Evaluation and Treatment of Sacral Somatic Dysfunction

Diagnosis and Treatment of Sacral Somatic Dysfunction, with Indirect,Direct and HVLA Techniques (Counterstrain and Muscle Energy)
F. P Wedel, D.O. Associate Adjunct Professor in Osteopathic Principles and Practice A.T. Still University School of Osteopathic Medicine in Arizona

Learning Objectives
Review the following diagnostic and treatment techniques related to sacral somatic dysfunction:
Lumbosacral spring test Sacral palpation Respiratory motion test Seated flexion test Sacral somatic dysfunctions see table Clinical presentations applicable to sacral diagnosis and treatment Techniques for sacral somatic dysfunction

Sacral Techniques Covered:

Supine, indirect, respiratory cooperation, for bilateral flexion Supine, direct, muscle energy, for bilateral flexion Prone, direct, respiratory cooperation, for bilateral extension - Supine, indirect, respiratory cooperation, for bilateral extension- Prone, direct, LVMA, for sacral rotation on same axis (anterior torsions)4. Prone, direct, muscle energy, for sacral rotation on same axis (anterior torsions)-Prone, direct, LVMA, for unilateral flexion (shear) - Prone, direct, LVMA, for unilateral extension (shear) 5. HVLA for Anterior and Posterior sacral torsions
1. 2. 3.

Sacral Clinical Presentations

Presentations commonly associated with sacral somatic dysfunction and/or benefiting from correction of that dysfunction:
Low back pain traumatic history Status Post Labor History of difficult labor Constipation Menstrual cramps / dysfunction Prostate dysfunction

BACKGROUND SACRAL STRUCTURE,LIGAMENTS AND MUSCLES

THE SACRUM Means sacred because of its density it is the last bone to decay and because it protects the reproductive system

Forces on the sacrum

Angle of the sacroiliac joint wedges the sacrum in an anterior direction
Prevents posterior movement

Dorsal (posterior) sacroiliac ligaments much stronger than anterior sacroiliac ligaments Purpose: counteract significant pelvic forces pushing apex posteriorly.

Major Pelvic Ligaments

Iliolumbar
from ilia to 5th lumbar vertebrae

Sacrospinous
Sacrum to spine of the ischium

Sacrotuberous
Sacrum to ischial tuberosity

Sacroiliac Ligament
Covers much of the sacroiliac joint, ant & post

Iliolumbar ligaments Stabilizes the 5th (4th) Lumbar vertebrae to the ilia

Wedging of the sacrum creates an anterior force

Iliolumbar lig

Sacrospinous

Sacrotuberous Ligament
Runs from lower sacral tubercles to ischial tuberosity Gluteus maximus attachment Tendon of the biceps femoris attachment Connects with fascia of the pelvis
from sacrum to ischial tuberosity stabilizes anterior motion

Sacrospinous ligament

Sacrotuberous ligament

Both Sacrospinous & Sacrotuberous

stabilize to prevent posterior - superior rotation of the sacral apex around a transverse axis

Sacroiliac Ligament
Sacroiliac
actually three ligaments
Anterior or ventral sacroiliac from 3rd sacral segment to lateral preauricular sulcus interosseous sacroiliac massive bond between the upper parts of the joint dorsal sacroiliac Partly covers the interosseous, from lateral sacral crest to PSIS and internal iliac crest.

Ventral/Anterior Sacroiliac

Sacroiliac Ligament

interosseous

Posterior sacroiliac

Pelvic muscle attachments from above.

Posterior Muscular Attachments Attach to Sacrum
Erector Spinae
Iliocostalis Longissimus Erector Spinae

Multifidus

Attach to Innominates
Obliques (internal, external, transverse) Quadratus Lumborum

Posterior Muscles

Iliocostalis

Longissimus

Erector Spinae (sacrospinalis)

Terminal Attachment of S1 the Spinal Dura

S2 S3 S4 S5

Multiple axes of motion:

Transverse (3)
Superior S1 Middle S2 Inferior S3

Sacral Axes

Vertical (sagittal) A/P Oblique (2)

Left Right

SACRAL ANATOMICAL AXIS

Transverse axis Superior: the cranial&primary respiratory mechanism creates motion around this axis Middle: sacral base anterior and posterior (FB/BB) occur around this axis Inferior: the innominates rotate around this axis

SACRAL PHYSIOLOGIC AXIS

Oblique: both left and right oblique axes are named for the superior pole Sagittal: includes both mid-sagittal and an infinite number of parasagittal axes Horizontal: functional axis of sacral flexion/extension occur around this axis (analogous to the middle transverse axis above)

(footnote on functional anatomy)

Why are the Oblique Axes so significant?

