Hesch Institute Presents:: Quotation

TITLE OF WEBINAR
Is it time for a major shift

in how we interpret
sacroiliac joint biomechanics,
Hesch evaluation, and treatment?
Institute
Presents:
Hesch Method
Hesch Method
1 2
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Yes, It is remarkably
long overdue.
Website: HeschInstitute.com
Hesch Method Hesch Method
3 4
QUOTATION Origins of the Sacroiliac Joint

Dysfunction Model
“Fortunately, biomechanical The traditional physical therapy model of
research into the pelvic girdle is pelvic joint pathomechanics can be traced
increasing and, as new knowledge to a landmark 1958 article by Fred
is acquired, the theoretical Mitchell, Sr, DO titled Structural Pelvic
construct provided here may well Function, in which he culled several
need modification.” disparate writings on the pelvic joints
bringing them together into a cohesive
Philip E. Greenman D.O. whole.
5 6
CPTA Virtual Conference 2020 1

Origin of Muscle Energy Technique (MET) This biomechanical model has infiltrated
far and wide and is found in other
Muscle Energy Technique (MET) writings of his osteopathic texts and physical therapy
son Fred Mitchell Jr. DO, whose first MET texts, articles and continuing education
workbook was written in 1973 with Moran, & programs. Incredibly, much of the
Pruzzo. mythology from this work continues to
infiltrate PT practice today.
7 8
In standing and walking the sacroiliac joint

(SIJ) assumes a stable position and very The model taught by Hesch Institute
minimal movement occurs as has been negates three patterns in the traditional
validated with several stereophotogrammetry model as they are untenable:
studies. Reality informs that in weight-bearing
the entire movement of the pelvis occurs • Unilateral sacral flexion
primarily with the articulation of the trunk
• Unilateral sacral extension
including muscles, lumbar facets, disc, and
ligaments, and with the pelvis as a unit moving • Upper pubic rotation (axis on lower part of
symmetrically or asymmetrically on the joint)
femoral heads.
9 10
The model taught by Hesch Institute Advanced palpation is utilized, and
recognizes 12 patterns of pelvic movement treatment consists of a passive fulcrum with
dysfunction which are not reported in the mild force application sustained for a
body of literature on the sacroiliac, pubic minimum of 2‐minutes, sometimes 5‐
joint and sacrococcygeal joint. minutes
11 12

With standing trunk or hip flexion tests or
sitting spine flexion tests the intrinsic SIJ
Every movement dysfunction has a self‐ movement is so negligible such that it
treatment technique such that the clinician
cannot reasonably be perceived with
does not have to perform passive care and by
2nd day the patient is independent in visual observation, therefore, the
managing that aspect of their rehab. 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.
13 14
It appears that knowledge regarding how Multiple studies on SIJ movement using the
the entire pelvis moves (absent movement standard of the industry which is
stereophotogrammetry, including symptomatic
occurring inside the SIJ) is absent or is
populations has consistently demonstrated very
minimally addressed in the education of minimal movement in the SIJ. Specifically,
physical therapists. A fundamental there is less than 2-degrees rotation and less
reinterpretation of lumbopelvic-hip than 2mm of glide in the frontal, sagittal and
biomechanics is encouraged. transverse planes.
15 16
How Can We Improve Palpatory Accuracy?
This small amount of movement cannot be objectively  Use minimal palpation in standing because standing

evaluated in the rehab setting, it cannot be quantified, has increase in muscle tone whereas sitting, prone and
and it is imperative that our language accurately supine have less muscle contraction and less
reflects that reality and that nocebo messages are compensatory patterns.
avoided regarding “joint dysfunction.” The rehab  Discard the iliac crest based on multiple studies with
profession needs to embrace contemporary studies and low intertester reliability
the explanatory model for what we encounter and treat  Instead, palpate the rather flat anterior iliac shelf (flat
in the clinic needs to evolve. portion just above the ASIS)
 Palpate anterior upper, middle and lower pubic bone
17 18

