Treatment of Sacroiliac Treatment of Sacroiliac J oint Dysfunction J oint Dysfunction - PDF Document

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  1. Treatment of Sacroiliac Treatment of Sacroiliac J oint Dysfunction J oint Dysfunction Movement of sacrum on Movement of sacrum on ilium ilium

  2. Sacroiliac J oint Axes Sacroiliac J oint Axes ? ? Superior Superior ? ? Middle Middle ? ? Inferior Inferior ? ? Right Oblique Right Oblique ? ? Left Oblique Left Oblique

  3. Sacroiliac J oint Sacroiliac J oint Movement Movement ? ? Nutation Nutation: Anterior ? ? Counternutation Counternutation: Posterior extension extension ? ? Forward rotation around an oblique Forward rotation around an oblique axis axis ? ? Backward rotation around an oblique Backward rotation around an oblique axis axis : Anterior nutation : Posterior nutation nutation or flexion or flexion nutation or or

  4. Sacroiliac J oint Sacroiliac J oint Movements Movements ? ? Physiologic Physiologic – – Left sacral torsion on left oblique axis Left sacral torsion on left oblique axis – – Right sacral torsion on right oblique axis Right sacral torsion on right oblique axis – – Bilateral anterior sacral Bilateral anterior sacral nutation – – Bilateral posterior sacral Bilateral posterior sacral nutation – – Anterior sacral Anterior sacral nutation nutation with exhalation – – Posterior sacral Posterior sacral nutation nutation with inhalation ? ? Non Non- -physiologic physiologic – – Left sacral torsion on right oblique axis Left sacral torsion on right oblique axis – – Right sacral torsion on left oblique axis Right sacral torsion on left oblique axis – – Left unilateral anterior Left unilateral anterior nutation – – Right unilateral anterior Right unilateral anterior nutation – – Left unilateral posterior Left unilateral posterior nutation – – Right unilateral posterior Right unilateral posterior nutation nutation nutation with exhalation with inhalation nutation nutation nutation nutation

  5. Sacral Sacral Nutation Nutation ? ? “ “Sacral locking Sacral locking” ” ? ? Base of sacrum moves into pelvis Base of sacrum moves into pelvis – – Inferoposterior Inferoposterior glide of surface of sacrum on surface of sacrum on ilium – – Coronal axis of Coronal axis of interosseous ligament ligament – – Iliac bones approximate, Iliac bones approximate, ischial tuberosities tuberosities spread spread – – Limited by Limited by interosseous interosseous, ant. sacroiliac, sacroiliac, sacrotuberous sacrotuberous and sacrospinous sacrospinous lig ? ? Bilateral Bilateral – – Early trunk extension Early trunk extension – – End range trunk flexion End range trunk flexion – – Exhalation Exhalation ? ? Unilateral Unilateral – – Hip flexion Hip flexion glide of articular articular ilium interosseous ischial , ant. and lig

  6. Sacral Sacral Counternutation Counternutation ? ? “ “Sacral unlocking Sacral unlocking” ” ? ? Backward motion of base of sacrum Backward motion of base of sacrum out of pelvis out of pelvis – – Anterosuperior Anterosuperior glide of surface of sacrum on surface of sacrum on illium – – Coronal axis of Coronal axis of interosseous – – Iliac bones spread, Iliac bones spread, ischial tuberosities tuberosities approximate approximate – – Limited by long post sacroiliac Limited by long post sacroiliac ligament and ligament and multifidus multifidus contraction ? ? Bilateral Bilateral – – Early trunk flexion Early trunk flexion – – End of trunk extension End of trunk extension – – Inhalation Inhalation ? ? Unilateral Unilateral – – Hip extension Hip extension glide of articular articular illium interosseous ligament ischial ligament contraction

  7. Reciprocal Movement at Reciprocal Movement at Lumbosacral Lumbosacral J unction J unction ? ? Flexion of L5S1 Flexion of L5S1 – – Sacral base moves Sacral base moves posteriorly ( (counternutates counternutates) ) ? ? Extension of L5S1 Extension of L5S1 – – Sacral base moves Sacral base moves anteriorly ( (nutates nutates) ) ? ? Right rotation and left Right rotation and left sidebending – – Sacral base rotates to left and side bends right Sacral base rotates to left and side bends right posteriorly into extension into extension anteriorly into flexion into flexion sidebending of L5 of L5