They are the Axes of Walking.

The walking cycle as it applies to our discussion

1. From a standing (neutral) position, when you take a step forward, your weight is shifted onto one lower extremity. 2. This induces spinal column SB to the weight bearing side, and pins the upper pole of the sacrum on the side of the SB. 3. As the free lower extremity swings forward, it carries the free pole of the sacrum anterior, creating rotation of the sacrum about the Oblique Axis, towards the weight bearing extremity. Ex.: RL on LOA RR on ROA

Bottom Line: You form Oblique Axes with every step you take!

TESTS

To make a Sacral Diagnosis you will need to know the following:

Static (Pure) Landmarks
Sacral base ILA ASIS & PSIS Pubes - Ant/ Post -Ant/Post -Sup./Inf. -Sup./Inf & Ant./Post - Deep/Shallow - Tight/ Loose/ Equal

Mixed Landmarks
Sacral Sulcus STL

Motion Testing

Spring test
L5 Sacrum

Record Positive Right, Positive Left, or Negative Test

Most of those pieces we have discussed, except...

There is one that we have not talked much about yet. The Spring Test. Its purpose: To be an indicator of whether you are dealing with a sacral Oblique Axis that is a:

Forward Torsion (Neutral)

or Backward Torsion (Non-Neutral).

Vs.

Spring Test
1. 2. 3. 4. Find sacral base Place heel of hand over Lumbosacral junction Spring in an Anterior motion Results:
a. Positive test = If there is NO springing allowed = Non-neutral condition (AKA Backward torsion) b. Negative test = If there is springing allowed = Neutral condition.

Prone Landmarks

Sacral Base
Judge whether the tip of the thumb is more anterior on one side than the tip of the thumb on the other side. Can also bring index fingers over onto sacral base and take measurement on the lateralized side. Record which base is anterior.

Sacral Sulcus Depth

Palpable groove just medial to PSIS. Space between sacral spines and lateral sacral crest. Place thumbs in inferior border of PSIS. Move -1 up and medial to PSIS. Push thumb tips on sacral base. Pads of thumbs are on ilium and tips on sacral base. Measure the depth of each sacral sulcus relative to opposite sulcus? Record even, deep, or shallow, comparing one side to the other. Both sides may be shallow or deep as well.

Inferior Lateral Angle

1. Place flat of hand over sacrum near its caudal end and identify the coccyx. 2. Thumbs approximately 1 apart. Place thumbs in gluteal area about 1 caudal and on each side of coccyx. 3. Push thumbs cephalad until pads rest on inferior margin of ILA. Take a reading on the lateralized side: Inferior or superior? Possibly even? 4. Move thumbs approximately 1 cephalad from the inferior margin of the ILAs and place the pads of the thumbs over the posterior surface of the ILAs near the apex of the sacrum. 5. Use moderate equal pressure & judge if one side is more anterior or posterior than the other one or are they equal? Record on the lateralized side.

1. Place thumbs on the inferior margin of ILA. 2. Move thumbs inferiorly and laterally from the ILA bilaterally, palpating for the sacrotuberous ligament. 3. Ligament will be found between the ILA and the ischial tuberosity on each side. 4. Press thumbs anteriorly, superiorly, and 45-50 degrees laterally to check the tension on the sacrotuberous ligaments. 5. Are they equal in tension or is one tighter or looser than the other? Note which side is looser and which is tighter, relative to the other side.

Sacrotuberous Ligament

L5
Locate L5 transverse processes, bilaterally Place thumbs over L5 transverse processes, bilaterally Note relative positions of L5 transverse processes bilaterally
Which is anterior? Which is posterior? What is the preference of motion at L5 for Rotation?

