OMM, # 33
Monday, March 24, 4:00pm
Dr. Williams
Deana Mitchell for Jennifer Hurrell
Page 1 of 4
Treatment of Pubic Shear & Innominate Flare
Important Notes:
1. Always make sure that you lateralize before doing any treatments. Practice, practice,
practice. This heavily affects your diagnosis and treatments.
2. When comparing, use your dominant eye. Remember when we discussed this at the
beginning of the year?
3. When doing muscle energy, it’s a good idea to tell the patient to use 1/3 or ½ their
strength. Don’t get hurt!
4. All of these techniques are in the Kimberly manual The motion principals for the pelvis
are described on pages 13-14, and the actual treatments are located in chapter 10 on pages
185-210.
Compression of Pubic Symphysis
1. Definition: The pubic bones are forced toward each other at the pubic symphysis.
2. Another name for this is Pubic Adduction. Thus, the pubic bones are both adducted
towards each other. This is not a term that is used frequently.
3. Characteristic Findings
a. Tender over symphysis bilaterally.
b. Lack of apparent asymmetry.
c. Restriction of motion at the pubic ring and around the pubic area. The pubic
bones are pushed together and just not moving as well.
d. ASIS springing affected bilaterally (both sides do not spring easily).
e. This is common with pregnant women; the hormone relaxin can cause the
innominate/pubic symphysis to slip out and move abnormally.
4. NOTE: Pubic shears are usually associated with pubic compression. It’s a good idea to
decompress the pubic bones prior to treating a shear. You should do this to prepare the
area for treatment.
5. Treatment: Pubic Decompression, Muscle Energy
a. Pt. should be supine on the table with their knees and thighs flexed.
b. Pt’s feet should be flat and 10-12 inches apart.
c. Grasp both knees. Instruct the patient by stating, “Try to pull your knees apart.”
(This causes the abductor muscles pull laterally on innominate, compressing
the symphysis further to prepare it to relax.)
d. Repeat.
e. Next, have them separate their legs.
f. Pt’s feet should still be 10-12 inches apart. The heel of one hand should be in the
knee, while your posterior distal humerous is in the other knee.
g. Instruct the patient by stating, “Try to pull your knees together.”
h. Repeat. (average repeat is 3 times.)
i. You can also instruct the pateint to move his/her pelvis off of the table while they
pull their knees together. This is more work for the patient though.
Superior Pubic Shear
1. Definition: one pubic bone (one whole side) is displaced superiorly compared to the
other as related to the side of lateralization.
2. Etiology involved:
a. Trauma
b. Tight rectus abdominus muscle
3. Characteristic Findings:
OMM, # 33
Monday, March 24, 4:00pm
Dr. Williams
Deana Mitchell for Jennifer Hurrell
Page 2 of 4
a. First, do the lateralization tests to determine the involved side: ASIS
compression, standing and seated flexion. The best of 2/3 will give you your side
of lateralization for the patient.
b. The pubic bone is superior on the involved side.
c. There is generally a positive standing flexion test on the involved side.
d. ASIS is superior.
e. PSIS is inferior.
f. ASIS compression is restricted on the involved side.
g. It is tender to palpation over the pubic ramus.
h. NOTE: If you have a superior pubic shear, you will have a posteriorly rotated
innominate as well. However, you can have a posterior innominate without
having a superior pubic shear.
4. Treatment:
a. Pt. is supine with the DO on the dysfunctional side between the table and the leg.
b. Stabilize the opposite ASIS with your hand.
c. Have the patient move laterally until his/her ischial tuberosity is at the edge of
the table.
d. Abduct the knee to gap the symphysis.
e. Extend the thigh. This rotates the innominate anteriorly and carries the
symphysis inferiorly.
f. Instruct the patient to, “Lift knee towards the ceiling.”
g. Wait 3-5 seconds.
h. Extend the thigh to the new barrier. When you do this, you are accomplishing
two motions: Push the patient’s leg against the floor and extend it more with your
leg.
i. Repeat on the average of 3 times until best motion occurs.
j. Recheck.
