4. Article: Evaluating Sacroiliac Joint Play With Spring Tests

5.  Blog Comment: Sacroiliac Blog

6.  Sacrum:  Key Concepts

7.  Email:  Sacral Rotation Dialogue

8.  Email:  SIJ Dialogue

9.  Discussion of Symphysis Pubis

10.The Righting Reflex, Pelvis and Neck

11. Coccyx

12.  Abstract:  Downslip Ilium with Paradoxical Upslip Appearance

13.  Pubic Symphysis Q & A

14.  Letters to the Editor:  Sacroiliac

15.  False Positive Pelvic Instability in Pregnancy

16.  Use of McConnell Taping for SI Joint Dysfunction

17.   S-I Joint Dysfunction in Acute Low Back Pain

18.  Radiological Assessment of the S-I Joint in Low Back Pain Patients

19.  The Righting Reflex and the Cranicervical Response

Links to Additional Articles Not Published below:

 1. Article:  Evaluation and Treatment of the Most Common Patterns of Sacroiliac Joint Dysfunction

Jerry Hesch PT

INTRODUCTION
The sacroiliac joint (SIJ) has been implicated as a source of low back pain by many clinicians and researchers, including Lee (1989, 1992) and Vleeming and Mooney (1992). There is an interdisciplinary interest in the role of the SIJ and low back pain and its functional relation to the musculoskeletal system (Vleeming et al 1992, 1995). The SIJ may cause pain due to disease, inflammation, or movement dysfunction. Movement dysfunction may exist as hypermobility or hypomobility. According to Porterfield and DeRosa (1991), the normal SIJ functions as a triplane shock absorber and transfers upper body weight into the pelvis and lower extremities, and participates in the absorption of the force of heel strike. If the SIJ is hypomobile, it cannot effectively absorb stress from activities of daily living, and other structures may be overstressed, thus contributing to musculoskeletal pain and dysfunction. Examples are low back pain and hip pain. Ligamentous and capsular pain may be present if one or more of the pelvic bones has moved beyond the normal range of motion and became stuck, thus perpetuating soft tissue pain. Treatment can often produce dramatic results in a short period of time by passively restoring normal motion. In this example, the hypomobility is transient and is appropriately referred to as apparent hypomobility. True hypo-mobility or status hypomobility is much more resistant to treatment and at times non-responsive. Often, degenerative changes or disease has occurred over time, and thus normal mobility cannot be restored. Mild forms of true hypermobility can be managed readily, whereas moderate and severe forms are quite challenging. Other authors have addressed true hypermobility and instability within this book.

Apparent hypermobility and apparent hypo-mobility often coexist. Mobility testing of the pelvis reveals one direction of decreased mobility, whereas testing in the opposite direction reveals increased mobility. This is quite common, and treatment directed at restoring normal movement in the direction of hypomobility usually also restores normal movement in the direction of the apparent hypermobility. This chapter addresses common patterns of apparent hypomobility and apparent hypermobility.

It is an established fact that the SIJ has a small amount of functional motion, as does the symphysis pubis (Vleeming et al 1992). There may be a greater than normal amount of motion due to trauma, repetitive overload, inflammation, hormonal laxity, or heredity. Bernard (1992) has demonstrated through fluoroscopy that the SIJ does move with manually applied loads such as those utilized in evaluation and treatment. What has not been established is whether or not manual clinical tests and treatments specifically affect only the SIJ. It may be that mobility is evaluated and treated manually as part of the integrated system of the spine, pelvis, and hip. The SIJ is part of this system, and it does not function in an isolated fashion. Mobility tests that attempt to isolate actual joint play may yield useful information about the system; however, we cannot say with certainty that mobility tests exclusively isolate only the SIJ.

For several reasons, specific joint mobility tests (also called spring tests) may yield information about perceived thovement that may be greater than the actual movement that occurs. The bony landmarks used are at a distance to the joint and may thus amplify perceived motion. The spring test may be applied in one plane and yet may produce triplane motion in the joint, and the kinesthetic information may therefore seem amplified. A spring test may induce simultaneous motion at both SIJs and the symphysis pubis. A small degree of cartilage and bone deformation may also occur. Last, in spite of our best efforts to isolate the joint, the test might actually incorporate the lumbopelvic-hip region. These reasons do not detract from the clinical utility of the spring tests, as they evaluate an important and often overlooked aspect of joint function, which is joint play. This will be addressed later.

PALPATION OF LUMBOPELVIC LANDMARKS
Even though it is part of a standard lumbopelvic evaluation, accurate palpation of lumbopelvic landmarks in standing and sitting can at times be difficult owing to muscular response to gravity. In standing, the pelvic posture can be influenced by biomechanical dysfunction above and below the pelvis. Palpation of the landmarks in supine and prone lying may yield more accurate information about the isolated lumbopelvic structure as the influence of the upper and lower body is reduced. A higher inter- and intrarater agreement has been observed with supine and prone palpation as part of an evaluation protocol (Ellis et al 1989). An abbreviated evaluation that addresses bony palpation is presented in Fig. 42.1. Evaluation should also include palpation of all soft tissues, especially muscles and ligaments. A distinction needs to be made between positional dysfunction and movement dysfunction. Positional dysfunction describes how it is positioned; movement dysfunction describes how it cannot move. Evaluation and treatment that rely on position alone are at best speculative.