Record the Rotation of L5, Right, Left, or No Rotation

Motion Tests for Sacral Diagnosis

Lumbosacral Spring Test

Patient Prone Physician at Side of Table Place Heel of Hand over Lumbosacral Junction (L5-S1) Keep arms straight, and lean with body Spring Several Times Negative Test is a Mobility to Springing (motion is felt at joint) extension restriction Positive Test is Restriction to Anterior Springing (absent or restricted springing) flexion restriction

Hip Flop

ASIS Compression Test

Have the patient lie supine. The patient is then asked to raise his/her bottom up off the table and then set it back down again. Doctor Stands with head and shoulders centered over the patient. Contact the ASIS
Stabilize one ASIS while applying pressure at a 45 degree angle to the other ASIS

Positive test - restricted movement of the Sacroiliac joint -> rock like motion Negative test - a sense of give or resilience => bounce or spring like motion

ASIS compression test figure

Approx. 45 degree angle Aim toward SI Joint Positive - Resistance to compression (or a lack of spring)
Stabilization

DIAGNOSIS AND TREATMENT

Sacral Dysfunction Assessment

Are ILAs Symmetric Superior/Inferior? Yes
Physiologic: Oblique Axis: Sacral Torsions

No
Non - physiologic: Upslipped Innominate Unilateral Sacral Shear (Unilateral Sacral Flexion)

Is the Sacral Base Symmetric Anterior /Posterior?

No

Yes
Sacral Base Posterior Sacral Base Anterior
Sacral Margin Posterior

Neutral Sacrum

Sacral Base Anterior-synonyms

(several terms describing the same motion)

Sagittal Plane-Middle Transverse Axis Bilateral Sacral Flexion

Kimberly manual 2006, p. 193 (4521.11A-E) (different than the sacral flexion & extension in the Magoun-type cranial field model)

Nutation
From the Latin nutare- to nod Nutated Sacrum

Anterior Nutation

Sacral Base Anterior:

Base bilat. anterior on the middle transverse axis
Name: Sacral Base Anterior, Or bilat. Sacral Flexion, Or Nutation Landmarks: Sacral Base: Sacral Sulcus: ILA: STL: Motion: Sacral Base: ILA:

Bilat. Anterior Bilat. Deep Bilat. Posterior Bilat. Tight Bilat. + Bilat.

A+ Deep

A+ Deep

P-

P-

Sacral Base Anterior (Bilateral Sacral Flexion)

Inferolateral angles level Sulci deep bilaterally Sacral base anterior bilaterally Sacrotuberous ligaments tight bilaterally Base anterior springing present Apex anterior springing restricted Look for discontinuity at the lumbo-sacral junction

Supine, indirect, respiratory cooperation, for bilateral flexion - 4521.11C

Sacral Base Posterior-synonyms

Sagittal Plane-Middle Transverse Axis Bilateral Sacral Extension
Kimberly manual 2006, p. 197 (4522.11A-C) (different than sacral flexion & extension in the Magoun-type cranial field model)

Counter Nutation Posterior Nutation

Sacral Base Posterior:

Base bilat. posterior on the middle transverse axis
Name: Sacral Base Posterior, Bilat. sacral extension ,or Counternutation Landmarks: Sacral Base: Sacral Sulcus: ILA: STL: Motion: Sacral Base: ILA:

Bilat. Posterior Bilat. Shallow Bilat. Anterior Bilat. Loose Bilat. Bilat. +

PShallow

PShallow

A+

A+

Sacral Base Posterior (Bilateral Sacral Extension)

Inferolateral angles level Sulci shallow bilaterally Sacral base posterior bilaterally Sacrotuberous ligaments relaxed bilaterally Apex anterior springing present Base anterior springing restricted

SACRAL MECHANICS

Physiologic diagnoses of the sacrum occur in neutral and non-neutral mechanics:

Neutral Mechanics a.k.a.

or or

Left rotation on a Left Oblique Axis Forward Torsion Sacral Nutation

(all three are equivalent terms!!) In neutral mechanics, the sacrum rotates in the same direction as the oblique axis (left rotation on a left oblique axis)

Non-neutral Mechanics a.k.a.

or or

Right rotation on a Left Oblique Axis Backward Torsion Sacral Counter-Nutation

In non-neutral mechanics, the sacrum rotates in the opposite direction of the oblique axis (right rotation on a left oblique axis)

(all three are equivalent terms!!)

Lumbosacral motion
Lumbar spine and sacrum rotate in OPPOSITE directions

Neutral (type I) mechanics:

Example: L on LOA, the right sacral base moves anteriorly while L5 is SLRR

In non-neutral (type 2) mechanics, the sacral base rotates backwards

Example: R on LOA, the right sacral base moves posteriorly while L5 is RLSL

Lumbosacral Mechanics
Example L rotation on LOA Lumbar spine neutral: SL RR (note in all torsions, L5 will rotate opposite of sacrum) Requires normal lordosis Occurs when (R) sacral base rotates anterior (forward) and does not rotate back (feels springy) left ILA posterior, & inferior

SL RR
Lo

A
nL

OA

L5 Sacrum Relationship

There are 2 types of Sacral Oblique Axis Dysfunctions. N &N N

eutral
on eutral

Lets start with Neutral Dysfunctions.