  8. Muscle Functions Muscle Functions ? ? Piriformis Piriformis – – Anterior tilt and rotate sacrum to opposite side Anterior tilt and rotate sacrum to opposite side ? ? Assisted by Assisted by ipsilateral ipsilateral gluteus ? ? Contralateral Contralateral latissimus latissimus dorsi maximus maximus through LDF through LDF – – Nutation Nutation of sacrum and extension of LS junction of sacrum and extension of LS junction ? ? Long head of biceps Long head of biceps – – Backward tilt and rotate sacrum to same side Backward tilt and rotate sacrum to same side ? ? Longissimus Longissimus and and multifidus multifidus – – Pull sacral base superiorly and Pull sacral base superiorly and posteriorly dorsal ligaments dorsal ligaments gluteus maximus maximus dorsi and gluteus and gluteus posteriorly thru thru

  9. Normal Gait Mechanics Normal Gait Mechanics ? ? Innominate Innominate – – Right Right innominate – – Sacrum rotates toward it and Sacrum rotates toward it and sidebends from it from it ? ? Sacrum Sacrum – – Sacrum moves into right forward torsion on right Sacrum moves into right forward torsion on right oblique axis the returns to neutral oblique axis the returns to neutral ? ? L5 L5 – – As sacrum right rotates and left As sacrum right rotates and left sidebends left rotates and right left rotates and right sidebends sidebends innominate rotates rotates anteriorly anteriorly sidebends away away sidebends, L5 , L5

  10. Pelvic Girdle Function Pelvic Girdle Function ? ? Form closure Form closure – – Bones, joints, ligaments Bones, joints, ligaments ? ? Force closure Force closure – – Muscles, fascia Muscles, fascia ? ? Motor control Motor control – – Neural patterning Neural patterning ? ? Emotions Emotions – – Awareness Awareness Lee

  11. Impairments Impairments ? ? Excessive Excessive articular – – Fusion (AS) Fusion (AS) – – Capsular fibrosis Capsular fibrosis – – Overactivation Overactivation of global – – Joint fixation (underlying instability) Joint fixation (underlying instability) ? ? Insufficient Insufficient articular articular compression – – Ligamentous Ligamentous laxity laxity – – Underactivity Underactivity of local of local myofascial articular compression compression of global myofascial myofascial system system compression myofascial system system Lee

  12. Somatic Dysfunction Somatic Dysfunction ? ? Function Function – – Stability and motion of SI joints result of shape of joint Stability and motion of SI joints result of shape of joint surfaces (form closure) and altering of surfaces (form closure) and altering of ligamentous tension in response to changes of muscle tone (force tension in response to changes of muscle tone (force closure) (Isaacs & closure) (Isaacs & Bookhout Bookhout) ) ? ? Dysfunction Dysfunction – – Imbalance of tension and tone between muscles and Imbalance of tension and tone between muscles and ligaments which locks SI joint and prevents normal ligaments which locks SI joint and prevents normal function (Isaacs & function (Isaacs & Bookhout Bookhout) ) ? ? ARTT ARTT – – Asymmetry of position, restricted motion, tissue texture, Asymmetry of position, restricted motion, tissue texture, tenderness tenderness ligamentous

  13. Sacroiliac Somatic Sacroiliac Somatic Dysfunctions Dysfunctions ? ? Forward sacral torsion Forward sacral torsion ? ? Backward sacral torsion Backward sacral torsion ? ? Bilateral sacral anterior Bilateral sacral anterior nutation ? ? Bilateral sacral posterior Bilateral sacral posterior nutation ? ? Unilateral sacral anterior Unilateral sacral anterior nutation ? ? Unilateral sacral posterior Unilateral sacral posterior nutation nutation nutation nutation nutation

  14. Symptoms Symptoms ? ? Stiffness and pain with walking Stiffness and pain with walking ? ? Pain opposite side with walking Pain opposite side with walking – – SI ? ? Pain same side with walking Pain same side with walking – – IS ? ? Unilateral pain below L5 Unilateral pain below L5 ? ? Pain with sit to stand Pain with sit to stand ? ? Coccydynia Coccydynia (torsions) (torsions) ? ? Groin pain Groin pain SI IS

