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SACROILIAC JOINT DYSFUNCTIO.pptx

This document discusses sacroiliac joint dysfunction. It covers anatomy of the sacrum, sacral motions including nutation and counter nutation, and types of sacral somatic dysfunction. Diagnosis involves history, physical exam including special tests like Faber, Gillett and Yeoman's tests, and sacroiliac joint injections which are the gold standard. Management can include soft tissue techniques, muscle energy techniques, counterstrain and other osteopathic manipulative medicine.

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SACROILIAC JOINT DYSFUNCTION AHMED ABDELNASSER BARAKAT (BPT-DPT CAIRO UNIVERSITY) JABER HOSPITAL
Overview Sacral anatomy Sacral motions Sacral somatic dysfunctions Special tests for the sacrum Diagnosis of sacral somatic dysfunction
OBJECTIVES FOR TODAY LECTURE .UNDERSTAND THE ANATOMY AND LANDMARKS NECESSARY FOR SACRAL DIAGNOSIS .DESCRIBE THE MOTION OF THE SACRUM IN BOTH TRANSVERSE AND OBLIQUE AXIS .IDENTIFY THE RELATIONSHIP BETWEEN THE SACRUM , INNOMINATE , AND L5 .NAME OF DYSFUNCTION AS SACROILIAC OR LUMBOSACRAL .EXPLAIN PHYSICAL FINDINGS OF LANDMARKS AND SPECIAL TESTS TO OBTAIN ACORRECT SACRAL DIAGNOSIS SCRAL SULCUS , FABER TEST , SEATED FLEXION TEST .DESCRIBE THREE TYPES OF SACRAL SOMATIC DYSFUNCTION:- BILATERAL FLEXION AND EXTENSION UNILATERAL FLEXION AND EXTENSION TORTION FORWARD AND BACKWARD .DEFINE PHYSIOLOGIC AND NONPHYSIOLOGIC MOTION OF SACRUM
SIJ DYSFUNCTION MOSTLY MISDIAGNOSED OR NOT EVEN CONSIDERED SIJ CAN MIMIC DISCOGENIC LOW BACK PAIN OR RADICULAR PAIN POTENTIALLY LEADING TO MISDIAGNOSIS AND UNNECESSARY LUMBAR SURGERY
Overview Sacroiliac joint (SIJ) dysfunction generally refers to pain in the sacroiliac joint region that is caused by abnormal motion in the sacroiliac joint, either too much motion or too little motion. SIJ pain is common cause of axial low back pain affecting between (10%-25%) of people SIJ dysfunction are the fourth common cause of LBP and pelvic pain 6-13% source of LBP OR pelvis PAIN OR referred lower extremity pain SIJ surface area is greater in males than females AND THIS increased THE biomechanical loading in males
SACRAL STRUCTURE, LIGAMENTS, MUSCLES AND NERVES
THE SACRUM The sacrum, is a large triangular bone at the base of the spine that forms by the fusing of sacral vertebrae S1–S5 , between 18 and 30 years of age. The sacrum is situated at the upper, back part of the pelvic cavity, between the two wings of the pelvis.. The upper part of the sacrum connects with the last lumbar vertebra, and its lower part with the coccyx (tailbone) via the sacral and coccygeal cornua.
Major Pelvic Ligaments Iliolumbar ligament: from ilia to 5th lumbar vertebrae
Sacrospinous & Sacrotuberous Ligaments Sacrospinous : Sacrum to spine of the ischium Sacrotuberous : Runs from lower sacral tubercles to ischial tuberosity Gluteus maximus attachment Tendon of the biceps femoris attachment Both Ligaments are stabilize to prevent posterior – superior rotation of the sacral apex around a transverse axis.
Muscle Functions Piriformis Anterior tilt and rotate sacrum to opposite side Assisted by Ipsilateral gluteus maximus Contralateral latissimus dorsi and gluteus maximus through LDF Nutation of sacrum and extension of LS junction Long head of biceps Backward tilt and rotate sacrum to same side Longissimus and multifidus Pull sacral base superiorly and posteriorly via dorsal ligaments
COMPLEXITY OF SIJ INNERVATIONS !!! INNERVATIONS The sacroiliac joint receives its innervation from the ventral rami of L4 and L5, superior gluteal nerve, and dorsal rami of L5-S2. The nerve supply to the SI joint varies between individuals and innervation may be almost derived from the sacral dorsal rami.
Sacroiliac Joint Movement 1) Nutation: Anterior nutation or flexion 2) Counter nutation: Posterior nutation or extension 3) Forward rotation around an oblique axis 4) Backward rotation around an oblique axis
Sacroiliac Joint Movement Physiologic Left sacral torsion on left oblique axis Right sacral torsion on right oblique axis Bilateral anterior sacral nutation Bilateral posterior sacral nutation Anterior sacral nutation with exhalation Posterior sacral nutation with inhalation Non-physiologic Left sacral torsion on right oblique axis Right sacral torsion on left oblique axis Left unilateral anterior nutation Right unilateral anterior nutation Left unilateral posterior nutation Right unilateral posterior nutation
Reciprocal Movement at Lumbosacral Junction Flexion of L5-S1 – Sacral base moves posteriorly into extension (counternutates) Extension of L5-S1 – Sacral base moves anteriorly into flexion(nutates) Right rotation and left side bending of L5 – Sacral base rotates to left and side bends right
Impairments Excessive articular compression – Fusion (AS) – Capsular fibrosis – Over activation of global Myofascial system – Joint fixation (underlying instability) Insufficient articular compression – Ligamentous laxity – Underactivity of local Myofascial system
DIAGNOSIS OF SIJ DYSFUNCTION HISTORY AND PHYSICAL ASSESSMENT SIJ INJECTION THE GOLD STANDARD IMAGING STUDIES USUALLY NOT HELPFUL
HISTORY: POTENTIAL CAUSES TRAUMATIC FALL ON THE BUTTOCK MVA HEAVY LIFTING ATRAUMATIC ADJACENT SEGMENT DISORDER PRIOR LUMBAR FUSION L5-S1 L4-L5 SCOLIOSIS POSTPARTUM VAGINAL DELIVERY INFLAMMATORY ARTHROPATHY E.G ANKYLOSING SPONDYLITIS INFECTION
SIJ PAIN HISTORY AGGRAVATING FACTOR TRANSITIONAL MOTIONS ROLLING ONTO AFFECTED SIDE VS LYING SUPINE SIT TO STAND PROLONGED WALKING UNILATERALWEIGHT BEARING PUTTING ON PANTS/ SOCKS CLIMBING STAIRS PAIN WHILE STATIONARY SITTING WITH WEIGHT BEARING ON AFFECTED SIDE PROLONGED STANDING
RELIEVING WEIGHT BEARING ON UNAFFECTED SIDE LYING ON UNAFFECTED SIDE COMPRESSION MANUALLY OR WITH ABELT TO RELIEVE HYPERMOBILITY
SIJ PAIN HISTORY:- NEVER BEEN AT MIDLINE ALWAYS BELOW L5 AT THE LEVEL OF PSIS OR CAUDAL TO PSIS OCCASIONALLY PATIENT COMPLAINING OF GROIN ,POST LATERAL THIGH OR CALF PAIN EPICENTER MOST COMMONALY PATIENT POINTS TO PSIS /SACRAL SULCUS (FORTIN FINGER TEST )
CHIEF COMPLAINT PATIENT COMPLAIN OF :- LBP BELOW L5 PELVIC/BUTOOCK PAIN HIP/GROIN PAIN POOR SLEEP HABITS UNILATERAL LEG PAIN INSTABILITY SITTING PROBLEMS LOWER EXTREMITY PAIN
EXAMINATION SEQUENCE 1.Observation 2.Palpation 3. Temperature 4. Skin topography and texture 5. Fascia 6. Muscle 7. Tendon 8. Ligament 8. Erythema friction rub
