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OPP_1

Sacral Diagnosis & Evaluation

QuestionAnswer
What clinical evaluation or test assesses whether the sacrum is locked posteriorly with the facets of L5? Spring test
What does the sacral compression test assess? Sacroiliac joint
What does the seated flexion test assess? Sacroiliac joint
What is the most superior articulation to the sacrum? L5
Flexion and extension of the sacrum (forward and backward bending) occur on which axis? Transverse axis
What statement is true about motion testing of the sacrum? The seated flexion test only indicates whether the sacral somatic dysfunction is on the left or right side
Which landmark should be palpated and assessed to distinguish between a diagnosis of a sacral torsion and a unilateral sacral flexion? Inferior lateral angles of the sacrum
What is important in managing patients with sacral or sacroiliac problems? History of the problem
What are the major landmarks for diagnosis and treatment located inferiorly on the sacrum Inferior lateral angles
What forms the superior poles of the sacrum? Skewed square "base" of sacrum
How is the sacrum stabilized in its anatomical position? Held firmly by ligaments (not muscles) to articulate with right and left ilia, L5, and coccyx
What are the articulations of the sacrum Coccyx, ilia, and L5
What are the posterior muscles associated with the sacrum? What do they stabilize? Gluteus maximus, longissimus thoracis, iliocostalis lumborum, multifidus; stabilize lumbar spine and create working relationship with sacrum
What are the posterior ligaments associated with the sacrum? What do they do? Sacroiliac ligament, posterior sacrococcygeus; control posterior stability and range of motion
What are the anterior muscles of the sacrum? Iliacus, piriformis, and coccygeus
What are the anterior ligaments of the sacrum? Sacrospinous ligament, sacrotuberous ligament, anterior sacrococcygeus ligament, and anterior sacroiliac ligament
Why is the coccyx such an important landmark? What do particular problems tell us about the coccyx? All fascias and connective tissues of the pelvic floor attach to the anterior tip of the coccyx; coccyx problems could lead to bladder problems (incontinence due to trauma may have sacrococcygeal dysfunction)
What are the primary pelvic muscles? Intrinsic muscles of the pelvic diaphragm: levator ani (pubococcygeus, iliococcygeus, puborectalis) and coccygeus (ischiococcygeus) muscles
What is the innervation of the primary pelvic muscles? Parasympathetic - somatic nerves S2-S4
What do problems associated with levator ani lead to? Rectal dysfunction
What can rectal pain be attributed to? Colon tumors, hemorrhoids, constipation
What are the secondary pelvic muscles? Iliopsoas, obturator internus, piriformis
What happens if the secondary pelvic muscles are affected? Leads to inability to sit comfortably
What does piriformis hypertonicity cause? Buttocks pain that radiates down the thigh, but not usually below the knee
What does piriformis syndrome present as? Sciatic - pain in the butt
Where does the sciatic nerve travel in around 10% to 15% of the population? Through the belly of the piriformis
What are the accessory ligaments of the sacrum? What is their function? Sacrotuberous ligament, sacrospinous ligament, iliolumbar ligament; suspensory function
What are the true ligaments of the sacrum? What is their function? Anterior sacroiliac, interosseous sacroiliac, posterior sacroiliac; stabilize SI joint
What are the attachments for the ilio-lumbar ligament? Originates from transverse processes of L4 and L5 and attaches to medial side of iliac crest
What does dysfunction of the ilio-lumbar ligament present as? Groin pain
What are the attachments of the sacrotuberous ligament? Originates at ILA and attaches to ischial tuberosity
What are the attachments of the sacrospinous ligament? Originates at sacrum and attaches to ischial spine dividing the greater and lesser sciatic foramen
Describe how the sciatic nerve is formed? By lumbosacral trunk (ventral rami L4-L5), first three sacral ventral rami (S1-S3), and a portion of fourth (S4)
Describe the motor and sensory innervations of the pelvis. What is innervated? Parasympathetic fibers (S2-S4) for innervations of left colon and pelvic organs