EVALUATION AND TREATMENT OF SIJ DYSFUNCTION
PELVIC MOBILITY AND JOINT SPRING TESTS
Mobility tests can be general or specific. For example, an anteriorly directed force on the left of the sacrum at the level of the joint (S1, S2, and S3) induces a right rotational force and is a joint spring test. In contrast, right active lumbar and pelvic rotation is a general mobility test. Both types of test are important in evaluating clients with suspected SIJ dysfunction. The specific joint spring tests give more information about joint and ligament function. The general mobility tests will give more information about whole patterns of motion influenced by several joints and several muscle groups. The following gross motion tests are presented in the literature and are in fairly common use: the standing trunk flexion test, standing hip flexion (Gillet's) test, sitting flexion test, and long sit test (Potter & Rothstein 1985). These gross motion tests implicate faulty motion of the pelvis as a unit but are not very specific; however, they are often utilized to evaluate purported faulty 'sacroiliac joint motion'. The SIJ is within the pelvis, and a more appropriate description might be 'faulty lumbopelvic-hip' motion. These tests are useful screening tests but cannot provide the same information as the spring tests.

It is nearly impossible to perform a joint spring test in standing. It is much easier to perform isolated joint spring tests with the client supine and prone. As the SIJ functions as a shock absorber, the spring tests might be able qualitatively to assess that function. The use of the term 'spring' seems very appropriate when testing the quality of pelvic joint play as there is a very discernable elastic feel in loading the pelvic joints, in imparting the actual spring test, and in the quality of recoil.

Walker (1992) asks a relevant question with regards to motion testing: Is the motion present adequate in total range to be detected by observation and manual palpation, as extensively described by several clinicians? The minimal range of motion present in probably most of the population casts doubt on whether therapists can detect 1 to 3 degrees or 1 to 3 mm of motion occurring specifically at the SIJ. Perhaps the term play (joint play) should be used when referring to the SIJ, as motion implies quantity of motion similar to other synovial joints, which does not appear to be the case.

The SIJ does not exist in isolation with regard to anatomy and function. Perhaps more important than the fact that motion occurs within the SIJ is the concept that it occurs through the SIJ. Proper function of pelvic articulations requires the ability to translate forces through these articulations and to dissipate forces via viscoelastic properties. Articular spring tests are useful in evaluating these important properties of pelvic joint function.

Specific pelvic joint spring tests
All tests are carried out first on one side and then the other. Spring tests are always used even if the pelvis is symmetric as movement dysfunction may still be present. Firm and increasing pressure is applied to the part tested until motion no longer occurs. At is point the soft tissue and joint slack is taken up and maintained before imparting the spring test. The actual spring test is then performed when an additional force is imparted. The spring test should therefore test primarily joint play (qualitatively) in the joint, and to a lesser extent a response in the surrounding soft tissue. When performing the spring test, take note of the quality of the initial load, the end feel of the spring test, and the feel of recoil, as well as the subjective response. Retest several times if unsure. When evaluating the recoil, it is important to return to the point at which the slack is taken up, rather than abruptly letting go. The quality of the perceived joint play is rated as normal, hypomobile, or hypermobile.

Of course, there is a degree of subjectivity in rating joint play. Skill in joint spring testing comes with practice and training. Spring tests are not used to determine whether pain is present when one is evaluating biomechanical function of the pelvic girdle. It is not uncommon for clients to have biomechanical dysfunction that is subthreshold, so pain is not present. Additionally, the forces imparted with clinical tests applied to the knee do not replicate physiological forces (Noyes 1977), and this might also be true for the pelvis. However, if pain is encountered, it is acknowledged, the test is modified or deferred, and an interpretation of the pain is attempted.

Spring tests can be measured with force transducers, for example MicroFET muscle testing device (Hoggan Health Industries, Draper, UT, USA). This is a hand-held instrument that measures the amount of force applied by the clinician. After taking up the slack in the joint, the clinician can then apply an additional force and determine how much force is applied when joint play is perceived. Both sides are compared. The clinician can measure pre- and post-treatment force. Most force transducers used in the clinic describe force in pounds, or kilograms, although force described in Newtons (N) accounts for the influence of gravity. For the benefit of the interdisciplinary audience, all three measures will be presented. The spring tests average 88 N (201b, 9 kg) for taking up the slack and up to 176 N (40 lb, 18 kg) to apply the spring test. The force needed may vary from person to person. The above averages serve as a guideline with which to develop the skill of applying the spring tests. The appropriate amount of force is the least amount that yields useful information without increasing pain. The initial load takes from 2-3 s and performing the spring test takes 1-2 s, as does assessing the recoil. A study was performed to determine whether therapists could learn accurately to produce specific forces to the lumbar spine (Keating et al 1993). The authors concluded that therapists can learn to quantify applied forces, which has implications for evaluation and communication of joint behavior. This study is encouraging and a similar study with forces applied to the pelvis is needed.