PHYSICAL EXAMINATION : PAIN LOCALIZATION FORTIN FINGER TEST POINT TO PAIN WHILE STANDING ABLE TO LOCALIZE PAIN WITH ONE FINGER WITHIN 1 CM FROM PSIS ( INFEROMEDIAL) CONSISTENT OVER AT LEAST 2 TRIAL TENDERNESS OVER SIJ SULCUS NOT SITTING ON THE AFFECTED SIDE
Diagnose the Sacrum MOTION • Sitting Flexion Test (SFT) • Sacral Sulcus (SS) • Inferior Lateral Angle (ILA) • Spring Test (ST)
Seated Flexion Test Performing the Test: The examiner has a hand on each PSIS. The patient bends forward, while the examiner is comparing the movement of each PSIS. A positive test is if greater superior motion is felt on one PSIS compared to the other
Sacral Sulcus Depth 1. Begin by finding the PSISs by following the iliac crests posteriorly. 2. From the PSISs, move slightly medial and superior (about 1cm) so that you are now in It 2. With the patient prone, assess the sacral sulci (bases), just medial to the PSIS. The sacral sulcus is “deep” if it is closer to the table (feels more anterior) and “shallow” if it is farther from the table (feels more posterior)he sacral sulci.
PROVOCATION TESTS
Gaenslen's Test is one of the five provocation tests that can be used to detect musculoskeletal abnormalities and primary-chronic inflammation of the lumbar vertebrae and Sacroiliac joint (SIJ). The subsequent tests include; the Distraction Test, Thigh Thrust Test, Compression Test and the Sacral Thrust Test The patient lies in supine position near the edge of the table. The RT leg hangs over the edge of the table. And the other hip and knee are flexed towards the patient's chest
FABERS TEST The FABER test is used to identify the presence of hip pathology by attempting to reproduce pain in the hip, lumbar spine or sacroiliac region. The test is a passive screening tool for musculoskeletal pathologies, such as hip, lumbar spine, or sacroiliac joint dysfunction, or an iliopsoas spasm
FABERS test The patient is positioned in supine. The leg is placed in position (hip flexed and abducted with the lateral ankle resting on the contralateral thigh proximal to the knee. While stabilizing the opposite side of the pelvis at the anterior superior iliac spine, an external rotation, abduction and posterior force is then lightly applied to the ipsilateral knee until the end range of motion is achieved. A further few small- amplitude oscillations can be applied to check for pain provocation at the end range of motion. A positive test is one that reproduces the patient's pain or limits their range of movement.
FABERS TEST 1.Sarcoiliac Joint Pain on external hip rotation 1. Sacroiliac Joint Dysfunction 2. Sacroiliitis 2.Groin Pain on external hip rotation 1. Iliopsoas Strain or Iliopsoas Bursitis 2. Intraarticular Hip Disorder 1.Hip Impingement (femoral acetabular impingement) 2.Hip Labral Tear[8] 3.Hip loose bodies 4.Hip chondral lesion 5.Hip Osteoarthritis[10] 3.Posterior Hip Pain on external hip rotation 1. Posterior Hip Impingement
Sacroiliac stress test The patient lies supine. The examiner applies a vertically orientated, posteriorly directed force to both the anterior superior iliac spines (ASIS) A test is positive if it reproduces the patient's symptoms. This indicates SIJ dysfunction or a sprain of the anterior sacroiliac ligaments Cook and Hegedus (2013)
Gillet test The Stork test, also known as the Gillet Test, assesses the movement of the SIJ between the innominate and sacrum through the clinician's palpation, which may be a useful test for clinical evaluation of a subject's ability to stabilize intrapelvic motion The examiner palpates the inferior aspect of the PSIS of the tested side with one hand and the S2 spinous process with the other. The patient flexes the hip at 90 degrees. The examiner should feel the PSIS move inferiorly and laterally relative to the sacrum. A positive test is when this motion is absent. The examiner should then compare this to the opposite side. An alternate method for this test is to palpate both PSIS's at the same time and compare the end position. Meijne w et al.,2012
Yeoman’s test The patient is prone with the knee flexed 90°. The examiner raises the flexed leg off the examining table, hyperextending the hip. This test places stress on the posterior structures and anterior sacroiliac ligaments. Pain suggests a positive test
JUSTIFICATON FOR SIJ INJECTION POSITIVE HISTORY POSITIVE FORTIN TEST AND SIJ PHYSICAL EXAME POSITIVE PROVOCATIVE TESTS SIJ DIAGNOSTIC INJECTION
DIAGNOSTIC SIJ INJECTIONS GOLD STANDARD CONFIRM OR DENY SIJ AS THE SOURCE OF PAIN 20-30 MIN AFTER PROCEDURE PAIN SHOULD HAVE SUBSIDED (AT LEAST 80% BETTER
IASP : SIJ PAIN DIAGNOSTIC CRITERIA PAIN IS PRESENT IN THE REGION OF SIJ PROVOCATIVE TESTS REPRODUCES PATIENTS PAIN SIJ INJECTION RELIEVE THE PAIN OF PATIENT
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SACROILIAC JOINT DYSFUNCTION AHMED ABDELNASSER BARAKAT (BPT-DPT CAIRO UNIVERSITY) JABER HOSPITAL
Overview Sacral anatomy Sacral motions Sacral somatic dysfunctions Special tests for the sacrum Diagnosis of sacral somatic dysfunction
MANAGEMENT • Soft Tissue Techniques • Myofascial Release Techniques • Counterstrain Techniques • Muscle Energy Techniques • High-Velocity, Low-Amplitude Techniques • Facilitated Positional Release Techniques
Soft Tissue Techniques Soft tissue technique is defined by the Education Council on Osteopathic Principles (ECOP) as, "a direct technique, which usually involves lateral stretching, linear stretching, deep pressure, traction, and/or separation of muscle origin and insertion while monitoring tissue response and motion changes by palpation; also called Myofascial technique"
Prone Pressure 1.The patient is prone, with the head turned toward the physician. 2. The physician stands at the side of the table opposite the side to be treated 3. The physician places the thumb and thinner eminence of one hand on the medial aspect of the patient's lumbar paravertebral musculature overlying the transverse processes on the side opposite the physician 4. The physician places the thinner eminence of the other hand on the abducted thumb of the bottom hand. 5. Keeping the elbows straight and using body weight, the physician exerts a gentle force ventrally to engage the soft tissues and laterally perpendicular to the lumbar paravertebral musculature.