Inferior Pubic Shear
1. Definition: one pubic bone is displaced more inferiorly than the other.
2. Etiology:
a. trauma
b. tight adductors
3. Characteristics:
a. Pubic bone inferior on involved side.
b. ASIS inferior on involved side.
c. PSIS superior on involved side
d. AP compression test restricted on involved side.
e. Positive standing flexion test on involved side.
f. Tenderness to palpation over pubic symphysis.
g. When a patient says that their hip is hurting, this may be what is wrong, even
though it is really not the correct medical definition of the hip.
h. NOTE: If you have an inferior pubic shear, then you will also have an anteriorly
rotated innominate. You can have an anterior innominate without a inferior
pubic shear.
4. Treatment:
a. Pt should be supine with the DO on the side of the dysfunction.
b. Flex lower extremity at knee and hip and abduct thigh to gap pubic
symphysis.
OMM, # 33
Monday, March 24, 4:00pm
Dr. Williams
Deana Mitchell for Jennifer Hurrell
Page 3 of 4
c. Place knee against chest, cup cephalad hand against ASIS, grasp (or cup) the
ischial tuberosity with other hand. (This rotates innominate posteriorly to carry
pubic symphysis superiorly.)
d. Instruct the Pt to, “Push knee toward end of table against my chest.”
e. Move innominate to new restrictive barrier. When you are doing this, flex and
gap the patient more. You should be abducting their leg/knee more as well as
pushing the knee superiorly and posteriorly into the patient’s body. As you flex,
you are really taking the innominate and rotating it posteriorly (into the barrier),
as well as gapping the pubic symphysis.
f. Repeat until best motion. (approx. 3 times.)
g. Recheck.
Innominate Inflare
1. Definition: a condition where the innominate will rotate medially on a vertical axis.
a. You usually don’t see a lot of these.
b. Use the umbilicus as your reference point. This usually represents the midline.
c. Use your thumb and finger to estimate the length from each ASIS to the
umbilicus. You can use a measuring tape if you want. Dr. Williams suggested
measuring your hand, or measuring your thumb to your index finger, so you will
have a better estimate of your patient.
2. Physical Examination Findings:
a. ASIS more medial on involved side. (lateralized side.)
b. Use the umbilicus as reference point for anatomical midline.
c. Positive standing flexion test on involved side.
d. Ischial tuberosity farther from midline.
e. Tender over SI or pubic symphysis.
3. Treatment:
a. Pt. should be supine with the D.O. on the dysfunctional side.
b. Hip & knee partially flexed, foot on table close to buttocks.
c. Stabilize opposite ASIS. This is VERY important, especially in older patients.
A good thing to say to your patient is, “Don’t worry, you’re not going to fall,
you’ll hit me if you do and I’ll hold you up.”
d. Move knee laterally abducting thigh to innominate’s restrictive barrier.
e. Instruct the pateint to, “Move knee toward middle of table.”
f. Wait 3-5 seconds & abduct thigh to new restrictive barrier. You are treating in
an outflare mode when you do this.
g. Repeat until best motion. (usually 3 times.)
h. Recheck.
Innominate Outflare
1. Definition: a condition where the innominate will rotate laterally on a vertical axis.
2. Physical Examination Findings:
a. The side that lateralizes is the involved side.
b. Use the umbilicus as a point of reference for the anatomical midline.
c. ASIS more lateral on involved side.
d. Ischial tuberosity nearer the midline.
e. Tender to palpation over SI or pubic symphysis.
OMM, # 33
Monday, March 24, 4:00pm
Dr. Williams
Deana Mitchell for Jennifer Hurrell
Page 4 of 4
3. Treatment:
a. Pt. should be supine while the D.O. is on the dysfunctional side.
b. Pt’s knee & hip should be partially flexed.
c. Grasp the patella with one hand and hook fingers of the other hand over medial
margin of involved PSIS.
d. Move knee medially adducting thigh to restrictive barrier.
e. Instruct the Pt to, “Move knee outward.”
f. Wait 3-5 seconds and adduct the thigh to new restrictive barrier by pushing the
knee more medial. You are treating in an inflare mode when you do this.
g. Repeat until best motion. (average of 3 times.)
h. Recheck.