Palpation continued
 Palpate the top of pubic bones when hips and knees Practice palpation skills
are flexed (supine) to relax rectus abdominus and
reduce false positives Form a palpatory practice group
• Palpate the flat portion of the ischium (prone)
• Palpate the medial aspect of the ischium
• Use the Rule of Thirds to improve accuracy
19 20
Books on Palpation
MOTION OF THE BONY PELVIS
• Palpation and Assesment in Manual Therapy
• Palpation and Assesment in Manual Therapy
• Trail Guide of the Body  Is considerably greater than SIJ motion
• Palpatory Literacy
• The Muscle and Bone Palpation Manual  Is measured in inches, or centimeters, of
• Palpation Technique
glide, i.e. side-bending (hip hiking and hip
• Anatomical Landmark Palpation
• Clinical Guide to Musculoskeletal Palpation: A Clinical Guide
drop)
• Field's Anatomy, Palpation and Surface Markings
• Color Atlas of Skeletal Landmark Definitions E‐Book:  Is measured in large degrees of rotation, using
Guidelines for Reproducible Manual and Virtual Palpations double digits
21 22
Pelvis? Sacroiliac?
The bony pelvis The bony pelvis
is a separate has its own set of
structure from biomechanical
the sacroiliac rules
joint
23 24

What we see regarding bony landmark
asymmetry of the pelvis is due to:
• Many Professions Including Physical • Asymmetrical muscle control
Therapists confuse pelvic mechanics • Asymmetrical movement of the entire pelvis on
the femoral heads and movement with the
and ascribe pelvic pathomechanics to femeroacetabular joints
the sacroiliac joint. • Leg length asymmetry
• Developmental asymmetry of the hip, pelvis,
• Linguistic problems regarding pelvic
spine
motion versus purported SIJ motion. • Developmental or movement asymmetry in any
lower extremity joint
25 26
NAVIGATING THE LINGUISTIC DIVIDE

Please remember that there are several patterns of
Solution to the linguistic problems regarding symmetrical pelvic movement dysfunction.
pelvic motion versus purported SIJ motion.
 Whenever possible clarify when there is objective evidence for Therefore, it is relevant to perform passive spring‐

pathological motion (x-ray, CT, MRI, fluroscopy, digitized x-ray, etc). recoil testing on pelvises that appear to be in “correct
 Otherwise, suggest general terminologies that express a system of alignment
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.
27 28
The Palpation Rule of 3’rds Research: Traditional Evaluation

(Joint) False Tests
 Standing spine
flexion
 Standing hip flexion
 Seated flexion
 Long sit
 Prone knee bend
29 30

Don’t drink the
Standing posture invokes pelvic alignment
compensation, whereas gravity‐reduced Kool aide!
postures such as prone and supine
more accurately represent what is We must follow the science and stop
actually happening, it gets to the core believing that we can palpate pelvic
pattern without overlying obfuscation. bony landmarks and ascertain 2mm of
glide or 2‐degree of rotation inside the
Standing posture does not predict
sacroiliac joint. We cannot.
mobility and stability.
31 32
 We cannot isolate motion INSIDE the Asymmetrical motion or asymmetrical

SIJ by touching and observing pelvic position of pelvic landmarks only tells
bony landmarks in different postures us the entire pelvis is asymmetrical, it
and with movement of the spine or cannot, it does not tell us about
hips. asymmetry INSIDE the SIJ!!!
33 34
We can only discern motion that
Hesch Method utilizes 16 basic spring
traverses THROUGH the SIJ
tests evaluate motion going
determining hypmobility or
THROUGH the sacroiliac joint.
hypermobility with passive spring‐
recoil tests.
35 36

The spring tests determine if the
motion going THROUGH the SIJ, and
if it is hypomobile or hypermobile, and
Passive Spring-Recoil Micromotion Testing guides appropriate treatment, and
determines when stability and normal
mobility are achieved therapeutically.
37 38
Please realize that these test do not, cannot validate a
These tests are very similar to ligament correctable shift inside the SIJ such as “the ilium
stress tests applied to other joints of the rotated on the sacrum and got stuck. Motion being
blocked from traversing through the SIJ is probably
body. An arbitrary example would be the very oftentimes due to phenomenon extrinsic to the SIJ
Lachman’s anterior drawer test used to such as:
test integrity of the ACL. 1. Altered hip, pelvis and lumbar posture
The primary purpose of the pelvic spring- 2. Alteration in muscle tone
recoil tests is to evaluate mobility, or lack Why is this a high probability as opposed to the
of mobility or hypermobility. traditional theory of a rotation intrinsic to the SIJ?
39 40
Because the author has seen many, many x‐rays
showing pelvic asymmetry and in the MRI, there was How to Perform a Spring-Recoil Test
perfect congruency inside the SIJ in all images in the
frontal, sagittal and transverse planes.  Take up slack pushing on the pelvis in a specific
direction using an average of 15 lbs
Also, research has shown in several studies that
 Keep the slack taken up throughout the test
treatment does not alter the position within the SIJ,
and the same is true of extremes of posture and again,  Perform a forward spring which takes less than a
motion in the joints, even in symptomatic population second
is negligible, typically less than 2mm of glide and 2‐  Pay attention to the amount of forward movement and
degrees of rotation. There are exceptions such as severe pay attention to the recoil
trauma and this population is not ambulatory.
41 42