. This force is held for several seconds and is slowly released. 7. Steps 5 and 6 can be repeated several times in a gentle, rhythmic, and kneading fashion. 8. The physician's hands are repositioned to contact different levels of the lumbar spine, and steps 5 to 7 are performed to stretch various portions of the lumbar paravertebral musculature. 9. This technique may also be performed using deep, sustained pressure. 10. Tissue tension is reevaluated to assess the effectiveness of the technique.
Prone Traction 1. The patient is prone with the head turned toward the physician. (If the table has a face hole, keep the head in neutral.) 2. The physician stands at the side of the table at the level of the patient's pelvis. 3. The heel of the physician's cephalad hand is placed over the base of the patient's sacrum with the fingers pointing toward the coccyx 4. The physician does one or both of the following: a) The physician's caudad hand is placed over the lumbar spinous processes with the fingers pointing cephalad, contacting the paravertebral soft tissues with the thinner and hypothenar eminences b) The hand may be placed to one side of the spine, contacting the paravertebral soft tissues on the far side of the lumbar spine with the thinner eminence or the near side with the hypothenar eminence.
5. The physician exerts a gentle force with both hands ventrally to engage the soft tissues and to create a separation and distraction effect in the direction the fingers of each hand are pointing . Do not push directly down on the spinous processes. 6. This technique may be applied in a gentle, rhythmic, and kneading fashion using deep, sustained pressure. 7. The physician's caudad hand is repositioned at other levels of the lumbar spine and steps 4 to 6 are repeated. 8. Tissue tension is reevaluated to assess the effectiveness of the technique
Bilateral Thumb Pressure, Prone 1. Patient and therapist/physician position same as before technique 2. 2. The physician's thumbs are placed on both sides of the spine, contacting the paravertebral muscles overlying the transverse processes of LS with the fingers fanned out laterally 3. 3. The physician's thumbs exert a gentle force ventrally to engage the soft tissues cephalad, and laterally until the barrier or limit of tissue motion is reached . 4. 4. This stretch is held for several seconds, is slowly released, and is then repeated in a gentle, rhythmic, and kneading fashion. 5. 5. The physician's thumbs are repositioned over the transverse processes of each lumbar segment (L4, L3, L2, then L1) and steps 4 and S are repeated to stretch the various portions of the lumbar paravertebral musculature. 6. 6. This technique may also be performed using deep, sustained pressure. 7. Tissue tension is reevaluated to assess the effectiveness of the technique.
Prone Pressure with Counter leverage The physician places the thumb and thinner eminences of the cephalad hand on the medial aspect of the paravertebral muscles overlying the lumbar transverse processes on the side opposite the physician. The physician's caudad hand contacts the patient's anterior superior iliac spine on the side to be treated and gently lifts toward the ceiling To engage the soft tissues, the physician's cephalad hand exerts a gentle force ventrally and laterally, perpendicular to the lumbar paravertebral musculature This force is held for several seconds and is slowly released. Steps 4 to 6 are repeated several times in a slow, rhythmic, and kneading fashion. The physician's cephalad hand is then repositioned to contact different levels of the lumbar spine and steps 4 to 6 are performed to stretch various portions of the lumbar paravertebral musculature. This technique may also be performed using deep, sustained pressure. Tissue tension is reevaluated to assess the effectiveness of the technique.
Lateral Recumbent Position The patient lies in the lateral recumbent position with the treatment side up. The physician stands at the side of the table, facing the front of the patient. The patient's knees and hips are flexed, and the physician's thigh is placed against the patient's infrapatellar region. The physician reaches over the patient's back and places the pads of the fingers on the medial aspect of the patient's paravertebral muscles overlying the lumbar transverse processes To engage the soft tissues, the physician exerts a gentle force ventrally and laterally to create a perpendicular stretch of the lumbar paravertebral musculature
While the physician's thigh against the patient's knees may simply be used for bracing, it may also be flexed to provide a combined bowstring and longitudinal traction force on the paravertebral musculature. This technique may be applied in a gentle rhythmic and kneading fashion or with deep, sustained pressure This technique may be modified by bracing the anterior superior iliac spine with the caudad hand while drawing the paravertebral muscles ventrally with the cephalad hand The physician's hands are repositioned to contact different levels of the lumbar spine and steps 4 to 6 are performed to stretch various portions of the lumbar paravertebral musculature. Tissue tension is reevaluated to assess the effectiveness of the technique
Supine Extension The patient is supine. (The patient's hips and knees may be flexed for comfort.)The physician is seated at the side to be treated. The physician's hands (palms up) reach under the patient's lumbar spine, with the pads of the physician's fingers on the patient's lumbar paravertebral musculature between the spinous and transverse processes on the side closest the physician To engage the soft tissues, the physician exerts a gentle ventral and lateral force perpendicular to the thoracic paravertebral musculature. This is facilitated by downward pressure through the elbows on the table, creating a fulcrum to produce a ventral lever action at the wrists and hands.
The fingers are simultaneously drawn toward the physician, producing a lateral stretch perpendicular to the thoracic paravertebral musculature. This stretch is held for several seconds and is slowly released. Steps 4 to 6 are repeated several times in a gentle, rhythmic, and kneading fashion. The physician's hands are repositioned to contact the different levels of the lumbar spine and steps 4 to 6 are performed to stretch various portions of the lumbar paravertebral musculature. This technique may also be performed using deep, sustained pressure. Tissue tension is reevaluated to assess the effectiveness of the technique.