The basic sacroiliac joint spring tests
1. Prone sacral rotation. With the client prone, apply the ulnar border or the heel of your hand on the left side of the sacrum at the joint level (S1, 52, and S3). You must be medial to the posterior superior iliac spine (PSIS) to assure that you do not have contact on the ilium. Apply an anteriorly directed force of up to 88 N (201b, 9 kg) to take up the slack in the joint, and then an additional force of up to 176 N (40 lb, 18 kg) to assess joint play. Repeat the test on the other side. Pressure on the left side induces right rotation; pressure on the right induces left rotation.

2. Prone sacral side-bending. With the client prone, palpate the coccyx and locate the inferior lateral angles of the sacrum by pushing laterally and superiorly with your thumbs. You will have to depress the soft tissue to make bony contact. Then place the ulnar border of your hand on the left inferior lateral angle. Apply a superior force of up to 88 N (20 lb, 9 kg) to take up the slack. Only a minimal additional force of up to 49 N (11 lb, 5 kg) is required to assess joint play. Repeat the test on the right side.

3. Supine posterior rotation of the ilium (Fig. 42.4). With the client supine, place as much contact as possible with one hand on each ilium. The hand should mold to the anterior ilium to maximize comfort. Take up the slack on one side by applying up to 88 N (20 lb, 9 kg), directed at a 45" angle. The force applied is a posterior rotary force. After taking up the slack, apply an additional force up to 176 N (401b, I8 kg) to assess joint play, Repeat the test on the other side.

4. Prone anterior rotation of the ilium (Fig. 42.5). With the client prone, place the heel of your hand on the left superior ilium, just above and lateral to the PSIS. Apply a pure anterior force with up to 88 N (20 lb, 9 kg) of force to take up the slack. Then apply an additional force up to 176 N (40 lb, 18 kg) to assess joint play. Repeat the test on the right side.

5. Prone anterolateral glide of the ilium (Fig. 42.6). With the client prone, place the heel of your hand on the posterior ilium, including the medial portion of the PSIS and the portion of the ilium above and below the PSIS. Take care not to include the sacrum or the test will be invalid. Apply up to 88 N (20 lb, 9 kg) of force directed anterolaterally at a 45" angle. After taking up the slack in the joint, apply an additional force up to 18 kg to assess joint play. Repeat the test on the other side.

A diagnosis is established by a physician prior to using this approach to evaluation and treatment. Mechanical pain responds rather quickly to mechanical treatment, and thus care is not prolonged in the absence of progress. Whether or not this approach is effective can usually be determined within 2-3 visits, up to a maximum of 6. Previous to utilizing this approach, a thorough evaluation is performed, including the lumbar spine, the hip joints, a review of medical tests, history-taking, neurological screening, and consultation as appropriate. This approach can easily be integrated or interfaced with other approaches to low back pain.

Caution is warranted and treatment may be contraindicated in the presence of poor rapport, severe protective muscle guarding, no direction of movement that eases pain, recent herniated nucleus pulposus with nerve root compromise, paresthesia or sensory loss below the knee, and undiagnosed pain. This list is not exhaustive, and sound clinical judgement always takes precedence.

Treatment should be tolerated with minimal, if any, discomfort. Treatment is usually perceived as relieving pain and is always discontinued if pain increases to a moderate degree during the procedure. If painful, reassessment is carried out to determine the appropriate course of action. This method of evaluation emphasizes the role of joint function and treats on the basis of faulty joint play. It acknowledges that there is a relationship between pain and function, and that treatment should address both. The rationale for this treatment approach has been presented elsewhere (Hesch et al 1992).

THE MOST COMMON PATTERN OF LUMBOPELVIC MOVEMENT DYSFUNCTION
The most common pattern of faulty lumbopelvic movement dysfunction is based on the evaluation of palpation and spring tests described earlier. In an outpatient physical therapy clinic, this pattern is encountered on a daily basis. In certain patients, this pattern appears to be the root cause of the lumbopelvic pain syndrome; in others, it is only a contributing factor. There are many other patterns of lumbopelvic movement dysfunction, which are described in detail elsewhere (Greenman 1996, Hesch 1996). Based on this method of evaluation, 90% of the patient population with SIJ dysfunction will also have joint dysfunction of the lumbar spine (Kraemer, unpublished data).

There are eight components of the most common pattern. Patients typically present with all eight, but occasionally may have fewer:

1. left posterior pubic bone
2. left sacral rotation
3. left sacral side-bending fixation
4. right anterior ilium
5. left posterior ilium
6. type I right inflare
7. type I left outflare
8. type II left lumbar flexion movement dysfunction.

Left posterior pubic bone
Positional dysfunction. The entire anterior surface of the left pubic bone is posterior in relation to the right.