INSERT VIDEO ON SPRING‐RECOIL TEST
TECHNIQUE AND DESCRIBE
1. Normal test These passive spring‐recoil tests are
2. Able to take up slack but no spring motion
much more relevant than simply
interpreted as hypomobile (blocked motion)
3. Unable to take up slack (blocked motion)
looking at alignment, whether in static
4. It takes longer to take up the slack and forward or dynamic contexts.
spring and recoil take longer and are weak. This
hypermobility can be positional and corrects with
treatment, also can be due to muscle inhibition nd
is rarely due to ligament damage
43 44
This model also screens for

 This model DOES thoroughly
developmental asymmetry which appears
correct alignment but goes much
to be significantly under-represented in
further than that in improving joint
the traditional model.
function. It seeks to normalize both
mobility through the pelvis and also
improves stability through a variety of
mechanisms.
45 46
The traditional model of manual therapy uses a

GOOD NEWS!!! six-point mobility scale and it gets dubious with
 Traditional model of manual therapy uses a the use of +/- or ++/- -
six-point mobility scale and it gets dubious
Hesch model greatly simplifies mobility testing
with the use of +/- or ++/- -
with interpretation being Mobile/Normal,
o Hesch model greatly simplifies mobility Hypomobile (blocked mobility), or Hypermobile.
testing with dichotomous scale of: These are easily discerned, and avoids subtlety,
o Mobile/Normal, Hypomobile (blocked greatly enhancing confidence of the clinician
mobility), or Hypermobile, which is easily
discerned and avoids subtlety
47 48

Treating the direction of blocked
mobility/hypomobility gives “the biggest
bang for your buck”, is much more efficient
and efficacious than chasing subtleties. Sacroiliac Pain Provocation Tests
It is a much simpler model and has greater
intra and inter tester reliability and greatly
enhances confidence of the clinician
49 50
False Tests: Pain Provocation • Distraction/compression (rarely
positive)
What do they really tell us?
• Patrick Faber (force initially goes
• Thigh thrust (force goes through the through hip). Does it truly isolate the SIJ
hip), only with careful positioning is the and hip or does some force traverse the
posterior SIJ ligamentous complex isolated. lumbar spine?
It is unknown whether or not the include
• Gaenslen’s (force initially goes through
the lumbar spine, truly isolate the SIJ, and
hip) ). Does it truly isolate the SIJ and hip
force certainly traverses the hip
or does some force traverse the lumbar
• PA spring on sacrum (initially isolates spine?
L5‐S1 facets)
51 52
If three or more tests are positive (produce
pain) it predicts a positive response to
 We do not need to produce pain in
intraarticular SIJ injection, typically
performed under fluoroscopy. We will order to be given permission to treat a
elaborate on injection when we discuss pain, symptomatic or an asymptomatice
especially concerns regarding specificity. biomechanical dysfunction of the
lumbopelvic‐hip complex.
53 54

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

Hesch Method
55 56
PUBIC JOINT DYSFUNCTION,

SEPERATION/DIASTASIS
• Exercise
Placement of sacroiliac low at the level of
• Pelvic Support, the trochanters is a standard of care which
has good research support in cases of pubic
• General Intervention 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.
57 58
PELVIC SUPPORT • Shifting the medial compression force of

100N in steps of 10N to the greater
• Some studies support high position some trochanter did not change the muscle
studies support low position at level of activation pattern but further increased SIJ
trochanters in which 40% greater joint compression force by 40% compared to coxal
compression was achieved.
compression.
• Try both positions!
• 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
59 60

