Sacroiliac(SI) Joint Dysfunction,Evaluation and Treatment

Evaluation and Treatment
of
Sacroiliac Joint Dysfunction
MD. Monsur Rahman
(MPT-Musculoskeletal Disorders)

Introduction
 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.
(Bernard & Kirkildy, 1987; Fortin, et al., 1994, Cohen, 2007).
 SIJ dysfunction are the fourth common cause of LBP and pelvic pain (Paris & Viti, 2007).
 6-13% source of LBP, pelvis or referred lower extremity pain (Schwarzer, et al., 1995a, Bogduk,
1995).
 SIJ surface area is greater in males than females (Ebraheim & Biyani, 2003) increased
biomechanical loading in males (Vleeming et al.,2012).
(Dreyfuss, et al., 1994; Tulberg, et al., 1998; Van der Wurff, et al., 2000; Cibulka, 2002; Riddle and Freburger, 2002).

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.
 It forms joints with four other bones. The two projections at the sides of the sacrum are called
the alae (wings), and articulate with the ilium at the L-shaped sacroiliac joints.
 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.

Sacroiliac Ligament
• Sacroiliac ligament: actually three parts
1. Anterior or ventral sacroiliac
from 3rd sacral segment to lateral preauricular sulcus
2. interosseous sacroiliac
massive bond between the upper parts of the joint
3. dorsal sacroiliac
Partly covers the interosseous, from lateral sacral crest to PSIS
and internal iliac crest.

Pelvic muscle attachments
from above.
Posterior Muscular Attachments
Attach to Sacrum
• Erector Spinae
• Iliocostalis
• Longissimus
• Erector Spinae
• Multifidus
Attach to Innominates
• Obliques (internal, external, transverse)
• Quadratus Lumborum

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 thru dorsal ligaments

INNERVATIONS
 SIJ innervated by L4-S1. (Solonen ,1957)
 Supply from dorsal rami L5, S1, S2 and S3. (Bradley, 1985)
 Supply by fifth lumbar nerve. (Ikeda,1991)
 Exclusively innervated by S1-S4 dorsal rami. (Grob et al.,1995)
 Dorsal sacral plexus (S1-S3). (Willard et al.,1998)
→ COMPLEXITY OF SIJ INNERVATIONS !!!

SACROILIAC JOINT STRUCTURE
 Diarthrodial joint with two bony surfaces, sacrum and ilium 1-2 mm wide
 Joint surfaces are lined with hyaline cartilage, and the iliac cartilage seems thinner and
more fibrocartilaginous than that of sacrum side.
 Superior third of hyaline iliac cartilage is strongly attached to surrounding stabilizing
ligaments, forming wide margins of fibrocartilage.
 Inferior third of the joint along iliac bone has some histologic characteristics of a “synovial
joint”.
(Puhakka et al., 2004)

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

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

Sacroiliac Somatic
Dysfunctions
• Forward sacral torsion
• Backward sacral torsion
• Bilateral sacral anterior nutation
• Bilateral sacral posterior nutation
• Unilateral sacral anterior nutation
• Unilateral sacral posterior nutation

Symptoms
• Stiffness and pain with walking
• Pain opposite side with walking
• Pain same side with walking
• Unilateral pain below L5
• Pain with sit to stand
• Coccydynia (torsions)
• Groin pain

(Kuchera,2007, Journal of American Osteopathic Association, ES31, Suppl6, 107, 11)
A B C D
Myotomal pain referral regions from muscle trigger points:
(A) Quadratus lumborom.
(B) Piriformis.
(C) Iliopsoas.
(D) Rotatores and Multifidis muscles.

(Kuchera,2007, Journal of American Osteopathic Association, ES31, Suppl6,107,11)
A B C
Sclerotomal pain referral regions from ligaments:
(A) Iliolumbar ligament
(B) sacrospinous and sacrotuberous ligaments.
(C) posterior sacroiliac ligament.