Movement dysfunction. Spring tests at the symphysis pubis are rarely utilized as palpatory findings correlate very highly with the spring test findings, and clients are often quite tender even with mild pressure. If an anterior-to-posterior spring test is performed, it will reveal hyper-mobility on the left and hypomobility on the right.

Other findings. Tenderness of the soft tissue overlying the left pubic bone and at the left sacrospinous ligament may correlate with a posterior pubic bone. No doubt, changes in the dimension of the sciatic notch would accompany a pubic shift, and there may be adverse tension or compression of sciatic notch contents.

Treatment.

Left sacral rotation
Positional dysfunction. With the patient prone, the entire left side of the sacrum is prominent as the sacrum appears rotated left about a vertical axis.

Movement dysfunction. The prominent left side will have decreased anterior mobility; the deep right side will have increased anterior mobility (spring test 1).

Other findings. Sacral rotation has a direct effect on L5-S 1 facet motion. Self-treatment for left posterior pubic bane. Patient Position: supine with hips and knees in neutral position. Self-treatment: place a rolled Ci cm diameter) towel horizontally under the left ischium and maintain for 2-5 min. Then retest via palpation. Left sacral rotation treatment. Patient position: supine with hips and knees flexed. Padded dowel placed vertically on the left side of the sacrum to encompass L5-5I, and S1-3. Padded dowel is 2.5 cm x 10 cm wood dowel covered with pipe foam for comfort. Treatment: maintain this position for 2 min. After treatment, retest mobility.

Left sacral side-bending fixation
Positional dysfunction. The left inferior lateral angle will be inferior in relation to the right.

Movement dysfunction. There is a lack of superior glide when tested at the Left inferior lateral angle (spring test 2).

Other findings. Sacral side-bending can perpetuate faulty lumbosacral motion coupling. Treatment. Left sacral side-bending treatment. Patient position: prone with the trunk side-bent to the right. This is done to minimize left lumbosacral facet compression during mobilization, and to pull the sacrum into right side-bending. Therapist position: the ulnar border of the hand is on the undersurface of the inferior lateral angle of the sacrum an the left side. Treatment: gently take up any available slack and perform five gentle oscillations. The combined force to take up the slack and perform oscillations rarely exceeds 137 N (31 lb, 14 kg). After treatment, retest mobility with the spring test.

Right anterior ilium
Positional dysfunction. The anterior superior iliac spine (ASIS) anterior, medial, and inferior; anterior iliac shelf inferior; posterior superior iliac spine PSIS anterior; posterior iliac shelf superior; and ischial tuberosity superior.

Movement dysfunction. Reduced posterior rotation (spring test 3).

Other findings. Dysfunction of the anterior ilium is very common (DonTigny 1993), particularly on the right side, but rarely on the left. It is a common postural adaptation due to asymmetric sitting posture, getting in and out of the car in a hurried fashion thus twisting the spine on the pelvis, holding babies supported on one side of the pelvis, etc. It is present to some degree in most of the adult population and is often asymptomatic. In acute injuries, the client may have had an anterior ilium for quite some time, then overloaded the joint and soft tissues, enhancing a pattern that was previously quiescent. Anterior ilium is a contributor to faulty biomechanics of the spine and lower extremity, and is therefore often addressed in clients who do not appear to have sacroiliac joint pain.

Anterior ilium
Fig. .42.11 Self-treatment for right anterior ilium. The client places the right foot on a stool with the hip flexed to 90" and abducted to 45". The client then reaches for the floor with the right hand, which is medial to the right knee. The stretch is performed gently for 2 min. After treatment, retest mobility. Alternate method: in sitting, supine or side-lying, bring the knee on the right side to the outside of the right axilla and stretch gently for 2 min. After treatment, retest mobility contributes to left lumbar rotation via pull of the right iliolumbar ligament.

Left posterior ilium
Positional dysfunction. AS15 superior, lateral, posterior; anterior iliac shelf superior; posterior iliac shelf inferior; ischial tuberosity inferior; and PSIS posterior.

Movement dysfunction. Decreased anterior rotation of the left ilium (spring test 4). Other findings. Dysfunction of the posterior left ilium does not always follow that of the anterior right ilium, but when present is usually more symptomatic than that of the anterior ilium. Clients usually also have limited and painful lumbar extension, with restricted facet joint movement.

Position dysfunction. Right ASIS medial and anterior; right PSIS lateral and anterior; left ASIS lateral and posterior; left PSIS lateral and posterior.

Fig. 42.12 Side-lying treatment for left posterior ilium. Patient position: side-lying with the left hip on top flexed 60-90", assuring that the ilium does not rotate posteriorly. Two or three pillows are placed under the left thigh to keep it both horizontal and comfortable. Therapist position: left palmar contact is made on the posterior ilium, 2-4 cm above the level of the PSIS. The patient's left knee rests against the therapist's abdomen. Treatment: the therapist takes up the slack by gently pushing the client's femur posteriorly into end-range and pulling the ilium anteriorly into end-range with the left hand. Gently oscillate the ilium anteriorly 10 times with the left hand, After treatment, retest mobility with spring test.

