OPP 18 Sacrum Dx Tx

Sacral osteology

• lumbosacral facets

  • 5 segments

• lumbosacral junction

  • may contain transitional vertebra

    • lumbarization

    • sacralization

• 4 coccygeal segments

Sacralization

fusion of lumbar vertebrae into sacrum

Lumbarization

non-disjunction of sacral vertebrae into individual vertebrae

Ferguson’s angle

line of inclination of sacrum w line parallel to ground

• sacroiliac joint is L-shaped + converges posteriorly

• 25-35 degrees

Psoas syndrome

tight + inflamed + spastic psoas major → pain

Meralgia paresthetica

compression of lateral femoral cutaneous n.

True pelvic ligaments

• anterior sacroiliac

• interosseous

• posterior sacroiliac

Accessory ligaments

• sacrotuberous

• iliolumbar

• sacrospinous

Sacral plexus significance

contains both motor + sensory innervation

Sacral parasympathtics levels

S2-S4

Ganglion impar

where right + left sympathetic chain joints + rest on the anterior surface of coccyx

Important landmarks for sacral dx

• sacral sulcus

• sacral foramina

• inferior lateral angle (ILA)

• ischial tuberosity

Sacral axis of rotation

Transverse axes

• superior (3)

• middle (4)

• inferior (5)

Oblique axes

• right (2)

• left (6)

Superior transverse axis

• located at S2

• posterior to SI joint

• respiratory + craniosacral motion:

Middle transverse axis (sacroiliac axis)

• located at anterior convexity + S2 sacral body

• postural flexion + extension

Inferior transverse axis

• posterior inferior part of the inferior limb of SI joint

• ilial (innominate) rotation

Sacral flexion

• base of sacrum moves anterior for anatomic flexion

• motion is about middle transverse axis

Oblique axes

• right + left

  • named for superior start location

• most likely a combination of side-bending + rotation

Sacral extension

• base of sacrum moves posteriorly

• movement about middle transverse axis

Sacral rotation

• about vertical axis

• more of a theoretical consideration

Side-bending

• about A-P axis

Standing flexion test

• pt shoulder width apart

• palpate + hook under PSIS w thumb on pt

• slowly bends forward

Results

• pos → PSIS moves superiorly → iliosacral dysfunction

  • but if both seated + standing flexion tests are positive → fs sacroliliac dysfunction but possible iliosacral dysfunction

• neg → PSIS moves symmetrically

Seated flexion test

• pt seated

• palpate + hook under PSIS w thumb on pt

• pt slowly bends forward

Results

• pos → PSIS moves superiorly → sacroiliac dysfunction

• neg → PSIS moves symmetrically

Spring test

• find sacral base

• place hand over lumbosacral juction

• apply rhythmic gentle + rapid downward pressure

Results

• neg → good spring

  • nice + normal + negative

  • eg forward torsion + uni/bilateral flexion

• pos → bad spring

  • posterior + painful + positive

  • eg backward torsion + uni/bilateral extension

Left on left torsion (left torsion about left oblique axis)

• deep sulcus → R

• seated flexion test → R

• inferior/posterior ILA → L

• sacrotuberous ligament taught → L

• Spring test → neg

Right on right torsion (right torsion about right oblique axis)

• deep sulcus → L

• seated flexion test → L

• inferior/posterior ILA → R

• sacrotuberous ligament taught → R

• Spring test → neg

Forward sacral torsions (2)

• left on left torsion

• right on right torsion

Backward sacral torsions

• left rotation on right axis

• right rotation on left axix

Left on right torsion (left rotation on right oblique axis)

• deep sulcus → R (shallow on left)

• seated flexion test → L

• inferior/posterior ILA → L

• sacrotuberous ligament taught → L

• Spring test → pos

Right on left torsion (right rotation on left oblique axis)

• deep sulcus → L (shallow on right)

• seated flexion test → R

• inferior/posterior ILA → R

• sacrotuberous ligament taught → R

• Spring test → pos

Unilateral sacral flexion

• left unilateral

• right unilateral

Left unilateral sacral flexion

• deep sulcus → L

• inferior/posterior ILA → L

• sacrotuberous ligament taught → L

• seated flexion test → pos L

Right unilateral sacral flexion

• deep sulcus → R

• inferior/posterior ILA → R

• sacrotuberous ligament taught → R

• seated flexion test → pos R

Bilateral flexion

• Motion decreased bilaterally

• sacrum flexes

  • but is restricted in extension

• spring test → negative

• seated flexion test → positive bilaterally

  • or false negative bc symmetrical

Bilateral extension

• motion decreased bilaterally

• sacrum extends

  • but is restricted in flexion

• spring test → postive

Backward Bending test (sphinx test)

Motion about an oblique axis test

Motion about transverse axis test

• pt laying prone

• put hands over sacrum

  • first hand pointing cephalad

  • top hand pointing caudad

• apply alternating pressure (rocking hands top and bottom)

• assess quality of motion

Sacral rocking tx

• Indications: Dysmenorrhea, Pelvic congestion syndrome, Sacroiliac dysfunction 

• Patient prone 

• Physician at either side 

• Place the heel of the cephalad hand on the base with the fingers pointing caudad (or cephalad with the other hand opposite) 

• Place the caudad hand in the opposite direction on top of the other hand 

• Exert a ventral force to engage the sacrum 

• Introduce a rocking motion to the sacrum synchronous with the patient’s respiration 

• Sacral extension (base moves posterior) – inhalation 

• Sacral flexion (base moves anterior) – exhalation 

• Continue for several minutes 

Counterstrain sacral locations

Common causes of sacroiliac dysfunction (10)