Describe the autonomic innervations of the pelvis. Sacral sympathetic trunk and parasympathetic nerves of pelvic splanchnics (S2-S4)
One of the two areas of the body with the highest incidence of atypical joint structure and joint mechanics L5-S1 (Lumbosacral joint)
What is lumbarization? Case where S1 vertebra is not fully fused with S2 vertebra; results in increased mobility at S1-S2; increases lumbar lordosis
What is sacralization? Case where L5 fuses with and joins the sacrum; results in reduced mobility at L5; decreases lumbar lordosis
What can be done to help patients with sacralization or lumbarization? Counsel them on how to modify activities of daily living (posture, etc.) to decrease lumbosacral back pain; do not recommend surgery for these people
What is the shape of the iliosacral joint? Upside down "L" shape or auricular shape
What is often reported on radiology reports when evaluating lumbosacral junction? Ferguson's angle
What is a physiologic Ferguson's angle? 35 degrees
What would cause a Ferguson's angle to increase? Spondylolisthesis (anterior slippage) of L5 on S1
What people are at risk for spondylolisthesis? Pregnant women (disk problems because pregnancy exaggerates lumbar lordosis) and gymnysts (backflips)
How is the architecture of the sacroiliac joint unique? Bevelled - it is not perpendicular (there is no clear-cut anterior/posterior direction of motion)
What are the multiple axes (cardinal motion axes) used to describe some of the unique sacral motion? 3 Transverse - superior (S1), middle (S2), and inferior (S3); 2 Oblique - left and right; 1 vertical axis; and 1 anteroposterior axis
What motion occurs on the superior transverse sacral axis? Respiratory mechanism motion; respiratory axis
What motion occurs on the middle transverse sacral axis? Flexion/extension; postural axis
What motion occurs on the inferior transverse sacral axis? Rotation of innominates; walking axis
What physiologically happens to the sacral base upon inhalation? Moves posteriorly; lumbar lordotic curve decreases
What physiologically happens to the sacral base upon exhalation? Moves anteriorly; lumbar lordotic curve increases
What are the 4 types of motion at the sacroiliac joint? Postural, dynamic (gait cycle dependent), respiratory (pulmonary), and inherent (cranio-sacral)
When considering postural motion, in which direction does the sacral base move when a person is seated and torso is forward bent? Moves anterior
What happens physiologically to the sacral base when a person is standing and begins forward bending? What happens when forward bending continues? Initially, sacral base begins to move anterior, tightening SI ligaments; as forward bending continues, innominate moves posterior in relation to feet - this shift in the base of support causes sacral base to move posteriorly
What motion occurs during ambulation? Dynamic
What happens physiologically to the sacrum as weight-bearing shifts from one side to the other while walking? Sacrum engages 2 sacral oblique axes
What happens at midstance during ambulation? Ipsilateral ilium elevation
What causes the left sacral axis to be engaged? Weight-bearing on left leg (stepping forward with right leg) - opposite is true for weight-bearing on right leg
Name and briefly describe the 3 types of sacral diagnosis. Sacral torsion - motion (forward/backward) on oblique axes; flexion/extension - motion on transverse axis; unilateral sacral shear (unilateral sacral flexion)
What is the relationship of bending of the sacrum to the bending of the lumbar spine with hyper-flexion and hyper-extension? The bending of the sacrum is reciprocal to the bending of the lumbar spine
What does lumbar hyper-extension promote? What does lumbar hyper-flexion promote? Lumar hyper-extension promotes sacral flexion and lumbar hyper-flexion promotes sacral extension
When is the sphinx position utilized? Diagnosis
What type of motion correlates with the sphinx position? Lumbar hyper-extension promoting sacral flexion
What are three essential points to consider for sacral diagnosis? Which sacral base is anterior (sacral sulcus deep); which ILA of sacrum is inferior and posterior; performance of one sacral motion test (Sphinx, spring, and seated flexion)
What is the seated flexion test used for? Screening test to help specify side of the dysfunction (not for full diagnosis)