Self-treatment for left posterior ilium. Patient position: supine with the left leg off the table. The left hip is maximally adducted. The right hip is flexed and abducted with foot flat on the table. Treatment: maintain this position and let it stretch passively for 2 min. The left thigh should literally be suspended above horizontal by the hip capsule and soft tissues, otherwise the degree of adduction is inadequate.

Flare exercise 1. Lie on your stomach with a 7 cm diameter, 25 cm long rolled towel placed vertically under your right anterior pelvis and thigh for 2 min. Flare exercise 3. In the same position as in Fig. 42.15 with the towel roll, bend your right hip to 90n and let it stretch out to the right side for 2 min. Keep your left leg straight. To assist the 90" angle of the hip, you may place a folded pillow under the right foot and lower leg.

Flare exercise 2. Lie on your back with the towel roll under the left part of your pelvis at a 30" angle for 2 min. The towel roll should encompass the ilium and the ischium, but not the sacrum. Keep both knees bent and feet tlat.

Movement dysfunction. Increased anterolateral mobility will he noted when tested at the right posterior ilium in prone (see Fig. 42.6 above). This hypermobility can be subtle. There will be a very apparent decrease of anterolateral mobility as tested in prone at the left posterior ilium.

Other findings. Type I right inflare is a very common pattern. As it is always accompanied by a type I left outflare, treating both sides is mandatory.

Treatment.

Type II left lumbar flexion movement dysfunction (Greenman 1996) when the L5-51 facet has restricted flexion on. In the same position as in Fig. 42.15 but without the towel roll, bend your left hip to 90"and with your left hand, push the left thigh to the right. Use a folded pillow under the foot and lower leg if needed to maintain 90" hip flexion, and stretch for 2 min one side, ipsilateral rotation will be induced when flexion is attempted. If a motion segment cannot flex on the left, it will remain in extension on the left when the rest of the spine flexes. This creates a pathological axis, and the vertebra will extend at the left facet, rotate to the left, and typically side-bend to the left. With flexion movement dysfunction, there may be a slight asymmetry in neutral. With active extension there is no asymmetry; with increasing flexion, there is increasing asymmetry. Palpation through the soft tissues overlying the transverse processes, facets, or laminae will demonstrate increased prominence on the left with flexion. In other words, the side with flexion dysfunction becomes prominent with flexion.

Treating type II left lumbar flexion motion dysfunction
This is by muscle energy treatment (Greenman 1996).

Patient position. Sitting with the lumbar spine in flexion.

Therapist position. Sitting behind the patient. The left thumb palpates the left lumbosacral junction. The right hand is placed in front of the right shoulder.

Treatment. Keep the left ischium in contact with the seating surface. The motion barrier is engaged with flexion from above downwards until the lumbosacral segment attempts to flex. Then side-bending to the right and rotation to the right are added until the L5-S1 segment is again engaged. Resist the patient with contact at the front of the right shoulder as he or she gently attempts to rotate left for 10 s isometrically. Then have the patient relax, and he or she will passively move into the harrier. Repeat three times.

Self-treatment.
Self-treatment for type 11 left lumbar flexion motion dysfunction. Keep the left ischium in contact with the seating surface. The patient sits with the lumbar spine in flexion, right side-bending, and right rotation, gently engaging the motion harrier as described above. Gentle active right rotation is repeated 30 times at mid-to-end range.

After treating the lumbar motion dysfunction, it is appropriate to re-evaluate and treat whatever other motion dysfunctions may be present in the lumbar spine, pelvis, and hip, as it is possible that other types of lumbopelvic and hip joint mobility dysfunction may be present (Greenman 1996, Hesch 1996). This is an appropriate time to address muscle function of the spine, pelvis, and hip. Compensation for the lumbopelvic dysfunction can occur in the lower extremity and in the spinal axis as high as the upper cervical spine. Left hip rotator muscle imbalance is almost always present, with shortened left external rotators.

CONCLUSIONS
1. The most common patterns of SIJ dysfunction based on palpation and joint spring tests have been presented. The spring tests may he more appropriate in testing joint play than are gross motion tests that purport to test SIJ motion. Both testing procedures may be more useful in addressing the lumbopelvic structure when used in combination. Additional spring tests are available for more complex presentations, including 12 newly encountered patterns of dysfunction (Hesch 1996).
2. The pelvis is the hub of the body, and movement dysfunction here can contribute to compensatory patterns above and below. Thus, when dysfunction of the lumbopelvic-hip complex is encountered, it is appropriate to evaluate and treat the entire kinetic chain.
3. Continued research on traditional and emerging methods of evaluation and treatment is needed. While research is in progress, we must be aware of what is already known and what new questions need to be answered regarding this complicated and somewhat mysterious articulation. As our understanding of the coupled lumbopelvichip complex and its relevance to the rest of the kinetic chain is growing, so must our treatment approaches. We must continue to treat it based on our current understanding, and we must strive diligently for better methods of evaluation and treatment.