MFR Techniques Ward describes Myofascial release technique as, "designed to stretch and reflexly release patterned soft tissue and joint related restrictions“ Myofascial Release is a safe and very effective hands-on technique that involves applying gentle sustained pressure into the Myofascial connective tissue restrictions to eliminate pain and restore motion. (John F. Barnes)
Bilateral Sacroiliac Joint with Forearm Pressure Supine 1.The patient lies supine and the physician sits at the side of the patient at the level of the mid femur to knee. 2. The physician asks the patient to bend the proximal knee so the physician's cephalad hand can internally rotate the hip until the pelvis comes off the table. 3. The physician's other hand is placed palm up under the sacrum 4. After returning the hip to neutral, the physician places the other forearm and hand over the anterior superior iliac spines (ASIS) of the patient's pelvis
5. The physician leans down on the elbow of the arm that is contacting the sacrum, keeping the sacral hand relaxed and with the forearm monitors for ease- bind asymmetry in left and right rotation and left and right torsion. 6. After determining the presence of an ease-bind asymmetry, the physician will either indirectly or directly meet the ease-bind barrier, respectively. 7. The force is applied in a very gentle to moderate manner. 8. This is held for 20 to 60 seconds or until a release is palpated
Bilateral Sacroiliac Joint with Forearm Pressure Prone The patient lies prone. The physician stands beside the patient. The physician places one hand over the inferior lumbar segment (e.g., L4-LS) and the other over the superior lumbar segment (e.g., LI-L2) The physician monitors inferior and superior glide, left and right rotation, and clockwise and counterclockwise motion availability for ease-bind asymmetry After determining the presence of an ease-bind asymmetry, the physician will either indirectly or directly meet the ease-bind barrier, respectively. The force is applied in a very gentle to moderate manner. This is held for 20 to 60 seconds or until a release is palpated.
Counterstrain Techniques Counterstrain technique was proposed by Lawrence H. Jones, DO, FAAO ( 1912- 1996). Jones initially believed that a patient could be placed in a position of comfort so as to alleviate the symptoms. After noticing a dramatic clinical response, he studied the nature of musculoskeletal dysfunctions and determined that tender points could be elicited by prodding with the fingertip. The Educational Council on Osteopathic Principles (ECOP) has defined this technique as, "a system of diagnosis and treatment that considers the dysfunction to be a continuing, inappropriate strain reflex, which is inhibited by applying a position of mild strain in the direction exactly opposite to that of the reflex; this is accompanied by specific directed positioning about the point of tenderness to achieve the desired therapeutic response.
Posterior Lumbar Tender Point PL1 to PL5 Tender Point location: The tender point lies at the inferolateral aspect of the spinous process or laterally on the transverse process of the dysfunctional segment. Treatment Position: 1. The patient lies prone and the physician, standing opposite the tender point, grasps the patient's lower thigh or tibial tuberosity on the side of the tender point. 2. 2. The physician extends the patient's thigh and hip until the dysfunctional segment is engaged. 3. 3. The physician adducts the patient's leg and slightly externally rotates it until the lower of the two segments involved in the dysfunction is engaged fully 4. 4. The physician fine-tunes through small arcs of motion (hip flexion and extension, external and internal rotation, and adduction and abduction).
PL5, Lower Pole Tender Point Location: The tender point lies at PL5 lower pole 2 cm below the PSIS . Treatment Position The patient lies prone, and the physician sits at the side of the table on the side of the tender point. The patient's lower extremity on the side of the tender point hangs off the side of the table with hip and knee flexed to 90 degrees. The physician internally rotates the patient's hip and thigh, and the patient's knee is adducted slightly under the table . The physician fine-tunes through small arcs of motion (hip flexion and extension, internal and external rotation, and knee adduction and abduction).
Muscle Energy Technique (MET) Muscle energy technique (MET) is a form of Osteopathic manipulative treatment developed by Fred L .Mitchell , Sr. , DO (1909- 1974). It is defined by the Education Council on Osteopathic Principles (ECOP) as, "a system of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the physician; this directed patient action is from a precisely controlled position, against a defined resistance by the physician"
Correction of Forward Sacral Torsion • Lie axis side down • Rotate trunk to right with right arm off table • Flex knees and hips to localize forces at L/S junction • Resist bottom heel lifting toward ceiling
Correction of Backward Sacral Torsion • Lie axis side down • Extend lower leg to induce some sacral flexion • Flex upper hip so leg off table • Extend trunk to L/S junction • Rotate trunk left to L/S junction • Resist lifting upper leg toward ceiling
Correction of bilateral anterior nutated sacrum • Patient seated • Feet apart and legs internally rotated • Patient flexes forward • ATC hands on sacral apex and thoracic spine • Maintain pressure on sacral apex (ILA’s) and resist trunk extension with full inhalation
Correction of Bilateral Posterior Nutated Sacrum • Patient seated • Feet together and legs externally rotated • Arms crossed • One hands on sacral base and another across anterior chest • Maintain pressure on sacral base and resist trunk flexion with full exhalation or have patient arch back by pushing abdomen to knees
Correction of Unilateral Anterior Sacral Nutation • Patient prone • Abduct (15°) and internally rotate left leg • Right hand on left ILA • Apply and maintain anterior and superior pressure on left ILA as patient inhales and holds breath • Maintains pressure as patient exhales Left Unilateral Anterior Nutation
Correction of Unilateral Posterior Sacral Nutation • Patient prone • Abduct (15°) and externally rotate right leg • Trunk extended via prone on elbow position • ATC’s right hand on right sacral base • Apply and maintain anterior and inferior pressure with right hand as patient exhales • ATC’s left hand applies posterior pressure to right ASIS • After exhalation, patient pulls ASIS toward table • Return to prone lying position while maintaining pressure Right Unilateral Posterior Sacral Nutation
Referances • Cohen, S.P. (2005). Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anesthesia & Analgesia, 101, 1440-53. • Atlas of osteopathic technique, Alexander S. Nicholas, DO,FAAO, Evan S. Nicholas, DO. • Issacs ER, Bookhout MR. Bourdillon’s Spinal Manipulation (6th Ed.). Butterworth-Heinemann:Boston, 2002 • Foundations of osteopathic medicine(3rd Ed.),Anthony Chila.
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SACROILIAC JOINT DYSFUNCTIO.pptx

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SACROILIAC JOINT DYSFUNCTIO.pptx

  • 2.
    SACROILIAC JOINT DYSFUNCTION AHMEDABDELNASSER BARAKAT (BPT-DPT CAIRO UNIVERSITY) JABER HOSPITAL
  • 3.