What does the physician do during the seated flexion test? Using the pads of his/her thumbs, the physician evaluates (bilaterally) the sacral sulci and determines which side has a greater excursion of motion - the side with greatest motion would be considered (+)
What does a (+) seated flexion test on one side indicate? Unilateral dysfunction
Differentiate between what a seated flexion test evaluates and what a standing flexion test evaluates. Seated flexion test provides information about sacroiliac dysfunctions and a standing flexion test provides information about ilisacral dysfunctions
Describe patient positioning and physician action during the lumbosacral spring test. Patient is prone and physician presses on LS junction with heel of hand
What makes the LS spring test (-)? Springing motion because the lumbars are lordotic (physiologic) and the sacral base is anterior
What makes the LS spring test (+)? Very little or no springing motion because the lumbars are kyphotic (non-physiologic)and the sacral base is posterior
What does lumbar extension normally cause the sacral base to do? Move anteriorly
How does the physician evaluate the patient during a sphinx test? Physcian places pads of thumbs on the sacral sulci and monitiors these points while patient slowly moves into sphinx-like position using their hands or forearms
What happens during a negative sphinx test? Lumbar extension causes sacral base to move anterior and the physician palpates the sacrum moving anteriorly
What does a positive sphinx test indicate? Sacral base is fixed posteriorly or in postural extension; sacral base is bilaterally or unilaterally posterior(extended) and will resist anterior motion or movement with lumbar extension (physician's thumbs will become asymmetric)
What are the finding for a backward sacral torsion dysfunction? Why? Physician's thumbs will become more uneven because restricted side of sacral base resists moving forward
What is sacral torsion? Asymmetric dysfunction where rotation is on an oblique axis; rotation about an oblique axis along with somatic dysfunction of L5 - it is a twisting of the sacrum and L5 in opposite directions
What is happening with one of the sacral sulci and the diagonal ILA in a sacral torsion? One side of the sacral base is anterior (sulcus is deep) and the diagonal (opposite) ILA side is posterior
How are the direction of rotation and the axis of rotation recorded for a sacral dysfunction? Always direction of rotation first and axis of rotation second
What is the oblique axis named for? The superior pole
What is the axis of rotation running from the left sacral base (superiorly) to the right ILA of sacrum (inferiorly)? Left oblique axis
Describe the assessment of the sacral sulci. Place thumb over each PSIS with tips of thumbs facing medially; move thumbs medially off PSIS and into area between PSISs (superior sulci); note which thumb feels as if it goes deeper in sulcus on same side as (+) seated flexion test
Describe the assessment of the ILAs. Place thumb over each ILA; roll each thumb to cranial (below) edge of ILA; with thumb pads, press cephalad (upwards against bone)
What should the physician check after determining the direction of sacral motion on the oblique axis? Assess the L5 direction of rotation
How does the physician assess the L5 direction of rotation? Locate iliac crest; drop thumbs onto transverse processes of L5; evaluate rotational component of L5
Which are more common - sacral torsions or sacral rotations? Sacral torsions
How would a physician record the findings: static - right sulcus deep, left ILA posterior; dynamic - (+) seated flexion on right, L5 rotated right, (-) L5 spring test, (-) sphinx test L on L FST
How would a physician record the findings: static - left sulcus deep, right ILA posterior; dynamic - (+) seated flexion on left, L5 rotated left, (-) L5 spring test, (-) sphinx test R on R FST
What are the two possibilites for FST? L on L FST or R on R FST
What are the overall characteristics for FST? (-) L5 spring test, (-) sphinx test, axis opposite from deep sulcus, L5 rotated in opposite direction of sacrum
What is the relationship between the direction of rotation and the name of the oblique axis in BST? Opposite one another
What is another name for BST? Backward rotation of sacrum on oblique axis