Examination
 Positional tests
 Motion tests
 Passive mobility tests
 Pain provocation tests
 Palpation

EXAMINATION SEQUENCE
1. Observation
2. Temperature
3. Skin topography and texture
4. Fascia
5. Muscle
6. Tendon
7. Ligament
8. Erythema friction rub

Visual observation of patient
Prior to touching the patient, the
examiner should visualize the area to be
examined for evidence of trauma,
infection,anomalies, Gross asymmetries,
skin lésions,and/or anatomic variations.

Temperature
Temperature is evaluated by
using the volar aspect of the
wrist or the dorsal hypothenar
eminence of the hand.

Skin Structure and Texture
A very light touch will be used.
Gentle palpation with the palmar surface of the tips of the fingers
will provide the necessary pressure.
The pressure will permit the finger pads to glide gently over the
skin without drag (friction).
Skin Structure and texture are evaluated for increased or
decreased humidity, oiliness, thickening, roughness.

Fascia
 Apply the enough pressure to
move the skin with the hand to
evaluate the fascia.
 The examiner moves the hand
very gently in left, right, clockwise,
and anti clockwise directions to
elicit motion and tension quality
barriers of ease and bind .
 Minimal changes in pressure to
evaluate the different levels of
fascia are helpful.

Muscles
• Muscle is deeper tissue; therefore, the next
degree of palpatory pressure is applied.
• The examiner adds slightly more pressure
to evaluate the muscle's consistency and
determines there is resistance to pressure.

LIGAMENTS
• Ligaments must be considered when restriction of joint
motion, hypermobility (joint laxity), pain.
Tenderness
L5-S1 – yellow
Lumbar – black
SI joint - blue

Erythema Friction Rub
• The final step is to perform the erythema friction rub, in which the pads of the examiner
second and third digits are placed just paraspinal and then in two to three quick strokes
drawn down the spine cephalad to caudal.
• Pallor or reddening is evaluated per spinal segment for vasomotor changes that may be
secondary to dysfunction.
• This is not typically done on the extremities, as the purpose of this test is to identify central
spinal areas of autonomic change related to segmental dysfunction

Diagnose the Sacrum
• Sitting Flexion Test (SFT)
• Sacral Sulcus (SS)
• Inferior Lateral Angle (ILA)
• Spring Test (ST)

Seated Flexion Test
• The patient is seated on a stool or treatment table with both feet flat
on the floor a shoulder-width apart.
• The examiner stands or kneel down behind the patient with the eyes
at the level of the patient's PSISs.
• The examiner’s thumbs are placed on the inferior aspect of the
patient's PSISs and a firm pressure is directed on the PSISs, not
skin or fascial drag, to follow bony landmark motion .
• The patient is instructed to forward-bend as far as possible within a
pain-free range.
Forward bending.
Hand placement on PSIS.

Cont…
• The test is positive on the side where the thumb (PSIS) moves more at the
end range of motion.
• A positive seated flexion test identifies the side of sacral dysfunction, not the
specific type of dysfunction.
•
• A negative test may indicate a pelvic on sacrum (iliosacral type) dysfunction,
such as innominate rotation.
Positive seated flexion test

Sacral Sulcus Depth
• Palpable groove just medial to PSIS.
• Space between sacral spines and lateral sacral crest.
• Place thumbs in inferior border of PSIS.
• Move ½ to 1” up and medial to PSIS.
• Push thumb tips on sacral base.
• Pads of thumbs are on ilium and tips on sacral base.
Measure the depth of each sacral
sulcus relative to opposite sulcus?
Record even, deep, or shallow,
comparing one side to the other.
Both sides may be shallow or deep as well.

Inferior Lateral Angle
1. Place flat of hand over sacrum near its caudal end and identify the coccyx.
2. Thumbs approximately 1” apart. Place thumbs in gluteal area about 1” caudal and on each side of
coccyx.
3. Push thumbs cephalad until pads rest on inferior margin of ILA. Take a reading on the lateralized
side: Inferior or superior? Possibly even?
4. Move thumbs approximately 1” cephalad from the inferior margin of the ILAs and place the pads
of the thumbs over the posterior surface of the ILAs near the apex of the sacrum.
5. Use moderate equal pressure & judge if one side is more anterior or posterior
than the other one or are they equal? Record on the lateralized side.