Left

Right Midline

Neutral - Left Oblique Axis Findings

Name: L on LOA, RL on LOA, L Forward Torsion Landmarks Static: Sacral Base: L posterior Sacral Sulcus: L shallow ILA: L Post/ Inf. STL: L Tight Motion Testing: Spring: - (neg) L5: SLRR Sacral Base L - R + ILA: L +/- R +/L5: S LRR

A+

P+/-

Left Midline

Right

Neutral - Right Oblique Axis Findings:

Name: R on ROA, RR on ROA, R Forward Torsion Landmarks Static: Sacral Base: R posterior Sacral Sulcus: R shallow ILA: R Post/Inf. STL: R tight Motion Testing: Spring: - (neg) L5: SRRL Sacral Base: L+ RILA: L +/- R +/-

A+

P+/-

Left Right Midline

Right Forward Torsion RR on ROA

Palpatory Experience
We can induce these Neutral diagnoses using the mechanics of the sacrum and spine SBL --> L on LOA

A+

P+/-

HVLA FOR ANTERIOR SACRUM

Anterior Sacrum Leg Pull HVLA (SDOFM 118 9.6) Associated with forward sacral torsions, eg. L on L
1. 2. 3. 4. Patient supine, physician stands at foot of table Grasp patients right ankle just Above malleoli with both hands. Instruct patient to relax all muscles in low back and leg Internally rotate leg to accumulate forces at Right Sacroiliac Joint (Gaps the SI joint) Keep leg and thigh at level of table Apply quick pull on leg, carrying right innominate anteriorly to meet sacrum (correcting the somatic dysfunction) Contraindicated in knee instability Recheck

5. 6.

7.

Posterior Sacrum Leg Pull HVLA (SDOFM 119 9.7) Eg. Right Posterior Sacrum = Sacrum rotated Right on the Left Oblique Axis.
1. 2. 3. 4. Patient supine, physician stands at foot of table Grasp patients right ankle just Above malleoli with both hands. Instruct patient to relax all muscles in low back and leg Internally rotate leg to accumulate forces at Right Sacroiliac Joint (Gaps the SI joint) Keep the knee extended and flex hip until tension is felt on hamstrings Apply final corrective force (quick pull on leg), carrying right innominate posteriorly to meet sacrum. Recheck

5. 6.

Contraindicated in knee instability

7.

Next, there are the Non-Neutral Sacral Dysfunctions

Left Midline

Right

Non-Neutral: Left Oblique Axis Findings

Name: R on LOA, RR on LOA, L Backward Torsion Landmarks Static: Sacral Base: L Anterior Sacral Sulcus: L Deep ILA: L Ant/ Sup STL: L Loose Motion Testing: Spring: + (positive) L5: RLSL Sacral Base L - R +/ILA: L+ R +/-

S L5: R L L

P+/-

A+

Left

Right Midline

Non-Neutral: Right Oblique Axis Findings

Name: L on ROA, RL on ROA, R backward Torsion Landmarks: Sacral Base: R Anterior Sacral Sulcus: R Deep ILA: R Ant./Sup. STL: R loose Motion Testing: Spring: + L5: RRSR Sacral Base: L +/- R ILA: L +/- R + P+/-

A+

Left

Right

Midline

Right Backward Torsion RL on ROA

Palpatory Experience
We can induce these Non-Neutral diagnoses using the mechanics of the sacrum and spine... SBL-> R on LOA
P+/-

A+

HVLA FOR POSTERIOR SACRUM

Anterior Sacrum Leg Pull HVLA (SDOFM 118 9.6) Associated with forward sacral torsions, eg. L on L
1. 2. 3. 4. Patient supine, physician stands at foot of table Grasp patients right ankle just Above malleoli with both hands. Instruct patient to relax all muscles in low back and leg Internally rotate leg to accumulate forces at Right Sacroiliac Joint (Gaps the SI joint) Keep leg and thigh at level of table Apply quick pull on leg, carrying right innominate anteriorly to meet sacrum (correcting the somatic dysfunction) Contraindicated in knee instability Recheck

5. 6.

7.