What are the two possible types of BST? L on R BST (L rotation on R axis) and R on L (R rotation on L axis)
What are the general characteristics of BST? (+) spring test, (+) sphinx test, axis is on opposite side from shallow sulcus, L5 is rotated in opposite direction of the sacrum
How would a physician record the findings: static - deep sulcus on right, right ILA anterior; dynamic findings - (+) seated flexion test on left, (+) L5 spring test, (+) sphinx test, L5 rotated right L on R BST
How would a physician record the findings: static - right sulcus shallow, left ILA anterior; dynamic - (+) seated flexion test on right, (+) L5 spring test, (+) sphinx test, L5 rotated left R on L BST
How does a physician differentiate between a sacral rotation and a sacral torsion? Sacral rotation has L5 rotated to same side as the sacrum
What are the 4 types of sacral rotations? L lumbar rotation on L FSR; R lumbar rotation on R FSR; L lumbar rotation on R BSR; and R lumbar rotation on L BSR
Describe the characteristics for unilateral sacral flexion. One sacral base will move anteriorly more than the other side; ILA (posterior) and deep sacral sulcus will occur on same side on a relatively vertical axis; sacrum does spring since one sacral base is carried forward
Do the findings of unilateral sacral flexion become more symmetric or asymmetric in the sphinx position? Symmetric
What are the findings for a left unilateral sacral flexion dysfunction? Static: L sulcus deeper, L ILA significantly inferior, L ILA slightly posterior; dynamic: (+) seated flexion test on left, (-) L5 spring test, (-) sphinx test
What are the findings for a right unilateral sacral flexion dysfunction? Static: R sulcus deeper, R ILA significantly inferior, R ILA slightly posterior; dynamic: (+) seated flexion test on right, (-) L5 spring test, (-) sphinx test
When do bilateral sacral dysfunctions occur? Occur when anterior or posterior movements stay "fixed" rather than variable; sacral base equally on the left and right stay "stuck"
Are bilateral sacral dysfunctions common or rare? Rare
Why is it hard to diagnose a bilateral sacral dysfunction? Tough to differentiate from normal sacral biomechanics
What are the findings for anterior base movement (bilateral sacral flexion)? Sacral base anterior (sacral sulcus deep bilaterally), ILAs even (symmetric superiorly and inferiorly), (-) spring test, sacral base moves forward easily in sphinx position
What are the findings for posterior base movement (bilateral sacral extension)? Sacral base posterior (sacral sulcus shallow), ILAs even (symmetric anteriorly and posteriorly), (+) spring test, buttocks curved in under trunk, sacral base does not come forward easily in sphinx position
In what motions does the sacrum move freely into during respiration? Flexion (exhalation) and extension (inhalation)
In what motions does the sacrum move freely into during gait? Physiologic torsions/rotations
What is noticed about the restriction of motion of the sacrum if normal sacral movement does not occur? One or both SI joints are restricting the motion
How does a sacral release treatment work? Treatment is guided towards releasing the restriction of the SI joints with the aid of pressure on the sacrum; sacrum can be "liberated" from the ilia with slight bilateral compression on ilia while contacting the sacrum and waiting for release of tissues
Describe balanced ligamentous tension of the sacrum. Where do the physician's hands go? BLT treatment is guided towards releasing the restriction of the SI joints with the aid of pulmonary respiration; fingertips contact sacral base to decompress from L5
Patient presents complaining of pain in the lower medial portion of their buttocks. What muscles could be affected (where is the somatic dysfunction?)? Medial portion of gluteus maximus or deep within the coccygeus muscle and pelvic floor
Patient presents complaining of pain in the lower medial portion of their buttocks -Where is the location of the tenderpoint? On lateral aspect of inferior angle of sacrum associated with attachment of the coccygeus muscle
How would a physician treat a tender point on the lateral aspect of the inferior lateral angle of the sacrum (associated with attachment of coccygeus muscle)? Patient lies prone; patient's lower extremity is extended and adducted enough to cross over contralateral leg; physician fine tunes until tenderness is completely alleviated