    Overview Sacral anatomy Sacral motions Sacralsomatic dysfunctions Special tests for the sacrum Diagnosis of sacral somatic dysfunction
  • 4.
    OBJECTIVES FOR TODAYLECTURE .UNDERSTAND THE ANATOMY AND LANDMARKS NECESSARY FOR SACRAL DIAGNOSIS .DESCRIBE THE MOTION OF THE SACRUM IN BOTH TRANSVERSE AND OBLIQUE AXIS .IDENTIFY THE RELATIONSHIP BETWEEN THE SACRUM , INNOMINATE , AND L5 .NAME OF DYSFUNCTION AS SACROILIAC OR LUMBOSACRAL .EXPLAIN PHYSICAL FINDINGS OF LANDMARKS AND SPECIAL TESTS TO OBTAIN ACORRECT SACRAL DIAGNOSIS SCRAL SULCUS , FABER TEST , SEATED FLEXION TEST .DESCRIBE THREE TYPES OF SACRAL SOMATIC DYSFUNCTION:- BILATERAL FLEXION AND EXTENSION UNILATERAL FLEXION AND EXTENSION TORTION FORWARD AND BACKWARD .DEFINE PHYSIOLOGIC AND NONPHYSIOLOGIC MOTION OF SACRUM
  • 5.
    SIJ DYSFUNCTION MOSTLYMISDIAGNOSED OR NOT EVEN CONSIDERED SIJ CAN MIMIC DISCOGENIC LOW BACK PAIN OR RADICULAR PAIN POTENTIALLY LEADING TO MISDIAGNOSIS AND UNNECESSARY LUMBAR SURGERY
  • 6.
    Overview Sacroiliac joint (SIJ)dysfunction generally refers to pain in the sacroiliac joint region that is caused by abnormal motion in the sacroiliac joint, either too much motion or too little motion. SIJ pain is common cause of axial low back pain affecting between (10%-25%) of people SIJ dysfunction are the fourth common cause of LBP and pelvic pain 6-13% source of LBP OR pelvis PAIN OR referred lower extremity pain SIJ surface area is greater in males than females AND THIS increased THE biomechanical loading in males
  • 7.
  • 8.
    THE SACRUM The sacrum,is a large triangular bone at the base of the spine that forms by the fusing of sacral vertebrae S1–S5 , between 18 and 30 years of age. The sacrum is situated at the upper, back part of the pelvic cavity, between the two wings of the pelvis.. The upper part of the sacrum connects with the last lumbar vertebra, and its lower part with the coccyx (tailbone) via the sacral and coccygeal cornua.
  • 9.
    Major Pelvic Ligaments Iliolumbarligament: from ilia to 5th lumbar vertebrae
  • 10.
    Sacrospinous & Sacrotuberous Ligaments Sacrospinous: Sacrum to spine of the ischium Sacrotuberous : Runs from lower sacral tubercles to ischial tuberosity Gluteus maximus attachment Tendon of the biceps femoris attachment Both Ligaments are stabilize to prevent posterior – superior rotation of the sacral apex around a transverse axis.
  • 12.
    Muscle Functions Piriformis Anterior tiltand rotate sacrum to opposite side Assisted by Ipsilateral gluteus maximus Contralateral latissimus dorsi and gluteus maximus through LDF Nutation of sacrum and extension of LS junction Long head of biceps Backward tilt and rotate sacrum to same side Longissimus and multifidus Pull sacral base superiorly and posteriorly via dorsal ligaments
  • 13.
    COMPLEXITY OF SIJ INNERVATIONS !!!INNERVATIONS The sacroiliac joint receives its innervation from the ventral rami of L4 and L5, superior gluteal nerve, and dorsal rami of L5-S2. The nerve supply to the SI joint varies between individuals and innervation may be almost derived from the sacral dorsal rami.
  • 15.
    Sacroiliac Joint Movement 1)Nutation: Anterior nutation or flexion 2) Counter nutation: Posterior nutation or extension 3) Forward rotation around an oblique axis 4) Backward rotation around an oblique axis
  • 16.
    Sacroiliac Joint Movement Physiologic Leftsacral torsion on left oblique axis Right sacral torsion on right oblique axis Bilateral anterior sacral nutation Bilateral posterior sacral nutation Anterior sacral nutation with exhalation Posterior sacral nutation with inhalation Non-physiologic Left sacral torsion on right oblique axis Right sacral torsion on left oblique axis Left unilateral anterior nutation Right unilateral anterior nutation Left unilateral posterior nutation Right unilateral posterior nutation
  • 17.
    Reciprocal Movement at LumbosacralJunction Flexion of L5-S1 – Sacral base moves posteriorly into extension (counternutates) Extension of L5-S1 – Sacral base moves anteriorly into flexion(nutates) Right rotation and left side bending of L5 – Sacral base rotates to left and side bends right
  • 18.
    Impairments Excessive articular compression –Fusion (AS) – Capsular fibrosis – Over activation of global Myofascial system – Joint fixation (underlying instability) Insufficient articular compression – Ligamentous laxity – Underactivity of local Myofascial system
  • 20.
    DIAGNOSIS OF SIJDYSFUNCTION HISTORY AND PHYSICAL ASSESSMENT SIJ INJECTION THE GOLD STANDARD IMAGING STUDIES USUALLY NOT HELPFUL
  • 21.
    HISTORY: POTENTIAL CAUSES TRAUMATIC FALLON THE BUTTOCK MVA HEAVY LIFTING ATRAUMATIC ADJACENT SEGMENT DISORDER PRIOR LUMBAR FUSION L5-S1 L4-L5 SCOLIOSIS POSTPARTUM VAGINAL DELIVERY INFLAMMATORY ARTHROPATHY E.G ANKYLOSING SPONDYLITIS INFECTION
  • 22.
    SIJ PAIN HISTORY AGGRAVATINGFACTOR TRANSITIONAL MOTIONS ROLLING ONTO AFFECTED SIDE VS LYING SUPINE SIT TO STAND PROLONGED WALKING UNILATERALWEIGHT BEARING PUTTING ON PANTS/ SOCKS CLIMBING STAIRS PAIN WHILE STATIONARY SITTING WITH WEIGHT BEARING ON AFFECTED SIDE PROLONGED STANDING
  • 23.
    RELIEVING WEIGHT BEARING ON UNAFFECTEDSIDE LYING ON UNAFFECTED SIDE COMPRESSION MANUALLY OR WITH ABELT TO RELIEVE HYPERMOBILITY
  • 24.