• Pelvic belts alter sacroiliac joint motion and Recommendations include rest and pelvic
provide partial relief of ligament strain that is supports as basic treatments. Additionally,
subjectively marked, although minimal in absolute the few clinical trials reported
terms. These findings confirm theories that recommended additional physiotherapy,
besides being mechanical stabilizers, the including strengthening and stabilizing
sacroiliac joint ligaments are likely involved in exercises, to reduce SPD symptoms.
neuromuscular feedback mechanisms. Urraca-Gesto MA1, Plaza-Manzano G, Ferragut-Garcías A, Pecos-Martín D,
• Sichting F1, Rossol J, Soisson O, Klima S, Milani T, Hammer N. Pain Physician. Pelvic belt Gallego-Izquierdo T, Romero-Franco N. Diastasis of symphysis pubis and
effects on sacroiliac joint ligaments: a computational approach to understand labor: Systematic review. J Rehabil Res Dev. 2015;52(6):629-40. doi:
therapeutic effects of pelvic belts. 2014;17(1):43-51. 10.1682/JRRD.2014.12.0302.
61 62
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 • Hip and Knee Relation to Sacroiliac
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
63 64
• The following study supports the A significant number of patients meeting strict
evaluation of hip rotation as part of diagnostic criteria for SI joint pain had
radiographic evidence of femoroacetabular
a thorough SIJ evaluation. Although
impingement (FAI) and hip arthrosis. The clinician
research is lacking, hip motion also
should maintain FAI in the differential diagnosis
includes the evaluation of hip when investigating patients with buttock pain.
extension.
• Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral Morgan PM1, Anderson AW, Swiontkowski MF.Symptomatic sacroiliac joint
hip rotation range of motion asymmetry in patients with disease and radiographic evidence of femoroacetabular impingement. Hip
sacroiliac joint regional pain. Spine. 1998, 1;23(9):1009-15. Int. 2013 Mar-Apr;23(2):212-7. doi: 10.5301/HIP.2013.10729.
65 66

• 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.
67 68
SIGNS AND SYMPTOMS NEW RESEARCH
Subjects: 24 healthy pregnant

women
• Lumbar dysfunction
Age 20-38 years
• Pelvic dysfunction Visual analogue scale for pain
Number of visits: 3-6
69 70
RESULTS
ADL’s Parameter Initial Discharge
• Function Pain 7.3 1.9
ADL’s 62.7% 76.1%
• Sports/Recreation Work 60.7% 80.3%
Sports/Rec 51.8% 78.7%
• Rx: Hesch only
71 72

RESEARCH
OLSON MASTER’S THESIS
Traditional method of evaluation has poor intra-
rater and inter-rater reliability • ESTABLISHING THE RELIABILITY OF
Hesch research THE HESCH METHOD’S SPRING AND
POSITIONAL TESTS IN PATIENTS
Olson 70% intratester reliability
WITH LOW BACK PAIN.
Showed pain relief after one visit-study by Olson
• Olson, L. TJ; Finch University of Health Sciences:
Chicago Medical School, Chicago, IL, USA.
73 74
DETAILS
RELEVANCE: Pursuing clinical success in
PURPOSE: A long-term controversy reducing LBP symptoms has often served as an
exists regarding the influences of pelvic
impetus to deliver treatments directed to the
joints on low back pain (LBP). The
purposes of this study were to: 1) assess pelvic joints. However, determining reliable and
the intratester reliability of the Spring useful pelvic mobility evaluation and treatment
tests utilized in the Hesch method, and techniques remains largely unexplored and
2) to determine the intratester reliability
of the 15 positional tests of the Hesch
underreported.
method.
75 76
METHODS: A pilot study was employed to

SUBJECTS: Twenty-eight subjects (ages 25-67) determine the reliability of force delivery
volunteered to participate in this study. All during treatment. Two steps were involved: a
subjects were recently diagnosed as having positional exam and pelvic Spring tests. Data
mechanical low back pain of possible SIJD was collected 3 times: prior to treatment,
immediately post treatment, and 2 weeks post
origin. The lottery technique randomly assigned
treatment. Treatment for the experimental
subjects to either the experimental or control group consisted of gentle mobilizations; for the
groups. control group, mock treatments involving
appropriate hand placement but no force.
77 78

