERENCESI.2.ALBEE,F. H. : A Studyof the AnatomyIliac Joint.J. Am. Med. Assn., LIII,BREWSTER,A. H. : NelsonLoose-LeafThomasNelson& Sons.3.BROOKE,4.CHAMBERLAIN,R. : TheSacro-IJiac5.D.DERRY,7.8.9.Joint.Am.E. : TheInfluence11.12.(Leipzig),PITKIN,CaliforniaH. C.: Proneand West.PITKIN,H.ANDPain.QUINAN,CLARENCE:III,in 1924.Examinationof the1930.andCompositionof theHumanE.Surg.,I, 1, 1878.KneeMed.,W.:In Differential51, 1933.DiagnosisH. C.: Sacrarthrogeneticand Joint Surg., and Psychiat.,Surgical154, Jan.SASHIN,DAVID:A Criticalof theSacro-IliacJoints.Treatment1932.andEyednessof LowTelalgia.PHEASANT,J. gery,XXIV,on theof the Sacro-ImportanceLondon,PubisJ. Roentgenol.,of SexLivingJ. Anat.,SymphysisClinical1909.and Physiol.,London,XLVI,184, 1911-1912.GOLDTHwAIT,J. E. : The Lumbo-SacralArticulation.An Explanationof ManyCases of “ Lumbago“,“Sciatica“,and Paraplegia.BostonMed. and Surg. J.,CLXIV,365, 1911.GOLDTHwAIT,J. E., AND OSGOOD,R. B. : A Considerationof the PelvicArticulationfroman Anatomical,Pathologicaland ClinicalStandpoint.BostonMed.andSurg. J., CLII,593, 634; 1905.KLEIN,G.: Zur Mechanikdes Ileosacralgelenkes.Ztschr. f. Geburtsh.u. Gynakol.,XXI,74, 1891.MEYER, G. H.: Der Mechanismusder Symphysissacro-iiaca.Arch. f. Anat. u.Physiologic10.Joint.E. : ThetheJ. LPain.I. A Studyof1936.SpeedersXXV,829, 1931.of Low BackDisabilities.Analysis of the AnatomyJ. Bone and Joint Surg.,BackandofRecklessJ. Boneandand the PathologicalChangesXII, 891, Oct. 1930.OFBONEANDJOINTSURGERY

tilt of the pelvis toward the left. Thus the lumbar spine showed a scoliosis that was convex toward theleft. 6. The lumbar lordosis usually wasincreased. 7. The vertebral bodies rotated toward the right side,-that is, toward the concavity ofthe scoliosis ‘. 8. Thetrunk, asawhole, tended tolist toward the right.

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