  15. Examination Examination ? ? Positional tests Positional tests ? ? Motion tests Motion tests ? ? Passive mobility tests Passive mobility tests ? ? Pain provocation tests Pain provocation tests ? ? Palpation Palpation

  16. Positional Tests Positional Tests ? ? Landmarks Landmarks – – ASIS ASIS – – PSIS PSIS – – Sacral Sacral sulcus – – ILA ILA – – Medial Medial malleoli – – L5 L5 – – Pubic tubercle Pubic tubercle ? ? Positions Positions – – Neutral, extended and Neutral, extended and flexed flexed sulcus malleoli (prone) (prone)

  17. Active Motion Tests Active Motion Tests ? ? Standing flexion Standing flexion test test ? ? Stork test Stork test – – Gillet Gillet’ ’s s test ? ? Seated flexion test Seated flexion test – – Piedallu Piedallu’ ’s s test test test

  18. Passive Mobility Testing Passive Mobility Testing ? ? Osteokinematic Osteokinematic – – Nutation/counternutation Nutation/counternutation ? ? Prone Prone – – Anterior/posterior Anterior/posterior innominate rotation rotation ? ? Sidelying Sidelying ? ? Arthrokinematic Arthrokinematic – – Inferoposterior Inferoposterior glide ? ? Anterior Anterior innominate – – Superoanterior Superoanterior glide ? ? Posterior Posterior innominate – – Horizontal translation Horizontal translation ? ? Squish test Squish test – – Vertical translation Vertical translation ? ? Lumbar spring test Lumbar spring test innominate glide innominate rotation glide innominate rotation rotation rotation

  19. Palpation Palpation ? ? Tension (ligaments) Tension (ligaments) – – Sacrotuberous Sacrotuberous – – Long dorsal ligament Long dorsal ligament ? ? Tone (muscles) Tone (muscles) – – Piriformis Piriformis – – Psoas/Iliacus Psoas/Iliacus – – Coccygeus Coccygeus – – Gluteus Gluteus maximus – – Latissimus Latissimus dorsi – – Multifidus Multifidus – – Erector Erector spinae ? ? Tenderness Tenderness maximus dorsi spinae

  20. Tenderness Tenderness ? ? L5S1 L5S1 – – yellow ? ? Lumbar Lumbar – – black ? ? SI joint SI joint - - blue yellow black blue

  21. Pain Provocation Tests Pain Provocation Tests ? ? Anterior gapping Anterior gapping (Distraction) (Distraction) ? ? Posterior gapping Posterior gapping (Compression) (Compression) ? ? Gaenslen Gaenslen’ ’s s ? ? Thigh thrust Thigh thrust ? ? Sacral thrust Sacral thrust

  22. Standing Standing ? ? Anatomic landmarks Anatomic landmarks ? ? Standing flexion test Standing flexion test – – Symmetrical superior movement of Symmetrical superior movement of PSIS ? ? Stork test ( Stork test (Gillet Gillet’ ’s s march test) march test) – – PSIS should drop (also move laterally after 90 PSIS should drop (also move laterally after 90° °) ) ? ? Hip drop test Hip drop test – – Anterior Anterior nutation nutation on side of bent knee, rotate on side of bent knee, rotate toward lumbar concavity toward lumbar concavity ? ? Side bending Side bending – – Anterior Anterior nutation nutation on side of convexity, rotate on side of convexity, rotate toward lumbar concavity toward lumbar concavity – – Anterior Anterior innominate innominate rotation (side of concavity), rotation (side of concavity), posterior posterior innominate innominate rotation (side of convexity) rotation (side of convexity) PSIS’ ’s s

  23. Seated Seated ? ? Seated forward flexion test Seated forward flexion test – – Symmetrical superior/anterior movement of Symmetrical superior/anterior movement of PSIS PSIS’ ’s s – – Positive seated flexion test indicates sacroiliac Positive seated flexion test indicates sacroiliac dysfunction dysfunction – – Indicates dysfunctional side Indicates dysfunctional side ? ? Palpation Palpation – – ILA ILA’ ’s s ? ? Symmetrical in upright, flexed and extended positions Symmetrical in upright, flexed and extended positions – – Lumbar Lumbar laminae laminae (L5) and transverse processes (L5) and transverse processes ? ? Symmetrical Symmetrical