RESULTS: Only 6 of the 10 Spring tests
ANALYSES: Cohen’s weighted Kappa was demonstrating fair to good reliability (Kappa =
used to assess intratester reliability of .441.666). Seven of the 10 Spring tests
both Spring and Positional tests. The demonstrated better than 70% agreement. Of
Spring tests were evaluated to be the 15 Positional tests, 3 demonstrated
hypermobile, normal, or hypomobile. The excellent reliability (Kappa = .781-.868) with 4
indicating fair to good reliability (Kappa = .429-
positional tests were also evaluated on a
.639). No single test had less than 60%
3-point scale although the labels varied agreement and 12 of the 15 positional tests
depending on the area assessed. demonstrated better than 70% agreement.
79 80
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.
Hesch Method
81 82
NERVOUS SYSTEM
 PAIN  SIJ Innervation Spans L2‐S2
 Joint mechanoreceptors type 1, 3, 4
 FUNCTION AND DYSFUNCTION
 Sympathetic nerves,
AND THE NERVOUS SYSTEM
parasympathetic in close proximity
83 84

Table 1. CLASSIFICATION OF ARTICULAR PELVIC JOINT RECEPTORS
RECEPTORS / MECHANORECEPTORS
Type I
Type II
Type III
Type IV
Wyke, also Sakomoto,
and others, 1972, 2010
85 86
PELVIC JOINT RECEPTORS PELVIC LIGAMENT-MUSCLE

SI Ligaments : FUNCTION PARADOX
97% nociceptors
Ligament – Muscle
3% proprioceptors
(Sakamoto 2001)
Muscle – Ligament
Histologic Study on Nerves
(Szadek 2009)
Clinical Gem: Treat Both!
87 88
SYMPHYSIS INNERVATION
Pudendal,
Ilioinjuinal,
Iliohypogastric,
Genital Portion: Genito-
Femoral
•(Becker 2010)
89 90

R. Maigne (Paris 2006)
A) Distribution of the spinal nerves T12 and L1
1. Anterior ramus
2. Posterior ramus
3. 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.
91 92
Are SIJD pain patterns unique?
 No! they are very similar to low
back, gluteal, hip, abdominal pain
patterns
93 94
CONTINUED
CONTINUED
 unlike lumbosacral pain which is at
 Some suggest that sij mediated pain is the waist and above
drawn below the waist
95 96

CONTINUED Continued
CONT.
 Oftentimes pain of sij original refers
 Oftentimes pain of sij original refers to
to buttock, hip (anterior, lateral,
buttock, hip (anterior, lateral,
posterior), inguinal area involving the
posterior), inguinal area involving the
iliacus or psoas, and the lower
iliacus or psoas, and the lower extremity.
extremity.
97 98
Continued
CONT.
 SIJD does not cause severe lancinating
 SIJD does not cause severe lancinating sciatica sciatica below the popliteal space, in spite
below the popliteal space, in spite of any belief of any belief otherwise.
otherwise.
 Again, discerning between sij mediated
 Again, discerning between sij mediated pain pain and lumbar mediated pain is difficult,
and lumbar mediated pain is difficult, except except that sciatica below the knee is
that sciatica below the knee is attributable to attributable to lumbar spine.
lumbar spine.
99 100
PAIN PROVOCATION TESTS
Continued
 are they a necessary permission‐
granting process in order to treat?
 Hesch method respects pain and is
primarily a biomechanical model  no, not in a preventative and
biomechanical model
101 102

 Furthermore, caution is urged and pain
provocation tests directed to the SIJ Are the
PAIN PROVOCATION TESTS same as
 Hip (femeroacetabular) pain provocation tests!
 This yields considerable room for thought,
dialogue, cautious interpretation and further
research
103 104
ANTERIOR SIJ COMPRESSION TEST COMPRESSION IN SIDE LYING
105 106
ANTERIOR SIJ DISTRACTION THIGH THRUST
107 108

HESCH MODIFIED THIGH THRUST
FABER TEST
109 110
GAENSLEN’S
 Finally, a pain provocation that is directed
to the sacrum/sij, although, it also affects
the lumbosacral articulations. Caution
urged!
111 112
SACRAL THRUST
113 114

INNOVATIVE AND EFFECTIVE
TREATMENT TO RESTORE NORMATIVE
FUNCTION IN:
 the pelvis
 sacroiliac
 symphysis pubis
 hip
 lumbar spine
115 116
A CONTEMPORARY ALTERNATIVE The Hesch Method vs. Traditional
Methods
to the traditional model, providing a  More palpation
logical, integrative system:
 Most palpation on stable surfaces
which quickly and efficiently improves
patient outcomes.  Separates pelvic biomechanics from
sacroiliac biomechanics
117 118
CONTINUED CONTINUED
 Passive motion testing to grade mobility
 Less reliance on pain provocation
 Less reliance on pain in general
tests
 Reinterprets some fundamental
 Less trust of standing presentation
biomechanics
 Distrust of gross SI motion tests
 Clearer language
119 120