Where is the location of the PS1 counterstrain tenderpoint? Located bilaterally and medial to the PSIS at the level S1
Where are the PS2, PS3, and PS4 counterstrain tenderpoints located? Midline on the sacrum of the corresponding sacral level
Where are the PS5 counterstrain tenderpoints located? Located bilaterally just medial and superior to ILA of the sacrum
What muscles are associated with the five different counterstrain points (what muscles attach to these areas of the sacrum?)? Erector spinae muscles and transversospinalis muscle
How would you treat a PS1 tenderpoint? Patient lies prone; physician applies posterior to anterior pressure on the ILA of the sacrum opposite the tenderpoint; fine-tune with more or less pressure on opposite ILA until tenderness is completely alleviated
How would you treat a PS5 tenderpoint? Patient lies prone; physician applies posterior to anterior pressure on sacral base opposite tenderpoint; fine-tune with more or less pressure on sacral base until tenderness is completely alleviated
How would you treat a PS2 tenderpoint? Patient lies prone; physician applies posterior to anterior pressure to apex of sacrum (extending the sacrum); fine tune with more or less pressure on sacrum until tenderness is completely alleviated
How would you treat a PS3 tenderpoint? Patient lies prone; physician may use flexion or extension; and fine-tune with more or less pressure on sacrum until tenderness is completely alleviated
How would you treat a PS4 tenderpoint? Patient lies prone; physician applies posterior to anterior pressure midline on the base of the sacrum (flex the sacrum); fine-tune with more or less pressure on sacrum until tenderness is completely alleviated
Describe the set-up for a forward sacral torsion treatment. Patient lying on their side - on the side of axis of dysfunction down; chest turned forward toward table; knees and hips flexed until motion is felt in the SI joint
Describe muscle energy treatment for a forward sacral torsion. Patient pushes feet toward ceiling against doctor's isometric counterforce; doctor takes patient's feet further toward floor to new feather edge; repeat several times, passive stretch; re-check
Describe the set-up for a backward sacral torsion treatment. Patient lies on side of axis of dysfunction down toward table; chest toward backward away from table; knees/hips flexed; patient straightens lower leg; patient's foot of upper leg hooked into straightened leg; legs moved off table toward floor
Describe muscle energy treatment for a backward sacral torsion treatment. Patient pushes ankle toward ceiling against doctor's isometric counterforce; doctor takes patient's feet further toward floor to new feather edge; repeat several times, passive stretch; re-check
What is the set-up for unilateral sacral flexion treatment? Patient is prone; doctor pushes patient's right leg toward the floor, while internally rotating leg, and should feel ILA tilt upwards toward the ceiling; doctor's heel of left hand should be repositioned inferiorly and against the bottom of the ILA
Describe the treatment for a right unilateral sacral flexion. Monitor right SI w/left middle finger, heel of left hand lies on right ILA; doctor's hand brings right leg off table; patient takes deep breath; on exhale doctor pushes ILA parallel to table and toward patient's head; release and re-evaluate
Describe how to implement HVLA for unilateral sacral flexion. Slightly elevate leg and place a wedge at level of ILA; internally rotate and slightly abduct the leg; apply traction through leg to localize to barrier; apply focused HVLA tub
Describe the treatment set-up for bilateral sacral flexion (bilateral anterior sacral base)? Patient supine knees flexed; monitor sacrum; further flex knees while monitoring L-S junction with hands; patient pushes knees away from head while Dr. offers isometric counterforce; repeat and re-evaluate
Describe how the treatment and set-up works for bilateral sacral extension. Patient prone; physician places heel of one hand at sacral base; as patient exhales, doctor's hand follow sacral bas anteriorly; as patient inhales, doctor's hand resists sacral base movement posteriorly; repeat and re-check
Created by: Cory67