Posterior Sacrum Leg Pull HVLA (SDOFM 119 9.7) Eg. Right Posterior Sacrum = Sacrum rotated Right on the Left Oblique Axis.
1. 2. 3. 4. Patient supine, physician stands at foot of table Grasp patients right ankle just Above malleoli with both hands. Instruct patient to relax all muscles in low back and leg Internally rotate leg to accumulate forces at Right Sacroiliac Joint (Gaps the SI joint) Keep the knee extended and flex hip until tension is felt on hamstrings Apply final corrective force (quick pull on leg), carrying right innominate posteriorly to meet sacrum. Recheck

5. 6.

7.

Contraindicated in knee instability

COUNTERSTRAIN FOR SACRAL TORSION (not the same as counterstrain for the sacrum)

Paper published by Ramirez in 1990s describing the following: Both anterior and sacral torsions were treated by: 1)noting the side of the tender sacral foramena (will be the same as the axis side of the torsion) 2)sitting on opposite side of the tender points and abducting prone patients leg 30 degrees off table and flexing hip 30 degrees 3) pushing anteriorly on ipsilateral PSIS with operators forearm for 90 seconds

SACRAL DIAGNOSIS
Diagnosis Seated Flexion Test Right Left Left Right Left Left Right Right Right Left Right Left N/A N/A Sacral Base/Sulci Anterior right Anterior right Anterior left Anterior Left Anterior Left Anterior Right Anterior Right Anterior Right Anterior Right Anterior Left Shallow R Shallow L Deep Bilateral Shallow Bilateral ILA levelness L5 Rot Right Right Left Left Left Right Right Left Spring Test Negative Positive Negative Positive Negative Positive Negative Positive Negative Negative Positive Positive Negative Positive LS Flexion Asymmtry Decreased Increased Decreased Increased Decreased Increased Decreased Increased Decreased Decreased Increased Increased N/A N/A Left on left Left on Right Right on right Right on Left Left Unilat Flex Left Unilat Ext Right Unilat Flex Right Unilat Ext Ant Margin - R Ant Margin L Post Margin R Post Margin L Bilateral Flexion Bilateral Extnsn Posterior left Posterior left Posterior Right Posterior Right Posterior Left Posterior Right Posterior right Posterior left Anterior Right Anterior Left Posterior Right Posterior Left
Shallow Bilateral

Deep Bilateral

Produced when the sacrum shifts forward within the sacroiliac joint. Two Types:

Unilateral Sacral Flexion Unilateral Sacral Extension

Sx: Chronic low back pain.

Naming the Shear

The shear is named for the side of the inferior ILA.. The sulcus is deep on same side- (which distinguishes this from a torsion) The seated flexion positive side will tell you how to interpret whether it is a unilateral flexion or extension, i.e.,sulcus deep and ILA on R with R seated flexion + = R unilateral Flexion; L unilateral extension if seated is + L with the same findings of: deep sulcus R and ILA post/inf R

THANK YOU

Sacral Somatic Dysfunction

(AKA Sacroiliac Dysfunction)

Physiologic:
Dysfunction that occurs around a Physiologic Axis

Non - physiologic:
Dysfunction that does not occur around an axis. Usually caused by trauma. 1. Upslipped Innominate 2. Unilateral Sacral Shear (Unilateral Sacral Flexion)

1. Vertical 2. Transverse 3. Oblique: Neutral and Non-Neutral

Piriformis Movement

The only Vertical Axis Diagnosis is

Name: Sacral Margin Posterior For Left Sacral Margin Posterior: Landmarks: Sacral Base: L Posterior Sacral Sulcus: L Shallow ILA: L Posterior STL: L Tight Motion: Sacral Base: L ILA: L

P Shallow

P-

Sacral Margin Posterior cont...

For right sacral margin posterior: Landmarks: Sacral Base: R posterior Sacral Sulcus: R shallow ILA: R posterior STL: R tight Motion: Sacral Base: R ILA: R -

P Shallow

Right Sacral Margin Posterior

Sacral Margin Posterior:

(ILAs are level superiorly/inferiorly)
On the posterior side: Entire sacral margin is posterior
Base is posterior ILA is posterior Sulcus is shallow Sacrotuberous ligament is tight Anterior springing at the superior and inferior poles is restricted

Sacral Margin Posterior can occur on either side of a Vertical axis, but it is always named for the posterior side!

P Shallow

P Shallow

Left Sacral Margin Posterior

Right Sacral Margin Posterior