Sacral Dysfunction Diagnosis and ME Flashcards
Sacral axes
Vertical axis
Superior transverse axis
- respiratory motion
Middle transverse axis
- postural/sacral axis
- Flexion and extensions of the sacrum move along this axis
Inferior transverse axis
- innominate motion
- innominate dysfunctions happen on this axis
Oblique axis
AP rotational axis
When are the oblique axes of the sacrum engaged?
During normal gait
During waiting, bending forward/backwards while also leaning or twisting from one side.
What is required to be assessed in order to make a sacral diagnosis?
Seated flexion test
Sacral sulci
Inferior lateral angles (ILAs) of the sacrum
L5 tri-planar diagnosis
What are the two tests to perform in order to confirm sacral diagnosis?
Sacral spring test
Sphinx test
Seated flexion test
Helps determine if there is sacroiliac joint dysfunction
- Exception is if the patient has bilateral shears (in this case, test will be a false negative)
- the side of (+) is the dysfunctional side
1) patient is seated on the table with feet resting on floor or supported
- hips and knees are @ 90 degree flexion
- * this is to prevent the patient from engaging lower extremity or back musculature which can provide a false negative or positive
2) layer palate through the patients tissue until you have the thumbs on the inferior aspects of the PSIS’s (thumbs horizontal orientation
3) patient is to slowly bend forward, rounding the entire spine into flexion, with arms between legs, until the physiological barrier is reached
4) which ever PSIS (if any) is more cephalad once the barrier has been reached, this is the dysfunctional side and results in (+) test.
- *this is because as the lumbar spine flexes, the dysfunctional side sacrum is “glued” to the innominate, which causes them to move together cephalad, rather than separately.
NOTE: a negative test can mean there is no sacroiliac somatic dysfunction OR there is a somatic dysfunction but it involves both sacroiliac joints (bilateral shears)
* NOTE: the seated flexion test is testing the inferior transverse axis movement*
Physical exam findings for sacral shears and sacral torsions
Sacral shears:
- (+) side on seated flexion is the side of somatic dysfunction
- (+) side is equal to the side of the oblique axis
- deep sacral sulcus and the posterior/inferior ILAs will be on the same side
Sacral torsions:
- (+) side is the side of somatic dysfunction
- (+) side is opposite the side of the oblique axis
- deep sacral sulcus and posterior/inferior ILAs will be on opposite sides
- L5 rotates in the opposite direction as the sacrum
Where are the sacral sulci and inferolateral angles (ILAs) located respectfully?
Sacral sulci
- medial to the PSISs in a “dip” at the base of the sacrum
- there are 2: left and right sacral sulci
Inferolateral angles (ILAs)
- at the inferior portion of the sacrum just superior to the coccyx
- they are the inferior and lateral angles of the sacrum and there are 2: left and right
How to assess the sacral sulci
1) stand beside the prone patient
2) palpate the inferior aspects of the PSISs bilaterally
3) move fingers medially and a bit superiorly off the inferior aspects of the PSISs and onto the sacrum (this should be where they are)
4) assess the sacral sulci on the (+) seated flexion side and compare it to the other side
- Deep sulci = closer to table ; farther from PSIS
- Shallow sulci = further from table ; closer to PSIS
How to assess the sacral ILAs
1) stand beside a prone patient with your dominant eye closest to the patient
2) use the thenar/hypothenar aspects of your palm to palpate down from the PSIS -> distal sacrum
3) moves thumbs onto the posterior surface of the inferior lateral angles (ILAs) of the sacrum and assess which one is most POSTERIOR
4) moves thumbs onto the inferior surfaces of the inferior lateral angles (ILAs) of the sacrum and assess which one is most INFERIOR
** note that whichever one is most posterior is also most inferior and vise versa (may not be able to feel both, only one or the other) **
Sacral shear details
non-physiological somatic dysfunctions
They are true sacroiliac joint dysfunctions
Involve slippage of the sacrum around the C-shaped articular surface of the sacrum
Occur around the middle-transverse axis