CONTINUED Assessing Hesch Technique for
your patient
 Treatment approach is very unique using  You should know if this approach is
working in 1‐3 visits.
low‐load, long‐duration force application
It works It works if combined with
 Heavy on self‐treatment other PT approaches
It works if combined with It doesn’t work

 Manual techniques only performed on other medical or
alternative approaches
initial 1 to 2 to 3 visits
121 122
INDICATIONS AND CONTRAINDICATIONS

FOR TREATMENT
TREATMENTS
Contraindications from Grieve
 External Force to correct (1976)
 Viscoelastic nature of corrective tissue Stoddard’s Warning Signs (1980)
Creep, (deformation over time) Patient rapport
 Workbook indicates when HEP is Patient response
needed
Poor response after 3 treatments
Treat in pain‐relieving direction
123 124
Evaluation
and
Treatment
Demonstration
Hesch Method
125 126

BEFORE THE MOST COMMON
PATTERN YOU MUST SCREEN Hip Internal Rotation Restriction
Hip Internal Rotation

Hip Extension
Pelvic Side-glide
127 128
Research versus clinical relevance: Do we do what

the literature dictates or do we use our
intelligence?
Good intra-tester Many clients have

reliability with prone normal prone hip IR but Hip Extension Restriction
testing of hip IR restricted supine hip IR.
Piriformis syndrome Supine IR testing
proposes prone testing addresses all external
of hip IR rotators.
129 130
Hip Extension Restriction

Limited hip extension creates false-
Sometimes clients compensate efficiently positive traditional sacroiliac tests.
and lack of extension is not visualized with
Note: Thomas test does not clear hip
posture and gait analysis.
extension, it is only a muscle length
Therefore, you must always specifically test test. You still must test prone
hip extension, always. extension.
131 132

Hip: Limited Extension
Hip Limited Extension: Supine
SUPINE
Femoral head in posterior glide and flexion Patella will not lift
Anterior mid and distal femur will be Prone-Post glided femoral head
prominent
Femur lacks A-P spring Limited PROM: extension (prone)
133 134
Hip Extension Restriction
Normal
Restricted
Treat
Still Restricted
Pelvic Side-glide Restriction
Corrected (very rare)
Re-treat
Screen for Pelvic Side

Glide
Still Restricted
Fixed Deformity
135 136
The Most Common Pattern

Physiological versus non-physiological
joint movement dysfunction
The MOST COMMON PATTERN Physiologic: Can move farther into

LUMBOPELVIC MOTION the pattern. Example: Anterior Ilium
DYSFUNCTION Non physiologic: Cannot move further
into the pattern. Example: Upslip
Ilium.
137 138

Left Posterior Pubic Bone Left Sacral Rotation
 Definite step-off going right to left
across fibrocartilage, mutable. More
 True joint fixation is probably very rare.
common in the female population.
 Muscle tone is increased on one side.
 80% are not a true posterior fixation,  Usually motion is blocked, and left side
there is no step-off.
prominent due to spasm or guarding of
 Spring Tests: only in Advanced Hesch the segmentally innervated Multifidi and
method. Erector Spinae muscles.
 Create a postural fixation with towel

roll under left ilium, placed vertically
139 140
Continued, Left Sacral Rotation Left Sacral Side Bending

 Landmarks: Entire left side prominent
 Palpate S1-S2-S3-S4 bilaterally, 1”
away from midline
 Spring Tests: Ulnar border of 5th
metacarpal on left side. Mid
metacarpal medial to PSIS, so you
 Spring Tests spring above and below, thus
encompassing S1-S2-S3
 Create a postural restriction by
 Create a postural fixation; have
placing a towel roll under the left partner hip-hike (ilium) on right side
ilium in prone. in prone
141 142
RIGHT ANTERIOR ILIUM Left Posterior Ilium

 Landmarks  Landmarks
 Spring Tests  Spring Tests
 Create a postural fixation by placing  Create a postural fixation by placing

a towel roll horizontally across the a towel roll horizontally under the
right posterior iliac shelf (above PSIS) left ASIS in prone.
in supine
143 144