    SIJ PAIN HISTORY:- NEVERBEEN AT MIDLINE ALWAYS BELOW L5 AT THE LEVEL OF PSIS OR CAUDAL TO PSIS OCCASIONALLY PATIENT COMPLAINING OF GROIN ,POST LATERAL THIGH OR CALF PAIN EPICENTER MOST COMMONALY PATIENT POINTS TO PSIS /SACRAL SULCUS (FORTIN FINGER TEST )
  • 25.
    CHIEF COMPLAINT PATIENT COMPLAINOF :- LBP BELOW L5 PELVIC/BUTOOCK PAIN HIP/GROIN PAIN POOR SLEEP HABITS UNILATERAL LEG PAIN INSTABILITY SITTING PROBLEMS LOWER EXTREMITY PAIN
  • 26.
    EXAMINATION SEQUENCE 1.Observation 2.Palpation 3. Temperature 4. Skintopography and texture 5. Fascia 6. Muscle 7. Tendon 8. Ligament 8. Erythema friction rub
  • 27.
    PHYSICAL EXAMINATION :PAIN LOCALIZATION FORTIN FINGER TEST POINT TO PAIN WHILE STANDING ABLE TO LOCALIZE PAIN WITH ONE FINGER WITHIN 1 CM FROM PSIS ( INFEROMEDIAL) CONSISTENT OVER AT LEAST 2 TRIAL TENDERNESS OVER SIJ SULCUS NOT SITTING ON THE AFFECTED SIDE
  • 28.
    Diagnose the Sacrum MOTION •Sitting Flexion Test (SFT) • Sacral Sulcus (SS) • Inferior Lateral Angle (ILA) • Spring Test (ST)
  • 29.
    Seated Flexion Test Performingthe Test: The examiner has a hand on each PSIS. The patient bends forward, while the examiner is comparing the movement of each PSIS. A positive test is if greater superior motion is felt on one PSIS compared to the other
  • 30.
    Sacral Sulcus Depth 1.Begin by finding the PSISs by following the iliac crests posteriorly. 2. From the PSISs, move slightly medial and superior (about 1cm) so that you are now in It 2. With the patient prone, assess the sacral sulci (bases), just medial to the PSIS. The sacral sulcus is “deep” if it is closer to the table (feels more anterior) and “shallow” if it is farther from the table (feels more posterior)he sacral sulci.
  • 32.
  • 33.
    Gaenslen's Test is oneof the five provocation tests that can be used to detect musculoskeletal abnormalities and primary-chronic inflammation of the lumbar vertebrae and Sacroiliac joint (SIJ). The subsequent tests include; the Distraction Test, Thigh Thrust Test, Compression Test and the Sacral Thrust Test The patient lies in supine position near the edge of the table. The RT leg hangs over the edge of the table. And the other hip and knee are flexed towards the patient's chest
  • 34.
    FABERS TEST The FABERtest is used to identify the presence of hip pathology by attempting to reproduce pain in the hip, lumbar spine or sacroiliac region. The test is a passive screening tool for musculoskeletal pathologies, such as hip, lumbar spine, or sacroiliac joint dysfunction, or an iliopsoas spasm
  • 35.
    FABERS test The patientis positioned in supine. The leg is placed in position (hip flexed and abducted with the lateral ankle resting on the contralateral thigh proximal to the knee. While stabilizing the opposite side of the pelvis at the anterior superior iliac spine, an external rotation, abduction and posterior force is then lightly applied to the ipsilateral knee until the end range of motion is achieved. A further few small- amplitude oscillations can be applied to check for pain provocation at the end range of motion. A positive test is one that reproduces the patient's pain or limits their range of movement.
  • 36.
    FABERS TEST 1.Sarcoiliac JointPain on external hip rotation 1. Sacroiliac Joint Dysfunction 2. Sacroiliitis 2.Groin Pain on external hip rotation 1. Iliopsoas Strain or Iliopsoas Bursitis 2. Intraarticular Hip Disorder 1.Hip Impingement (femoral acetabular impingement) 2.Hip Labral Tear[8] 3.Hip loose bodies 4.Hip chondral lesion 5.Hip Osteoarthritis[10] 3.Posterior Hip Pain on external hip rotation 1. Posterior Hip Impingement
  • 38.
    Sacroiliac stress test Thepatient lies supine. The examiner applies a vertically orientated, posteriorly directed force to both the anterior superior iliac spines (ASIS) A test is positive if it reproduces the patient's symptoms. This indicates SIJ dysfunction or a sprain of the anterior sacroiliac ligaments Cook and Hegedus (2013)
  • 39.
    Gillet test The Storktest, also known as the Gillet Test, assesses the movement of the SIJ between the innominate and sacrum through the clinician's palpation, which may be a useful test for clinical evaluation of a subject's ability to stabilize intrapelvic motion The examiner palpates the inferior aspect of the PSIS of the tested side with one hand and the S2 spinous process with the other. The patient flexes the hip at 90 degrees. The examiner should feel the PSIS move inferiorly and laterally relative to the sacrum. A positive test is when this motion is absent. The examiner should then compare this to the opposite side. An alternate method for this test is to palpate both PSIS's at the same time and compare the end position. Meijne w et al.,2012
  • 40.
    Yeoman’s test The patientis prone with the knee flexed 90°. The examiner raises the flexed leg off the examining table, hyperextending the hip. This test places stress on the posterior structures and anterior sacroiliac ligaments. Pain suggests a positive test
  • 41.
    JUSTIFICATON FOR SIJINJECTION POSITIVE HISTORY POSITIVE FORTIN TEST AND SIJ PHYSICAL EXAME POSITIVE PROVOCATIVE TESTS SIJ DIAGNOSTIC INJECTION
  • 42.
    DIAGNOSTIC SIJ INJECTIONS GOLDSTANDARD CONFIRM OR DENY SIJ AS THE SOURCE OF PAIN 20-30 MIN AFTER PROCEDURE PAIN SHOULD HAVE SUBSIDED (AT LEAST 80% BETTER
  • 43.
    IASP : SIJPAIN DIAGNOSTIC CRITERIA PAIN IS PRESENT IN THE REGION OF SIJ PROVOCATIVE TESTS REPRODUCES PATIENTS PAIN SIJ INJECTION RELIEVE THE PAIN OF PATIENT
  • 44.
  • 45.
  • 49.
    SACROILIAC JOINT DYSFUNCTION AHMEDABDELNASSER BARAKAT (BPT-DPT CAIRO UNIVERSITY) JABER HOSPITAL
  • 50.
    Overview Sacral anatomy Sacral motions Sacralsomatic dysfunctions Special tests for the sacrum Diagnosis of sacral somatic dysfunction
  • 53.