  24. Seated Flexion Test Seated Flexion Test If ILA ILA’ ’s s become symmetrical become symmetrical – – Rule out Rule out ? ? Unilateral anterior or posterior sacral Unilateral anterior or posterior sacral nutations ? ? Forward sacral torsion Forward sacral torsion ? ? If positive on left If positive on left – – Rule out Rule out ? ? Bilateral anterior or posterior Bilateral anterior or posterior nutations – – Could be Could be ? ? Left unilateral anterior Left unilateral anterior nutation ? ? ROR forward sacral torsion ROR forward sacral torsion ? ? LOR backward sacral torsion LOR backward sacral torsion ? ? If nutations nutations nutation

  25. Supine Supine ? ? Palpate Palpate – – ASIS ASIS’ ’s s, pubic tubercles, medial , pubic tubercles, medial malleoli ? ? Helps define etiology Helps define etiology ? ? Is it purely sacral or mixed problem (iliac and pubic Is it purely sacral or mixed problem (iliac and pubic dysfunction) dysfunction) ? ? Squish test Squish test – – Symmetrical resistance Symmetrical resistance ? ? Pain provocation tests Pain provocation tests – – Gaenslen Gaenslen’ ’s s test test – – SI compression/distraction SI compression/distraction ? ? Compression in Compression in sidelying sidelying – – Thigh thrust Thigh thrust ? ? ASLR (Active SLR test) ASLR (Active SLR test) malleoli

  26. Prone Prone ? ? Palpation Palpation – – Sacral base and Sacral base and ILA ? ? Prone and prone Prone and prone- -on elbows positions – – Malleoli Malleoli position position – – Long dorsal sacroiliac joint ligament Long dorsal sacroiliac joint ligament – – Sacrotuberous Sacrotuberous ligament – – Muscles Muscles ? ? Piriformis Piriformis, , gluteal gluteal, , paraspinal ? ? Mobility Mobility – – Spring test Spring test ? ? Lumbar Lumbar ? ? Sacral (transverse axis & oblique axis) Sacral (transverse axis & oblique axis) ? ? Pain provocation test Pain provocation test – – Sacral thrust Sacral thrust ILA’ ’s s on elbows positions ligament paraspinal

  27. Forward Sacral Torsion Forward Sacral Torsion ? ? Forward rotation around oblique axis Forward rotation around oblique axis – – 85% LOL (common in R handed people) 85% LOL (common in R handed people) ? ? Imbalance between Imbalance between piriformis muscles. After muscles. After posterolateral posterolateral disc. ? ? Symptoms Symptoms – – No low back pain, unless associated with ERS No low back pain, unless associated with ERS – – Piriformis Piriformis symptoms, symptoms, gluteal – – Occasional sciatica Occasional sciatica – – Standing, walking and stair climbing Standing, walking and stair climbing – – Little or no pelvic restriction with gait Little or no pelvic restriction with gait ? ? In gait, on R heel strike, sacrum turns L and L5 turns R In gait, on R heel strike, sacrum turns L and L5 turns R ? ? At R mid At R mid- -stance, sacrum rotates right on ROA, L5 rotates L stance, sacrum rotates right on ROA, L5 rotates L and SB R and SB R ? ? Must treat lumbar non Must treat lumbar non- -neutral dysfunctions first neutral dysfunctions first piriformis and hip rotator and hip rotator disc. gluteal pain pain

  28. Backward Sacral Torsion Backward Sacral Torsion ? ? Backward rotation around oblique axis Backward rotation around oblique axis – – 85% LOR 85% LOR ? ? Lumbar Lumbar sidebending sidebending and rotation to same side while and rotation to same side while fully flexed. Locks with attempt to return to upright fully flexed. Locks with attempt to return to upright position. position. – – Left L/S SB/ROT in F will cause right sacral rotation on LOA Left L/S SB/ROT in F will cause right sacral rotation on LOA – – “ “the well bent over and the cripple stood up the well bent over and the cripple stood up” ” syndrome ? ? Symptoms: Symptoms: – – Testicle pain, heel burning, lateral knee pain, back of leg Testicle pain, heel burning, lateral knee pain, back of leg numb; can numb; can’ ’t lie side of torsion; can t lie side of torsion; can’ ’t lie prone; morning stiffness; inability to cross legs; inability to sweep or stiffness; inability to cross legs; inability to sweep or vacuum; pain with walking; sit vacuum; pain with walking; sit- -to position position ? ? Must treat non Must treat non- -neutral lumbar dysfunction first neutral lumbar dysfunction first syndrome t lie prone; morning to- -stand; rising from FB stand; rising from FB