REFERENCES
Bernard T 1992 Video presentation on sacroiliac joint injections. First interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5-6 November

DonTigny R 1993 Mechanics and treatment of the sacroiliac joint. Journal of Manual and Manipulative Therapy 1: 3-12 Ellis T, Moore T, Jackson R, Martin R 1989 Palpation to assess ilial symmetry/asymmetry: isometric mobilization to restore ilial symmetry. In: Proceedings of the Manipulative Therapy Association of Australia 6th biannual conference proceedings. Manipulative Therapist Association of Australia, Adelaide, pp 63-70 Greenman P E 1996 Principles of manual medicine, 2nd edn. Williams & Wilkins, Baltimore

Hesch J 1996 Course workbook - The Hesch method of treating sacroiliac joint dysfunction: an integrated approach. Albuquerque, New Mexico

Hesch J, Aisenbrey J, Guarino J 1992 Manual therapy evaluation of the pelvic joints using palpatory and articular spring tests. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) First interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5-6 November, pp 435-459

Keating J, Matyas T A, Bach T M 1993 The effect of training on physical therapist's ability to apply specific forces of palpation. Physical Therapy 73: 38-46

Lee D 1989 The pelvic girdle. Churchill Livingstone, Edinburgh

Lee D 1992 The relationship between the lumbar spine, pelvic girdle, and hip. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) First interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5-6 November, pp 463-478

Noyes F 1977 Functional properties of knee ligaments and alterations induced by immobilization. Clinical Orthopedics 123: 210

Paris S 1991 Introduction to evaluation and manipulation of the spine. Institute of Graduate Physical Therapy, St Augustine Porterfield J, DeRosa C 1991 Mechanical low back pain. WB Saunders, Philadelphia

Potter N, Rothstein J 1985 Intertester reliability for selected tests of the sacroiliac joint. Physical Therapy 11: 1671-1677

Vleeming A, Mooney V 1992 Introduction. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) Proceedings of the first interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5-6 November

Vleeming A, Stoeckart R, Snijders C J 1992 General introduction. In: Vleeming A, Mooney V, Snijders C J, Dorman T (eds) Proceedings of the first interdisciplinary world congress on low back pain and its relation to the sacroiliac joint. San Diego, CA, 5-6 November, pp 3-64

Vleeming A, Mooney V, Dorman T, Snijders C J 1995 Second interdisciplinary world congress on low back pain. San Diego, CA, 9-11 November

Walker J M 1992 The sacroiliac joint: a critical review. Physical Therapy 72: 903-916

