Sacral Diagnosis & Evaluation
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| What clinical evaluation or test assesses whether the sacrum is locked posteriorly with the facets of L5? | Spring test
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| What does the sacral compression test assess? | Sacroiliac joint
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| What does the seated flexion test assess? | Sacroiliac joint
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| What is the most superior articulation to the sacrum? | L5
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| Flexion and extension of the sacrum (forward and backward bending) occur on which axis? | Transverse axis
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| 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
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| 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
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| What is important in managing patients with sacral or sacroiliac problems? | History of the problem
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| What are the major landmarks for diagnosis and treatment located inferiorly on the sacrum | Inferior lateral angles
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| What forms the superior poles of the sacrum? | Skewed square "base" of sacrum
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| 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
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| What are the articulations of the sacrum | Coccyx, ilia, and L5
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| 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
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| What are the posterior ligaments associated with the sacrum? What do they do? | Sacroiliac ligament, posterior sacrococcygeus; control posterior stability and range of motion
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| What are the anterior muscles of the sacrum? | Iliacus, piriformis, and coccygeus
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| What are the anterior ligaments of the sacrum? | Sacrospinous ligament, sacrotuberous ligament, anterior sacrococcygeus ligament, and anterior sacroiliac ligament
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| 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)
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| What are the primary pelvic muscles? | Intrinsic muscles of the pelvic diaphragm: levator ani (pubococcygeus, iliococcygeus, puborectalis) and coccygeus (ischiococcygeus) muscles
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| What is the innervation of the primary pelvic muscles? | Parasympathetic - somatic nerves S2-S4
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| What do problems associated with levator ani lead to? | Rectal dysfunction
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| What can rectal pain be attributed to? | Colon tumors, hemorrhoids, constipation
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| What are the secondary pelvic muscles? | Iliopsoas, obturator internus, piriformis
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| What happens if the secondary pelvic muscles are affected? | Leads to inability to sit comfortably
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| What does piriformis hypertonicity cause? | Buttocks pain that radiates down the thigh, but not usually below the knee
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| What does piriformis syndrome present as? | Sciatic - pain in the butt
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| Where does the sciatic nerve travel in around 10% to 15% of the population? | Through the belly of the piriformis
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| What are the accessory ligaments of the sacrum? What is their function? | Sacrotuberous ligament, sacrospinous ligament, iliolumbar ligament; suspensory function
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| What are the true ligaments of the sacrum? What is their function? | Anterior sacroiliac, interosseous sacroiliac, posterior sacroiliac; stabilize SI joint
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| 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
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| What does dysfunction of the ilio-lumbar ligament present as? | Groin pain
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| What are the attachments of the sacrotuberous ligament? | Originates at ILA and attaches to ischial tuberosity
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| What are the attachments of the sacrospinous ligament? | Originates at sacrum and attaches to ischial spine dividing the greater and lesser sciatic foramen
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| 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)
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| Describe the motor and sensory innervations of the pelvis. What is innervated? | Parasympathetic fibers (S2-S4) for innervations of left colon and pelvic organs
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| Describe the autonomic innervations of the pelvis. | Sacral sympathetic trunk and parasympathetic nerves of pelvic splanchnics (S2-S4)
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| One of the two areas of the body with the highest incidence of atypical joint structure and joint mechanics | L5-S1 (Lumbosacral joint)
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| What is lumbarization? | Case where S1 vertebra is not fully fused with S2 vertebra; results in increased mobility at S1-S2; increases lumbar lordosis
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| What is sacralization? | Case where L5 fuses with and joins the sacrum; results in reduced mobility at L5; decreases lumbar lordosis
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| 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
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| What is the shape of the iliosacral joint? | Upside down "L" shape or auricular shape
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| What is often reported on radiology reports when evaluating lumbosacral junction? | Ferguson's angle
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| What is a physiologic Ferguson's angle? | 35 degrees
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| What would cause a Ferguson's angle to increase? | Spondylolisthesis (anterior slippage) of L5 on S1
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| What people are at risk for spondylolisthesis? | Pregnant women (disk problems because pregnancy exaggerates lumbar lordosis) and gymnysts (backflips)
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| How is the architecture of the sacroiliac joint unique? | Bevelled - it is not perpendicular (there is no clear-cut anterior/posterior direction of motion)
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| 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
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| What motion occurs on the superior transverse sacral axis? | Respiratory mechanism motion; respiratory axis
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| What motion occurs on the middle transverse sacral axis? | Flexion/extension; postural axis
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| What motion occurs on the inferior transverse sacral axis? | Rotation of innominates; walking axis
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| What physiologically happens to the sacral base upon inhalation? | Moves posteriorly; lumbar lordotic curve decreases
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| What physiologically happens to the sacral base upon exhalation? | Moves anteriorly; lumbar lordotic curve increases
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| What are the 4 types of motion at the sacroiliac joint? | Postural, dynamic (gait cycle dependent), respiratory (pulmonary), and inherent (cranio-sacral)