  29. Sacral Torsion Diagnosis Sacral Torsion Diagnosis ? ? Sulcus Sulcus deep and ILA posterior on opposite sides deep and ILA posterior on opposite sides ? ? Sulcus Sulcus determines torsion determines torsion – – Left Left sulcus sulcus deep is RST deep is RST ? ? Axis and direction determination Axis and direction determination – – Piriformis Piriformis ? ? Left tight creates ROA Left tight creates ROA ? ? Positive left seated flexion test indicates tight left Positive left seated flexion test indicates tight left piriformis – – Spring test positive in backward, negative in forward Spring test positive in backward, negative in forward – – Forward torsions become asymmetric in flexion and Forward torsions become asymmetric in flexion and symmetric in extension ( symmetric in extension (ILA ILA’ ’s s) ) – – Backward torsions become asymmetric in extension and Backward torsions become asymmetric in extension and symmetric in flexion ( symmetric in flexion (ILA ILA’ ’s s) ) ? ? Normal lumbar adaptation Normal lumbar adaptation – – ROT in direction of deep ROT in direction of deep sulcus piriformis sulcus, SB away , SB away

  30. Sacral Torsions Sacral Torsions

  31. Bilateral Anterior Sacral Bilateral Anterior Sacral Nutation Nutation ? ? Also known as bilaterally flexed sacrum or bilateral Also known as bilaterally flexed sacrum or bilateral inferior sacral shear inferior sacral shear ? ? Forward rotation on MTA Forward rotation on MTA – – Rare Rare ? ? Jumping from a height and landing Jumping from a height and landing ? ? Symptoms: Symptoms: – – Persistent Persistent lumbosacral lumbosacral and and gluteal – – Lumbosacral/gluteal Lumbosacral/gluteal pain worse with forward bending, pain worse with forward bending, walking, standing, down stairs walking, standing, down stairs – – Prefers to lie prone Prefers to lie prone – – Stands with accentuated Stands with accentuated lordosis lordosis – – Uncomfortable sitting Uncomfortable sitting – – Lumbosacral Lumbosacral flexion limited flexion limited gluteal pain pain

  32. Bilateral Posterior Sacral Bilateral Posterior Sacral Nutation Nutation ? ? Also known as bilaterally extended sacrum Also known as bilaterally extended sacrum or bilateral superior sacral shear or bilateral superior sacral shear ? ? Backward sacral rotation on MTA Backward sacral rotation on MTA ? ? Lifting heavy load in midline position Lifting heavy load in midline position ? ? Symptoms: Symptoms: – – Constant Constant lumbosacral lumbosacral pain – – Lumbosacral Lumbosacral pain worse with backward bending, pain worse with backward bending, sit sit- -to to- -stand, walking down stairs, patient prefers stand, walking down stairs, patient prefers to sit slumped with arms on thighs, lie supine or to sit slumped with arms on thighs, lie supine or fetal position, stands with flat back fetal position, stands with flat back – – Lumbosacral Lumbosacral extension limited extension limited pain

