Shotgun (Pubic Symphysis) Manipulation

Patient and Practitioner set-up

1. The patient is supine in hook-lying (knees bent) position.
2. The table should be high enough for the practitioner to comfortably place their forearm between the patient's knees.

Passive Motion Assessment

1. Often pubic manipulation is attempted when SIJ dysfunction has been confirmed and SIJ techniques alone do not completely resolve symptoms.
2. Subjective symptoms for pubic symphysis dysfunction may include adductor /groin pain, feeling of adductor tightness, rectus abdominis tendonitis or pain, and symptoms similar to femoral acetabular impingement (FAI).
3. Pubic symphysis caudal and cranial mobilization may also be used to "assess" stiffness via palpation, but obviously, this is a sensitive region for the patient and the technique may have limited reliability.

Lockout Position:

You may notice that this technique is quite different from the other techniques included in the manipulations courses. That is because this is actually a muscle energy technique (MET) that often results in cavitation, and although not a true manipulation is the closest approximation of a manipulation available for this joint.

1. The patient is asked to isometrically abduct bilaterally in hook-lying position against practitioner resistance, 3 times for 3 - 5 seconds.
2. There are several methods for applying resistance, but the Brookbush Institute prefers sequentially wider contraction, starting with knees together, then knees approximately 12" apart, and then knees wide enough to allow the practitioner's forearm to fit length-wise between them.
3. After the last isometric hold, the practitioner will slip their forearm between the patient's knees, with palm against the knee on one side and soft part of the arm above the elbow against the knee on the other side.
4. The practitioner then immediately cues the patient to adduct against the patient's arm.
   • This should occur quickly, with a goal of immediately following the isometric abduction with a near-maximal isometric contraction of the adductors. The contraction of the adductors should distract the pubic symphysis, allowing the two sides of the pubis to "realign", and an audible pop may occur. Note, as with all manipulations an audible cavitation is not necessary for the technique to be effective.

High-Velocity Thrust

1. Although the technique above does not often require a high-velocity thrust, a thrust may be added.
2. If the same protocol above is followed, but the last step is replaced by placing both forearms between the knees with palms on medial condyles, the practitioner can add a quick thrust into abduction as the patient is maximally adducting.
3. The amount of motion is the same as other manipulations, relatively small and rapid (maybe 4 - 6").