Spring Test
Technique:
 With the patient prone, the examiner
applies an anteriorly directed pressure
over the sacrum. One hand is placed
directly on the sacrum and is being
reinforced by the other hand.
 Purpose is to apply an anterior shear
force to both sacroiliac joints since the ilia
are fixed by the examination bench.
 The test is positive if pain is reproduced in
the sacroiliac region
Laslett et al (2005)
 Also known as sacral compression test, downwards pressure test , sacral thrust test
 Spring Test + ev = Extension dysfunction

Left Unilateral Flexion
D
P
SFT/L
SS/L
ILA/L
S

Right Unilateral Extension
D
PI
SFT/R
SS/LD
ILA/L
AI
S

Right Unilateral Extension
D
P
SFT/R
SS/SR
ILA/L
A
S

Left Unilateral Extension
D
R
SFT (-) ev
SS/DR
ILA/R
Spring Test (+) ev
S
ILA
SS
P

Right Unilateral Flexion
DSFT (-) ev
SS/DR
ILA/R
Spring Test (-) ev
S
ILA
SS
P

Torsion
Forward Torsion
• R on R
• L on L
• Flexion dysfunction
Backward Torsion
• R on L
• L on R
• Extension dysfunction

R on R
D
P
SFT/+ev on L
SS/D on L
ILA/R
S
ILA

L on L
D
P
SFT/+ev on R
SS/D on R
ILA/L
ILA

R on L Backward Torsion
D
P
SFT/+ev on R
SS/D on L
ILA/L
ILA
S

L on R Backward Torsion
D
P
SFT/+ev on R
SS/D on L
ILA/L
ILA
S

L on R Backward Torsion
D
P
SFT
SS/ D on R
ILA/P in L
Spring Test (+) ev
ILA
S

R on R Forward Torsion
D
P
SFT
SS/ D on L
ILA/P in R
Spring Test (-) ev
ILA
S

L5 Findings
• Side Bending= Axis
• If L5 SB in left then sacrum rotate in left axis
• If L5 SB in right then sacrum rotate in right axis

L5 SB on Right and Rotate to the left
D
 L5 SB on R and rotate
to the left (Axis on R)
R on R Flexion dysfunction
 So Sacrum rotate to the right

L5 SB on Left and Rotate to the left
D L5 SB on L and rotate to
the left (Axis on R)
R on L Extension dysfunction
 So Sacrum rotate to the right

FABERS test
 The patient is positioned in supine, 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 ASIS, 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

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)

Laguerre test
Procedure:
• Patient in supine, examiner flexes, abducts & laterally rotates
the patients affected leg . Applies gentle pressure at the end
range of motion.
Interpretation:
Positive Laguerre’s Test
• Ipsilateral sacroiliac pain: Sacroiliac joint
pathology (ligamentous sprain, instability,
sacroiliitis)
• Hip pain: Hip joint pathology (arthritis, ligament
sprain, rule out hip fracture and infection)

Gillet test
 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

Respiratory motion test
• With the patient prone, the examiner hand rest gently on the sacrum with fingertip at the
sacral base and palm at coccyx
• Ask the patient to take the deep breath and follow the sacrum into anatomical extension
with inhalation and anatomical flexion with exhalation.
• Restriction of sacral extension indicates flexion ease
• Restriction of sacral flexion indicates extension ease

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.

6. 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
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.

Cont…
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. 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. 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. This stretch is held for several seconds, is slowly released, and
is then repeated in a gentle, rhythmic, and kneading fashion.
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
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.

Cont….
 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 Points

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. The physician extends the patient's thigh and hip until the
dysfunctional segment is engaged.
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. 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.

Sacroiliac(SI) Joint Dysfunction,Evaluation and Treatment

Sacroiliac(SI) Joint Dysfunction,Evaluation and Treatment

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