  33. Bilateral SI Dysfunctions Bilateral SI Dysfunctions

  34. Unilateral Anterior Unilateral Anterior Sacral Sacral Nutation Nutation ? ? Also known as inferior sacral shear, unilateral flexed sacrum Also known as inferior sacral shear, unilateral flexed sacrum or side bent lesion or side bent lesion ? ? Usually traumatic Usually traumatic – – Land on one leg with spine extended (volleyball/basketball) Land on one leg with spine extended (volleyball/basketball) Superior transverse axis Superior transverse axis ? ? Associated with posterior Associated with posterior innominate innominate rotation and non L5 dysfunction (L L5 dysfunction (L innominate innominate posterior rotation with L5 ERSL) – – Treat L5 dysfunction first Treat L5 dysfunction first ? ? Less common than torsions 3:2, left flexion most common Less common than torsions 3:2, left flexion most common ? ? Symptoms Symptoms – – Pain usually in sacral and Pain usually in sacral and gluteal gluteal areas, unilateral – – Ipsilateral Ipsilateral sciatica sciatica – – Gait problem, pain opposite side Gait problem, pain opposite side – – Worse with standing (<20 min) Worse with standing (<20 min) – – Relieved by sitting Relieved by sitting ? ? Tests for sacral Tests for sacral sulci sulci and and ILA ILA’ ’s s definitive rotation and non- -neutral posterior rotation with L5 ERSL) neutral areas, unilateral definitive

  35. Unilateral Posterior Unilateral Posterior Sacral Sacral Nutation Nutation ? ? Also known as superior sacral shear or unilateral sacral Also known as superior sacral shear or unilateral sacral extension extension ? ? Superior transverse axis Superior transverse axis ? ? Rare, most common on right Rare, most common on right ? ? May be associated with anterior May be associated with anterior innominate ? ? May be confused with R on L torsion May be confused with R on L torsion ? ? Caused by bending and twisting followed by forceful extension Caused by bending and twisting followed by forceful extension with load. with load. Hypertonus Hypertonus of of ipsilateral ipsilateral longissimus result of result of thoracolumbar thoracolumbar area strain area strain ? ? Often treating source of Often treating source of hypertonus hypertonus (TL junction) fixes problem problem ? ? Sometimes must treat L5 (FRSR) Sometimes must treat L5 (FRSR) innominate dysfunction dysfunction longissimus thoracis thoracis as as (TL junction) fixes

  36. Unilateral Sacral Unilateral Sacral Nutation Diagnosis Diagnosis Nutation ? ? Sulcus Sulcus deep and ILA inferior/posterior on deep and ILA inferior/posterior on same side (anterior same side (anterior nutation ? ? Flexed and extended positions Flexed and extended positions – – ILA ILA’ ’s s never become symmetric with unilateral never become symmetric with unilateral nutations nutations ? ? Seated flexion test Seated flexion test – – Positive on left with left anterior Positive on left with left anterior nutation ? ? Normal lumbar adaptation Normal lumbar adaptation – – ROT in direction of deep ROT in direction of deep sulcus nutation) ) nutation sulcus, SB away , SB away

  37. Unilateral SI Dysfunctions Unilateral SI Dysfunctions

  38. Treatment Treatment ? ? Muscle energy Muscle energy ? ? Joint mobilization Joint mobilization ? ? Joint manipulation Joint manipulation ? ? Muscle stretching Muscle stretching ? ? Trunk stabilization Trunk stabilization

  39. Correction of Forward Correction of Forward Sacral Torsion Sacral Torsion ? ? Lie axis side down Lie axis side down ? ? Rotate trunk to right Rotate trunk to right with right arm off table with right arm off table ? ? Flex knees and hips to Flex knees and hips to localize forces at L/S localize forces at L/S junction junction ? ? Resist bottom heel Resist bottom heel lifting toward ceiling lifting toward ceiling ROR

  40. Correction of Backward Correction of Backward Sacral Torsion Sacral Torsion ? ? Lie axis side down Lie axis side down ? ? Extend lower leg to Extend lower leg to induce some sacral induce some sacral flexion flexion ? ? Flex upper hip so leg Flex upper hip so leg off table off table ? ? Extend trunk to L/S Extend trunk to L/S junction junction ? ? Rotate trunk left to L/S Rotate trunk left to L/S junction junction ? ? Resist lifting upper leg Resist lifting upper leg toward ceiling toward ceiling LOR

  41. Correction of Bilateral Correction of Bilateral Anterior Anterior Nutated Nutated Sacrum Sacrum ? ? Patient seated Patient seated ? ? Feet apart and legs Feet apart and legs internally rotated internally rotated ? ? Patient flexes forward Patient flexes forward ? ? ATC hands on sacral ATC hands on sacral apex and thoracic spine apex and thoracic spine ? ? Maintain pressure on Maintain pressure on sacral apex ( sacral apex (ILA resist trunk extension resist trunk extension with full inhalation with full inhalation ILA’ ’s s) and ) and