    MANAGEMENT • Soft TissueTechniques • Myofascial Release Techniques • Counterstrain Techniques • Muscle Energy Techniques • High-Velocity, Low-Amplitude Techniques • Facilitated Positional Release Techniques
  • 54.
    Soft Tissue TechniquesSoft tissue technique is defined by the Education Council on Osteopathic Principles (ECOP) as, "a direct technique, which usually involves lateral stretching, linear stretching, deep pressure, traction, and/or separation of muscle origin and insertion while monitoring tissue response and motion changes by palpation; also called Myofascial technique"
  • 55.
    Prone Pressure 1.The patientis prone, with the head turned toward the physician. 2. The physician stands at the side of the table opposite the side to be treated 3. The physician places the thumb and thinner eminence of one hand on the medial aspect of the patient's lumbar paravertebral musculature overlying the transverse processes on the side opposite the physician 4. The physician places the thinner eminence of the other hand on the abducted thumb of the bottom hand. 5. Keeping the elbows straight and using body weight, the physician exerts a gentle force ventrally to engage the soft tissues and laterally perpendicular to the lumbar paravertebral musculature.
  • 56.
    . This forceis held for several seconds and is slowly released. 7. Steps 5 and 6 can be repeated several times in a gentle, rhythmic, and kneading fashion. 8. The physician's hands are repositioned to contact different levels of the lumbar spine, and steps 5 to 7 are performed to stretch various portions of the lumbar paravertebral musculature. 9. This technique may also be performed using deep, sustained pressure. 10. Tissue tension is reevaluated to assess the effectiveness of the technique.
  • 57.
    Prone Traction 1. Thepatient is prone with the head turned toward the physician. (If the table has a face hole, keep the head in neutral.) 2. The physician stands at the side of the table at the level of the patient's pelvis. 3. The heel of the physician's cephalad hand is placed over the base of the patient's sacrum with the fingers pointing toward the coccyx 4. The physician does one or both of the following: a) The physician's caudad hand is placed over the lumbar spinous processes with the fingers pointing cephalad, contacting the paravertebral soft tissues with the thinner and hypothenar eminences b) The hand may be placed to one side of the spine, contacting the paravertebral soft tissues on the far side of the lumbar spine with the thinner eminence or the near side with the hypothenar eminence.
  • 58.
    5. The physicianexerts a gentle force with both hands ventrally to engage the soft tissues and to create a separation and distraction effect in the direction the fingers of each hand are pointing . Do not push directly down on the spinous processes. 6. This technique may be applied in a gentle, rhythmic, and kneading fashion using deep, sustained pressure. 7. The physician's caudad hand is repositioned at other levels of the lumbar spine and steps 4 to 6 are repeated. 8. Tissue tension is reevaluated to assess the effectiveness of the technique
  • 59.
    Bilateral Thumb Pressure, Prone 1.Patient and therapist/physician position same as before technique 2. 2. The physician's thumbs are placed on both sides of the spine, contacting the paravertebral muscles overlying the transverse processes of LS with the fingers fanned out laterally 3. 3. The physician's thumbs exert a gentle force ventrally to engage the soft tissues cephalad, and laterally until the barrier or limit of tissue motion is reached . 4. 4. This stretch is held for several seconds, is slowly released, and is then repeated in a gentle, rhythmic, and kneading fashion. 5. 5. The physician's thumbs are repositioned over the transverse processes of each lumbar segment (L4, L3, L2, then L1) and steps 4 and S are repeated to stretch the various portions of the lumbar paravertebral musculature. 6. 6. This technique may also be performed using deep, sustained pressure. 7. Tissue tension is reevaluated to assess the effectiveness of the technique.
  • 60.
    Prone Pressure withCounter leverage The physician places the thumb and thinner eminences of the cephalad hand on the medial aspect of the paravertebral muscles overlying the lumbar transverse processes on the side opposite the physician. The physician's caudad hand contacts the patient's anterior superior iliac spine on the side to be treated and gently lifts toward the ceiling To engage the soft tissues, the physician's cephalad hand exerts a gentle force ventrally and laterally, perpendicular to the lumbar paravertebral musculature This force is held for several seconds and is slowly released. Steps 4 to 6 are repeated several times in a slow, rhythmic, and kneading fashion. The physician's cephalad hand is then repositioned to contact different levels of the lumbar spine and steps 4 to 6 are performed to stretch various portions of the lumbar paravertebral musculature. This technique may also be performed using deep, sustained pressure. Tissue tension is reevaluated to assess the effectiveness of the technique.
  • 61.
    Lateral Recumbent Position Thepatient lies in the lateral recumbent position with the treatment side up. The physician stands at the side of the table, facing the front of the patient. The patient's knees and hips are flexed, and the physician's thigh is placed against the patient's infrapatellar region. The physician reaches over the patient's back and places the pads of the fingers on the medial aspect of the patient's paravertebral muscles overlying the lumbar transverse processes To engage the soft tissues, the physician exerts a gentle force ventrally and laterally to create a perpendicular stretch of the lumbar paravertebral musculature
  • 62.
    While the physician'sthigh against the patient's knees may simply be used for bracing, it may also be flexed to provide a combined bowstring and longitudinal traction force on the paravertebral musculature. This technique may be applied in a gentle rhythmic and kneading fashion or with deep, sustained pressure This technique may be modified by bracing the anterior superior iliac spine with the caudad hand while drawing the paravertebral muscles ventrally with the cephalad hand The physician's hands are repositioned to contact different levels of the lumbar spine and steps 4 to 6 are performed to stretch various portions of the lumbar paravertebral musculature. Tissue tension is reevaluated to assess the effectiveness of the technique
  • 63.
    Supine Extension The patientis supine. (The patient's hips and knees may be flexed for comfort.)The physician is seated at the side to be treated. The physician's hands (palms up) reach under the patient's lumbar spine, with the pads of the physician's fingers on the patient's lumbar paravertebral musculature between the spinous and transverse processes on the side closest the physician To engage the soft tissues, the physician exerts a gentle ventral and lateral force perpendicular to the thoracic paravertebral musculature. This is facilitated by downward pressure through the elbows on the table, creating a fulcrum to produce a ventral lever action at the wrists and hands.
  • 64.
    The fingers aresimultaneously drawn toward the physician, producing a lateral stretch perpendicular to the thoracic paravertebral musculature. This stretch is held for several seconds and is slowly released. Steps 4 to 6 are repeated several times in a gentle, rhythmic, and kneading fashion. The physician's hands are repositioned to contact the different levels of the lumbar spine and steps 4 to 6 are performed to stretch various portions of the lumbar paravertebral musculature. This technique may also be performed using deep, sustained pressure. Tissue tension is reevaluated to assess the effectiveness of the technique.