 2. Letter to the Editor: Physical Therapy Journal, "Ilial Anterior Rotation Hypermobility"

Published Letter to the Editor Physical Therapy Journal On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590.   On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590. 23 February 2009 Jerry Hesch, PT, MHS, is Manager, Hesch Seminars and Physical Therapy, LLC, 1609 Silver Slipper Ave, Henderson, NV 89002-9334 Send rapid response to journal: Re: On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590. Email Jerry Hesch This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic. In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint dysfunction (SIJD). This is very appropriate, as research and opinion have been presented indicating that asymmetrical pelvic position and movement, and its testing and treatment, do not necessarily imply actual position and movement dysfunction (PMD) intrinsic to the sacroiliac joint (SIJ).2-4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors1 clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (ie, ilium moving on sacrum) also implies the alternate possibility of PMD of the pelvis (entire pelvis moves as a unit). The clinical reality perhaps is that at times these may be mutually exclusive entities and at other times they may be a combination of both. The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and lateral (external) rotation of the hip, as described by DonTigny.6 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would occur primarily in the sagittal plane, less so in the frontal plane, and only slightly in the transverse plane. In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named “upslip.”7,8 I suggest that in the prone position, the client could be screened for upslip PMD. A superior spring to the ischial tuberosity and an inferior spring to the posterior iliac shelf would both be blocked with upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as the authors noted with passive testing. Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD than I do clients with symptomatic SIJ/pelvic dysfunction.9,10 In my opinion, treating clients who have asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention and reducing the suboptimal biomechanical influence on proximal and distal structures. The Ostgaard test is a special test (provocative), which was described in the article.1 The test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported by Ostgaard11 and the authors1 to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, I believe that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide. I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions, and empiricism on the subject. References 1. Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590. 2. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368. 3. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165. 4. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129. 5. Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997. 6. DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44. 7. Nyberg R. Pelvic girdle. In: Payton O, Di Fabio RP, Paris SV, et al. Manual of Physical Therapy. New York, NY: Churchill Livingstone Inc; 1989:378–380. 8. Greenman P. Principles of diagnosis and treatment of pelvic girdle dysfunction. In: Greenman P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:257. 9. Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California. 10. Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7. 11. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19:894–900.   Author Response 27 March 2009 H Todd Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, Carbondale, IL Send rapid response to journal: Re: Author Response Email H Todd Vaughn I would like to thank Poulter,1 Cibulka,2 and Hesch3 for their responses to the case report titled “Ilial Anterior Rotation Hypermobility in a Female Collegiate Tennis Player.”4 I appreciate their professional input regarding the case report and admire their commitment to holding the physical therapy profession accountable for fostering evidence-based practice. Several criticisms were made; some I feel are justifiable, whereas others warrant a response. I will address each of the responders separately. Poulter states, “The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm. This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, TENS, ice, ultrasound, massage and taping.” A treatment-based classification system identifies a heterogenous group of patients and places them into subgroups based on the examination data. The classification of the patient in each subgroup guides the treatment plan.5 The assumption of this type of classification system is that all patients will fall into a particular subgroup. Each patient is unique and may have multiple impairments that require a multi-treatment approach. Based on examination data, my patient would need to be classified in both the mobilization and immobilization treatment subgroups, as proposed by Fritz and George.5 Currently, there is only a treatment-based classification system for classifying patients with acute low back pain to treatment subgroups.5 I propose that a treatment-based classification system be developed for patients with sacroiliac joint dysfunction (SIJD). I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.6 I certainly could have classified my patient as having general low back pain and ignored the patient’s mechanism of injury and the impairments identified in the examination. This approach was used by the athletic trainer for 2 weeks after the patient’s first onset of pain. The athletic trainer had the patient continue this active treatment paradigm until she no longer could play tennis, walk with a normal gait pattern, and sit with normal posture. Poulter suggests that a body chart and valid outcome measures should have been utilized in the case report. I agree that a body chart would have increased clarity of the location of the patient’s pain. The patient reported right low back pain as a general descriptor; her pain was palpated inferior to the posterior-superior iliac spine (long dorsal sacroiliac ligament). I also agree that the Oswestry Disability Index7 could have been used with this patient. However, it was apparent, based on the patient’s goals, that returning to competitive tennis was the true measure of attaining her functional outcome. Poulter asked, “Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode?” Based on the history, examination, and mechanism of injury, I believed the patient developed right ilial anterior rotation hypermobility secondary to excessive stress to her long dorsal sacroiliac ligament (LDL). The LDL restrains anterior ilial rotation and was susceptible to sprain secondary to performing repetitive 2-hand backhands. The literature suggests that ligaments can regain 50% of their normal tensile strength by 6 months after injury, 80% after 1 year, and 100% after 1 to 3 years.8-10 The subsequent treatment program was designed to stress the LDL gradually over time, being careful not to exceed its tensile strength during the remodeling phase. The sacroiliac belt and taping technique were necessary at 6 months during tennis play secondary to the high pelvic rotational forces and the LDL only having approximately 50% of its tensile strength. The patient was reexamined 1 year later and was found to have no impairments or functional limitations. We hypothesized at 1 year that the ligament had regained its tensile strength and, therefore, the sacroiliac belt and taping technique no longer were necessary for tennis. I do not understand the basis for Poulter’s comment suggesting that I contributed to the patient’s 6-month chronic episode. Furthermore, I believe that I was able to offer the patient a solution to her complex problem. Cibulka states, “How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity?” I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD, where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.9 I apologize to Cibulka for not citing his article titled “Unilateral Hip Rotation Range of Motion Asymmetry in Patients With Sacroiliac Joint Regional Pain”11 in my literature review. Its omission was not intentional, and the article should have been included. I also agree that the terms used to describe the sacroiliac joint need to be operationally defined. There is too much “jargon” that leads to confusion when discussing the sacroiliac joint. Hesch discussed several interesting points in his response. I agree that the corrective exercise for the right ilial anterior rotation hypermobility could have been enhanced by adding abduction and lateral (external) rotation of the hip. The “upslip” of the innominate should have been examined with passive mobility testing in the prone position, as Hesch suggested. Hesch also brings up an interesting point that the Ostgaard test theoretically could induce anterior rotation of the ilium. Extensive research is needed to validate tests related to the diagnosis of SIJD. H Todd Vaughn HT Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, 374 E Grand Ave, Mail Code 6740, Carbondale, IL 62901 (USA), and Senior Physical Therapist, Select Medical Corporation, NovaCare Rehabilitation, Benton, Illinois. References 1 Poulter DC. