What is the recommended physical exam approach for a patient with suspected pubic symphysis dysfunction?

Physical Examination for Suspected Pubic Symphysis Dysfunction

A systematic physical examination focusing on the pubic symphysis and surrounding structures is essential for diagnosing pubic symphysis dysfunction, including palpation of the symphysis pubis, assessment of pelvic stability, and functional movement testing.

Key Components of the Physical Examination

1. Patient Positioning and Initial Assessment

• Examine the patient in multiple positions:
  • Standing: Observe posture, pelvic alignment, and gait pattern
  • Supine: For detailed palpation and stability tests
  • Lateral decubitus: To assess for pain relief in this position 1

2. Palpation Techniques

• Direct palpation of the pubic symphysis joint for:
  • Tenderness at the joint line
  • Step deformity or asymmetry
  • Swelling or inflammation
• Palpate surrounding structures including:
  • Adductor muscle attachments
  • Rectus abdominis insertion
  • Pubic rami

3. Stability Assessment Tests

• Modified Trendelenburg test: Patient stands on one leg while examiner observes for excessive pelvic drop
• Pubic symphysis compression test: Apply gentle compression across the pelvis laterally
• Pubic symphysis distraction test: Apply gentle outward pressure on the iliac crests
• FABER test (Flexion, ABduction, External Rotation): May reproduce pain with pubic dysfunction

4. Functional Movement Assessment

• Assess pain with:
  • Single leg stance
  • Stair climbing
  • Sit-to-stand movements
  • Rolling in bed
  • Walking (observe for waddling gait)
• Document activities that exacerbate symptoms 2

5. Special Tests for Pubic Symphysis Dysfunction

• Active straight leg raise test: Patient lifts leg 20cm while supine; pain or difficulty indicates dysfunction
• Pubic symphysis gap test: Palpate for excessive movement at the joint during leg movements
• Modified Flamingo test: Patient stands on one leg with examiner palpating the pubic symphysis for movement

Comprehensive Assessment Approach

Multi-Compartment Evaluation

• Assess all pelvic compartments as pubic symphysis dysfunction often coexists with other pelvic floor disorders 1, 3:
  • Anterior compartment (bladder, urethra)
  • Middle compartment (uterus, vaginal vault)
  • Posterior compartment (rectum)

Functional Impact Assessment

• Evaluate impact on:
  • Mobility and activities of daily living
  • Urinary function (potential association with overactive bladder) 4
  • Sexual function
  • Sleep disturbances (especially in pregnancy-related cases) 2

Additional Diagnostic Considerations

When to Consider Imaging

• Plain radiographs (X-ray) should be considered for patients with:
  • Severe pain
  • History of trauma
  • Suspected significant diastasis
  • Failure to respond to conservative management 1

Advanced Imaging Indications

• Consider MR defecography or other advanced imaging when:
  • Physical examination findings are discordant with symptoms
  • Multiple compartment involvement is suspected
  • Patient is unable to tolerate adequate physical examination 1

Common Pitfalls to Avoid

• Failing to assess all pelvic compartments, as dysfunction often involves multiple areas simultaneously 3
• Overlooking associated conditions like stress urinary incontinence 3
• Neglecting to perform a stress test when urinary symptoms are present 3
• Focusing only on the pubic symphysis without evaluating sacroiliac joint function, as these are biomechanically linked 5
• Performing overly aggressive maneuvers that could exacerbate symptoms, particularly in pregnancy-related cases 6

By following this systematic physical examination approach, clinicians can accurately diagnose pubic symphysis dysfunction and develop appropriate management strategies to improve patient outcomes.