Can be bilateral (in flexion or extension) or unilateral (in flexion or extension)
Sacral torsion details
Can be physiologic or non-physiologic somatic dysfunctions (depends on source)
L5/S1 joint dysfunction (false sacroiliac joint dysfunction)
Caused by an imbalance between the muscles that affect sacral motion in relationships to L5 motion
Can be anterior Or posterior
- anterior torsions = rotation and oblique axis are ipsilateral
- posterior torsions = rotation and oblique axis are contralateral
- this is because the oblique axis of movement must go through a non-dysfunctional SI joint*
How to name sacral torsions
Anterior sacral torsions
- sacral base rotates forward and around the oblique axis
- the side of rotation is the side towards the anterior surface of the sacrum
Posterior sacral torsions
- sacral base rotates backward and around the oblique axis
- the side of rotation is they side toward the anterior surface of the sacrum
- the deep sacral sulcus and Posterior ILA will be on the opposite sides*
** the oblique axis and the seated flexion test side will be opposite**
How to help determine direction of sacral rotation
Picture a face on the anterior portion of the sacrum
Whichever direction the face is looking, that is the rotational side
How to tri-planar diagnose L5 vertebra
1) stand beside a prone patient or seated patient with your eyes at level with lower lumbar spine and the dominant eye is closest to patient
2) find L5 vertebra
3) layer by layer palpate until the transverse processes of L5 are palpated
4) assess the quality and quantities of
- rotation (posterior -> anterior pressure)
- side bending (lateral -> medial pressures from each side)
- flexion and extension (same movements just see if its easier in one or the other)
5) Note diagnosis afterwards
Sacral spring test
1) stand behind the prone patient with the dominant eye closest to patient
2) place medial aspect of the palm along the patients lumbosacral junction, with contact on the sacrum in order to cause flexion
3) apply a gentle posterior -> anterior springing force tot he junction
4) assess the quality of springing motion of the sacral base between innominates
- this helps with diagnosis
- A (-) test (good spring) indicates bilateral/unilateral sacral flexion or anterior sacral torsions (Left/left; right/right)*
- A (+) test (poor spring) indicates bilateral/unilateral sacral extension or posterior sacral torsions (left/right; right/left)
Sacral diagnosis and the expected quality/quantity of motion with the sacral spring test
Bilateral flexion = most spring
Unilateral flexion = slightly less spring but still a lot
Unilateral extension = slightly less spring than unilateral flexion
Bilateral extension = little spring
Sphinx test (backward bending) steps
1) stand beside a prone patient with the dominant eye closest to the patient
2) palpate the inferior aspects of the PSISs bilaterally
3) move your fingers medially and a bit superiorly off the sacrum so you are on the sacral sulci
4) assess the sacral sulci bilaterally and then have the patient move into the sphinx position (propping themselves up on their elbows)
5) see if the symmetry of the sacral sulci changes (gets better or gets worse)
6) see if the symmetry of the ILAs Changes (gets better or gets worse)
Sphinx test results meanings
(-) sphinx test (the symmetry improves)
- found in unilateral sacral flexion and anterior sacral torsions
- dysfunctional sacral base is already anterior (stuck forward)
- backward bending (sphinx position) causes the non-dysfunctional sacral base to move more anterior, causing asymmetries to appear more symmetrical (deep sulci becomes shallow; anterior ILA (non-dysfunctional) moves posteriorly)
(+) sphinx test (worsened symmetry)
- found in unilateral sacral extension and posterior sacral torsions
- dysfunctional sacral base is stuck posteriorly
- backward bending (sphinx position) causes the non-dysfunctional sacral base to move more anteriorly, causing asymmetries to be more prominent (deep sulci becomes more deep; dysfunctional sacral ILAs move more posterior
Bilateral sacral flexion shear physical exam findings
Increased lumbosacral angle
Increased lumbar lordosis
Negative seated flexion test