  • 65.
    MFR Techniques Ward describesMyofascial release technique as, "designed to stretch and reflexly release patterned soft tissue and joint related restrictions“ Myofascial Release is a safe and very effective hands-on technique that involves applying gentle sustained pressure into the Myofascial connective tissue restrictions to eliminate pain and restore motion. (John F. Barnes)
  • 66.
    Bilateral Sacroiliac Jointwith Forearm Pressure Supine 1.The patient lies supine and the physician sits at the side of the patient at the level of the mid femur to knee. 2. The physician asks the patient to bend the proximal knee so the physician's cephalad hand can internally rotate the hip until the pelvis comes off the table. 3. The physician's other hand is placed palm up under the sacrum 4. After returning the hip to neutral, the physician places the other forearm and hand over the anterior superior iliac spines (ASIS) of the patient's pelvis
  • 67.
    5. The physicianleans down on the elbow of the arm that is contacting the sacrum, keeping the sacral hand relaxed and with the forearm monitors for ease- bind asymmetry in left and right rotation and left and right torsion. 6. After determining the presence of an ease-bind asymmetry, the physician will either indirectly or directly meet the ease-bind barrier, respectively. 7. The force is applied in a very gentle to moderate manner. 8. This is held for 20 to 60 seconds or until a release is palpated
  • 68.
    Bilateral Sacroiliac Jointwith Forearm Pressure Prone The patient lies prone. The physician stands beside the patient. The physician places one hand over the inferior lumbar segment (e.g., L4-LS) and the other over the superior lumbar segment (e.g., LI-L2) The physician monitors inferior and superior glide, left and right rotation, and clockwise and counterclockwise motion availability for ease-bind asymmetry After determining the presence of an ease-bind asymmetry, the physician will either indirectly or directly meet the ease-bind barrier, respectively. The force is applied in a very gentle to moderate manner. This is held for 20 to 60 seconds or until a release is palpated.
  • 69.
    Counterstrain Techniques Counterstrain techniquewas proposed by Lawrence H. Jones, DO, FAAO ( 1912- 1996). Jones initially believed that a patient could be placed in a position of comfort so as to alleviate the symptoms. After noticing a dramatic clinical response, he studied the nature of musculoskeletal dysfunctions and determined that tender points could be elicited by prodding with the fingertip. The Educational Council on Osteopathic Principles (ECOP) has defined this technique as, "a system of diagnosis and treatment that considers the dysfunction to be a continuing, inappropriate strain reflex, which is inhibited by applying a position of mild strain in the direction exactly opposite to that of the reflex; this is accompanied by specific directed positioning about the point of tenderness to achieve the desired therapeutic response.
  • 70.
    Posterior Lumbar TenderPoint PL1 to PL5 Tender Point location: The tender point lies at the inferolateral aspect of the spinous process or laterally on the transverse process of the dysfunctional segment. Treatment Position: 1. The patient lies prone and the physician, standing opposite the tender point, grasps the patient's lower thigh or tibial tuberosity on the side of the tender point. 2. 2. The physician extends the patient's thigh and hip until the dysfunctional segment is engaged. 3. 3. The physician adducts the patient's leg and slightly externally rotates it until the lower of the two segments involved in the dysfunction is engaged fully 4. 4. The physician fine-tunes through small arcs of motion (hip flexion and extension, external and internal rotation, and adduction and abduction).
  • 71.
    PL5, Lower PoleTender Point Location: The tender point lies at PL5 lower pole 2 cm below the PSIS . Treatment Position The patient lies prone, and the physician sits at the side of the table on the side of the tender point. The patient's lower extremity on the side of the tender point hangs off the side of the table with hip and knee flexed to 90 degrees. The physician internally rotates the patient's hip and thigh, and the patient's knee is adducted slightly under the table . The physician fine-tunes through small arcs of motion (hip flexion and extension, internal and external rotation, and knee adduction and abduction).
  • 72.
    Muscle Energy Technique(MET) Muscle energy technique (MET) is a form of Osteopathic manipulative treatment developed by Fred L .Mitchell , Sr. , DO (1909- 1974). It is defined by the Education Council on Osteopathic Principles (ECOP) as, "a system of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the physician; this directed patient action is from a precisely controlled position, against a defined resistance by the physician"
  • 73.
    Correction of ForwardSacral Torsion • Lie axis side down • Rotate trunk to right with right arm off table • Flex knees and hips to localize forces at L/S junction • Resist bottom heel lifting toward ceiling
  • 74.
    Correction of BackwardSacral Torsion • Lie axis side down • Extend lower leg to induce some sacral flexion • Flex upper hip so leg off table • Extend trunk to L/S junction • Rotate trunk left to L/S junction • Resist lifting upper leg toward ceiling
  • 75.
    Correction of bilateralanterior nutated sacrum • Patient seated • Feet apart and legs internally rotated • Patient flexes forward • ATC hands on sacral apex and thoracic spine • Maintain pressure on sacral apex (ILA’s) and resist trunk extension with full inhalation
  • 76.
    Correction of BilateralPosterior Nutated Sacrum • Patient seated • Feet together and legs externally rotated • Arms crossed • One hands on sacral base and another across anterior chest • Maintain pressure on sacral base and resist trunk flexion with full exhalation or have patient arch back by pushing abdomen to knees
  • 77.
    Correction of UnilateralAnterior Sacral Nutation • Patient prone • Abduct (15°) and internally rotate left leg • Right hand on left ILA • Apply and maintain anterior and superior pressure on left ILA as patient inhales and holds breath • Maintains pressure as patient exhales Left Unilateral Anterior Nutation
  • 78.
    Correction of UnilateralPosterior Sacral Nutation • Patient prone • Abduct (15°) and externally rotate right leg • Trunk extended via prone on elbow position • ATC’s right hand on right sacral base • Apply and maintain anterior and inferior pressure with right hand as patient exhales • ATC’s left hand applies posterior pressure to right ASIS • After exhalation, patient pulls ASIS toward table • Return to prone lying position while maintaining pressure Right Unilateral Posterior Sacral Nutation
  • 79.
    Referances • Cohen, S.P.(2005). Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anesthesia & Analgesia, 101, 1440-53. • Atlas of osteopathic technique, Alexander S. Nicholas, DO,FAAO, Evan S. Nicholas, DO. • Issacs ER, Bookhout MR. Bourdillon’s Spinal Manipulation (6th Ed.). Butterworth-Heinemann:Boston, 2002 • Foundations of osteopathic medicine(3rd Ed.),Anthony Chila.
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