  42. Correction of Bilateral Correction of Bilateral Posterior Posterior Nutated Nutated Sacrum Sacrum ? ? Patient seated Patient seated ? ? Feet together and legs Feet together and legs externally rotated externally rotated ? ? Arms crossed Arms crossed ? ? ATC hands on sacral base ATC hands on sacral base and across anterior chest and across anterior chest ? ? Maintain pressure on Maintain pressure on sacral base and resist sacral base and resist trunk flexion with full trunk flexion with full exhalation or have patient exhalation or have patient arch back by pushing arch back by pushing abdomen to knees abdomen to knees

  43. Correction of Unilateral Correction of Unilateral Anterior Sacral Anterior Sacral Nutation Nutation ? ? Patient prone Patient prone ? ? Abduct (15 Abduct (15° °) and internally rotate left leg internally rotate left leg ? ? ATC ATC’ ’s s right hand on left right hand on left ILA ILA ? ? Apply and maintain Apply and maintain anterior and superior anterior and superior pressure on left ILA as pressure on left ILA as patient inhales and holds patient inhales and holds breath breath ? ? ATC maintains pressure ATC maintains pressure as patient exhales as patient exhales ) and Left Unilateral Anterior Nutation

  44. Correction of Unilateral Correction of Unilateral Posterior Sacral Posterior Sacral Nutation Nutation ? ? Patient prone Patient prone ? ? Abduct (15 Abduct (15° °) and externally ) and externally rotate right leg rotate right leg ? ? Trunk extended via prone on Trunk extended via prone on elbow position elbow position ? ? ATC ATC’ ’s s right hand on right sacral right hand on right sacral base base ? ? Apply and maintain anterior and Apply and maintain anterior and inferior pressure with right hand inferior pressure with right hand as patient exhales as patient exhales ? ? ATC ATC’ ’s s left hand applies posterior left hand applies posterior pressure to right ASIS pressure to right ASIS ? ? After exhalation, patient pulls After exhalation, patient pulls ASIS toward table ASIS toward table ? ? Return to prone lying position Return to prone lying position while maintaining pressure while maintaining pressure Right Unilateral Posterior Sacral Nutation

  45. Treatment Sequence Treatment Sequence ? ? Lumbar spine, pubes, Lumbar spine, pubes, innominate dysfunction, dysfunction, iliosacral iliosacral dysfunction, muscle imbalances ( imbalances (Greenman Greenman) ) ? ? Pubes, Pubes, innominate innominate shears, lumbar spine, sacroiliac shears, lumbar spine, sacroiliac dysfunction, dysfunction, iliosacral iliosacral dysfunction ( dysfunction (Issacs Bookhout Bookhout) ) ? ? Leg muscles, pubes, Leg muscles, pubes, iliosacral iliosacral (flares, shears, rotations), sacroiliac, lumbar (unless L5, shears, rotations), sacroiliac, lumbar (unless L5, then before sacrum) (Rex) then before sacrum) (Rex) ? ? Pubes, Pubes, iliosacral iliosacral (rotations, (rotations, innominate flares) sacroiliac (Mitchell) flares) sacroiliac (Mitchell) innominate shears, sacroiliac shears, sacroiliac dysfunction, muscle Issacs & & (flares, innominate innominate innominate shears, shears,

  46. References References ? ? Issacs Issacs ER, Manipulation (6 Manipulation (6th Heinemann:Boston Heinemann:Boston, 2002 ? ? Greenman Greenman PE. Principles of Manual Medicine PE. Principles of Manual Medicine (3 (3rd Ed.). Lippincott Lippincott Williams & Williams & Wilkins:Philadelphia Wilkins:Philadelphia, 2005 , 2005 ? ? Lee D. The Pelvic Girdle (3 Lee D. The Pelvic Girdle (3rd Livingstone:Edinburgh Livingstone:Edinburgh, 2004 ? ? Rex L. Rex L. Ursa Ursa Foundation, Edmonds, WA. Foundation, Edmonds, WA. ER, Bookhout Bookhout MR. thEd.). Butterworth Ed.). Butterworth- - , 2002 MR. Bourdillon Bourdillon’ ’s s Spinal Spinal rdEd.). rdEd.). Churchill Ed.). Churchill , 2004