Sacral sulci deep bilaterally and gets more deep with back bending
ILAs are posterior bilaterally and get more posterior in with back bending
L5 is likely in extension
Good sacral spring (negative sacral spring test)
No changes in asymmetry of the sacral sulci or ILAs in the sphinx position (null test)
Bilateral Sacral Extension sacral shear physical exam findings
Decreased lumbosacral angle
Decreased lumbar lordosis
Negative seated flexion test
Sacral sulci are shallow bilaterally and become more shallow with backward bending
ILAs are anterior bilaterally and become more anterior with backward bending
L5 likely in flexion
Poor sacral spring (positive sacral spring test)
No changes in asymmetry do the sacral sulci or ILAs when going into sophinx position (null test)
Right unilateral sacral flexion physical exam findings
Positive seated flexion test on the right
Deep sacral sulci (anterior) on the right
Shallow sacral sulci on the left
ILAs on the right are posterior/inferior
L5 is rotated right (since sacrum is rotated to the left)
Sacral spring test results are negative
Improved symmetry of the sacral sulci and ILAs in sphinx position
Left unilateral sacral flexion physical exam findings
Positive seated flexion test on the left
Deep sacral sulci (anterior) on the left
Shallow sacral sulci on the right
ILAs on the left are posterior/inferior
L5 is rotated left (since sacrum is rotated to the right)
Sacral spring test results are negative
Improved symmetry of the sacral sulci and ILAs in sphinx position
Right unilateral sacral extension physical exam findings
Positive seated flexion test on the right
Deep sacral sulci (anterior) on the left
Shallow sacral sulci on the right
ILAs on the left are posterior/inferior
L5 is rotated left (since sacrum is rotated to the right)
Sacral spring test results are positive
Worsened symmetry of the sacral sulci and ILAs in sphinx position
Left unilateral sacral extension physical exam findings
Positive seated flexion test on the left
Deep sacral sulci (anterior) on the right
Shallow sacral sulci on the left
ILAs on the right are posterior/inferior
L5 is rotated right (since sacrum is rotated to the left)
Sacral spring test results are positive
Worsened symmetry of the sacral sulci and ILAs in sphinx position
Left rotation on the left oblique axis sacral torsion physical exam findings
Positive seated flexion test on the right
Deep sacral sulci (anterior) on the right
ILAs on the left are posterior/inferior
L5 is rotated right with type 1 mechanics (since sacrum is rotated to the left)
Sacral spring test results are negative
Improved symmetry of the sacral sulci and ILAs in sphinx position
Right rotation on a right oblique axis sacral torsion physical exam findings
Positive seated flexion test on the left
Deep sacral sulci (anterior) on the left
ILAs on the right are posterior/inferior
L5 is rotated left with type 1 (since sacrum is rotated to the left)
Sacral spring test results are negative
Improved symmetry of the sacral sulci and ILAs in sphinx position
Left rotation on a right oblique axis sacral torsion physical exam findings
Positive seated flexion test on the left
Deep sacral sulci (anterior) on the right
Shallow sacral sulci on the left
ILAs on the left are posterior/inferior
L5 is rotated right with type 2 mechanics (since sacrum is rotated to the left)
Sacral spring test results are positive
Worsened symmetry of the sacral sulci and ILAs in sphinx position
Right rotation on a left oblique axis sacral torsion physical exam findings
Positive seated flexion test on the right
Deep sacral sulci (anterior) on the left
Shallow sacral sulci on the right
ILAs on the right are posterior/inferior
L5 is rotated left with type 2 mechanics (since sacrum is rotated to the left)
Sacral spring test results are positive
Worsened symmetry of the sacral sulci and ILAs in sphinx position
Where are you applying pressure for unilateral sacral flexion and extension somatic dysfunctions?
Sacral flexion:
On the ipsilateral ILA itself
Sacral extension:
- on the ipsilateral sacral base
When would you treat L5 vs the sacrum first on a sacral torsion dysfunction?
If L5 is rotated the same direction the sacrum is
- in this case L5 is uncompensated, so treating it should resolve the Sacral dysfunction