Inflare Outflare
Right Type 1 Inflare/
Left Type 1 Outflare  CAUTION: springing in supine is very
unreliable.
 Landmarks  Always do Springing with Awareness in

prone for inflare/outflare.
 Spring Tests
 To create a postural fixation, place a
towel roll vertically under the left ilium
(ASIS) in prone.
145 146
TYPE 2 LUMBAR FLEXION DYSFUNCTION
 Landmarks
 Tests
SACRAL
TORSION
Hesch Method
Hesch Method
147 148
Name That Axis 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
149 150

Sacral Torsion
LEFT RIGHT
 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.
151 152
153 154
Sacral torsion: side bending and rotation

occur in same direction or in opposite
direction.  Newway to name torsion
example: Left Lower Quadrant
You do not have to memorize the ways in
Prominent and Stuck
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.
155 156

157 158
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.
159 160
UPSLIP
 Very stable dysfunction
 Evaluation
 Treatment
161 162

POSTERIOR GLIDE SACRUM
WEIGHT SHIFT Birth And Trauma Related
Instability, Symphyseal
Diastasis
Orthopedic Trauma Literature
Older Tile Pelvic Fracture Scale
(includes pubic separation
Newer Young-Burgess
163 164
Pelvic Fracture / Symphyseal Diastasis ACUTE TREATMENT WITH SLING
APC‐I AP‐C II, AP‐C III
165 166
Severe unstable obstetric
SIJD WITH SEVERE SYMPHYSEAL
symphyseal diastasis of 4.7 cm Kowalk (1996)
.
DIASTASIS
Hesch model of posterior glide of ilia along plane
of SIJ, a component of cam motion is supported by
this image. Kowalk (1996)
167 168

Pelvic Belt AKA SI Belt or
Trochanter Belt
169 170
Release The Pattern Of Injury Removing The

Neural Inhibition,
Then Pursue Comprehensive Rehabilitation
Hesch Method
171 172
ADL’S
Automobile
Sitting AUDIENCE:
Standing, Twisting
Squat
Reach
THANK YOU
VERY MUCH!
Hesch Method
173 174

175

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TITLE OF WEBINAR

Is it time for a major shift

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Hesch Method Hesch Method

QUOTATION Origins of the Sacroiliac Joint

CPTA Virtual Conference 2020 1

Hesch Method Hesch Method

In standing and walking the sacroiliac joint

Hesch Method Hesch Method

CPTA Virtual Conference 2020 2

Hesch Method Hesch Method

How Can We Improve Palpatory Accuracy?

This small amount of movement cannot be objectively  Use minimal palpation in standing because standing

Hesch Method Hesch Method

CPTA Virtual Conference 2020 3

Hesch Method Hesch Method

Hesch Method Hesch Method

CPTA Virtual Conference 2020 4

Hesch Method Hesch Method

NAVIGATING THE LINGUISTIC DIVIDE

 Whenever possible clarify when there is objective evidence for Therefore, it is relevant to perform passive spring‐

Hesch Method Hesch Method

The Palpation Rule of 3’rds Research: Traditional Evaluation

CPTA Virtual Conference 2020 5

 We cannot isolate motion INSIDE the Asymmetrical motion or asymmetrical

Hesch Method Hesch Method

Hesch Method Hesch Method

CPTA Virtual Conference 2020 6

Hesch Method Hesch Method

Hesch Method Hesch Method

CPTA Virtual Conference 2020 7

This model also screens for

Hesch Method Hesch Method

The traditional model of manual therapy uses a

CPTA Virtual Conference 2020 8

Hesch Method Hesch Method

Hesch Method Hesch Method

CPTA Virtual Conference 2020 9

“In this cohort, patient physical exam maneuvers

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

PUBIC JOINT DYSFUNCTION,

PELVIC SUPPORT • Shifting the medial compression force of

CPTA Virtual Conference 2020 10

We recommend a combination of specific

CPTA Virtual Conference 2020 11

SIGNS AND SYMPTOMS NEW RESEARCH

Subjects: 24 healthy pregnant

• Function Pain 7.3 1.9

ADL’s 62.7% 76.1%

• Sports/Recreation Work 60.7% 80.3%

Sports/Rec 51.8% 78.7%

• Rx: Hesch only

CPTA Virtual Conference 2020 12

METHODS: A pilot study was employed to

CPTA Virtual Conference 2020 13

OLSON MASTER’S THESIS

CONCLUSIONS: Seven out of ten

Hesch Method Hesch Method

CPTA Virtual Conference 2020 14

Hesch Method Hesch Method

PELVIC JOINT RECEPTORS PELVIC LIGAMENT-MUSCLE