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| When considering postural motion, in which direction does the sacral base move when a person is seated and torso is forward bent? | Moves anterior
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| 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
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| What motion occurs during ambulation? | Dynamic
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| What happens physiologically to the sacrum as weight-bearing shifts from one side to the other while walking? | Sacrum engages 2 sacral oblique axes
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| What happens at midstance during ambulation? | Ipsilateral ilium elevation
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| 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
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| 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)
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| 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
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| 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
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| When is the sphinx position utilized? | Diagnosis
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| What type of motion correlates with the sphinx position? | Lumbar hyper-extension promoting sacral flexion
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| 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)
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| What is the seated flexion test used for? | Screening test to help specify side of the dysfunction (not for full diagnosis)
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| 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 (+)
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| What does a (+) seated flexion test on one side indicate? | Unilateral dysfunction
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| 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
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| Describe patient positioning and physician action during the lumbosacral spring test. | Patient is prone and physician presses on LS junction with heel of hand
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| What makes the LS spring test (-)? | Springing motion because the lumbars are lordotic (physiologic) and the sacral base is anterior
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| 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
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| What does lumbar extension normally cause the sacral base to do? | Move anteriorly
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| 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
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| What happens during a negative sphinx test? | Lumbar extension causes sacral base to move anterior and the physician palpates the sacrum moving anteriorly
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| 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)
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| 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
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| 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
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| 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
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| 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
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| What is the oblique axis named for? | The superior pole
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| What is the axis of rotation running from the left sacral base (superiorly) to the right ILA of sacrum (inferiorly)? | Left oblique axis
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| 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
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| 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)
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| What should the physician check after determining the direction of sacral motion on the oblique axis? | Assess the L5 direction of rotation
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| 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
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| Which are more common - sacral torsions or sacral rotations? | Sacral torsions
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| 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
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| 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
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| What are the two possibilites for FST? | L on L FST or R on R FST
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| What are the overall characteristics for FST? | (-) L5 spring test, (-) sphinx test, axis opposite from deep sulcus, L5 rotated in opposite direction of sacrum
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| What is the relationship between the direction of rotation and the name of the oblique axis in BST? | Opposite one another
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| What is another name for BST? | Backward rotation of sacrum on oblique axis
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| 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)
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| 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
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| 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
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| 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
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| How does a physician differentiate between a sacral rotation and a sacral torsion? | Sacral rotation has L5 rotated to same side as the sacrum
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| 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
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| 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
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| Do the findings of unilateral sacral flexion become more symmetric or asymmetric in the sphinx position? | Symmetric
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| 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
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| 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
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| 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"
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| Are bilateral sacral dysfunctions common or rare? | Rare
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| Why is it hard to diagnose a bilateral sacral dysfunction? | Tough to differentiate from normal sacral biomechanics
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| 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
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| 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
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| In what motions does the sacrum move freely into during respiration? | Flexion (exhalation) and extension (inhalation)
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| In what motions does the sacrum move freely into during gait? | Physiologic torsions/rotations
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Where is the location of the PS1 counterstrain tenderpoint? | Located bilaterally and medial to the PSIS at the level S1
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| Where are the PS2, PS3, and PS4 counterstrain tenderpoints located? | Midline on the sacrum of the corresponding sacral level
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| Where are the PS5 counterstrain tenderpoints located? | Located bilaterally just medial and superior to ILA of the sacrum
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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