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx. 2 Cibulka M. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx. 3 Hesch J. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx. 4 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590. 5 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000:25;106–114. 6 Brolinson PG, Kozar AJ, Cibor G. Sacroiliac dysfunction in athletes. Curr Sports Med Rep. 2003;2:47–56. 7 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940–2952. 8 Vailas AC, Tipton CM, Mathes RD, et al. Physical activity and its influence on the repair process of medial collateral ligaments. Connect Tissue Res. 1981;9:25–31. 9 Tipton CM, Matthes RD, Maynard JA, et al. The influence of physical activity on ligaments and tendons. Med Sci Sports Exerc. 1975;7:165–175. 10 Tipton CM, James SL, Mergner W, et al. Influence of exercise in strength of medial collateral knee ligaments of dogs. Am J Physiol. 1970;218:894–902. 11 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009–1015.   Here is a nice email from the author.   Sent: Thursday, April 02, 2009 11:14 AM Subject: Re:+Author+Response   Hi Jerry,   Thank you for your email.  I must admit I was a little  discouraged from the first two responders comments.  I really  appreciate your input and professionalism.  I shared your kind  comments with Wanda Nitsch (co-author).    I am always interested in research ideas.  I have not  encountered, or at least recognized, a patient with a posterior  glide of the sacrum.  It sounds like you would have a very  interesting case report that would add to the literature.   Other topics that interest me includes: management of lumbar  disc herniations; cervical dysfunctions and lordosis; and true  leg length discrepency and its implications on lumbar and LE  function/pain.    Thank you again for your professional feedback and  encouragement.  It is really appreciated!   Todd   Todd Vaughn PT,DPT,MS,OCS,MTC  Senior Lecturer  Physical Therapist Assistant Program Southern Illinois University Carbondale    This longer version was not accepted for publication. Letter to the Editor On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590. This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic.             In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint (SIJ) dysfunction (SIJD). This is very appropriate, as research and opinion have been presented, indicating that asymmetrical pelvic position and movement, and its testing and treatment, does not necessarily imply actual position and movement dysfunction (PMD/PMDs) intrinsic to the SIJ.2-4  However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (i.e. ilium moving on sacrum) also implies the alternate possibility of PMD dysfunction of the pelvis (entire pelvis moves as a unit). Clinical reality perhaps being, that at times these may be mutually exclusive entities, and other times may be a combination of both.             Palpation of the pubic tubercles was performed as part of a screen to the symphysis pubis, though findings were not detailed. Screening of the symphysis pubis can be very useful in screening for a unilateral SIJD such as RAIRH. As the ilium, ischium and pubic bone are fused in the adult, unilateral movement of the ilium on the sacrum i.e. RAIRH, induces mandatory motion of the ipsilateral pubic bone, along with palpable fibrocartilage disc deformation. If there is asymmetry when palpating across the pubic bone onto the fibrocartilage and onto the opposite pubic bone, and it returns to symmetry after resolving RAIRH, it is reasonable to assume a true Anterior Ilium with intrinsic SIJ movement of ilium on sacrum, rather than extrinsic pelvic PMD.             The traditional model utilizes the pubic tubercles and pubic crests for palpation. To that I add palpation at four different locations going from the face of the right pubic bone onto the fibrocartilagenous disc and onto the left pubic bone. This is relevant as the pubic bones are elongated structures of approximately 5cm. I also palpate from the right pubic crest onto the top of the fibrocartilage and then onto the opposite pubic crest. A mutable step up or step down at either location that reverts to symmetry with treatment of RAIRH, is indicative of a true intrinsic SIJD. One can have asymmetry of one pubic bone in relation to the opposite, however if they lie in the same para-frontal plane without step off and fibrocartilage disc deformation, this is simply a positional asymmetry of the pelvis, not an intrinsic SIJD. This asymmetry is easily demonstrated by taking a person with frontal plane symmetry, and asking them to step back with the left leg. The left pubic bone will be posterior in relation to the right, without any intrinsic SIJ or symphyseal PMD. To date, this concept has not been encountered in the literature and is ripe for research as are all other empirical observations mentioned herein. However, other possible scenarios are worthy of consideration. It seems probable that absent motion occurring within the symphysis pubis, a combination of RAIRH and a Left Posterior Ilium could occur simultaneously with motion occurring only in the left and right SIJ. Alternately, the entire pelvis could move in tri-dimensional space such as moving on the femoral heads without intrinsic SIJ or pubic symphysis motion. Finally, a combination of intrinsic and extrinsic PMD could exist. Additional landmark palpation as described above can be very informative. Very gentle passive accessory motion testing (spring testing) can also be utilized at the symphysis pubis. SIJD has many evaluation and treatment approaches, as noted in the literature, continuing education courses, and conferences. The pelvis and lumbar spine are inextricably linked. It is not unusual to find lumbar movement dysfunction that remains after resolving SIJ/pelvic PMD. The lumbar PMD may or may not be symptomatic, and it can be subtle in a neutral posture. Typically, it will become exaggerated in flexion, and less frequently, it enhances in extension.        It is also observed that RAIRH often coexists with a Left Posterior Ilium. However, the latter may not always be apparent per initial palpation and spring testing until after the RAIRH is resolved. A permutation can then occur, and Left Posterior Ilium is then encountered in prone and supine (stable) positions. Addressing both sides makes for a fairly quick and lasting gain. Often the presence of RAIRH is actually a part of a greater pattern of up to seven distinct PMDs of the SIJ/pelvis, which I refer to as “The Most Common Pattern”, as it is ubiquitous. Sequential treatment of each component is necessary in order to achieve symmetrical tri-plane position, mobility and stability.6-8 One component of this pattern is what I refer to as a Type 1 Right Inflare and a Type 1 Left Outflare PMD, which requires separate treatment after addressing Right Anterior Ilium and Left Posterior Ilium. Type 1 Inflare/Outflare PMD is much more common than the subtle Type 2 (Osteopathic) Inflare/Outflare. Type I Inflare/Outflare has a much greater anterior/posterior component, whereas Type 2 has a much greater medial/lateral component. Spring testing for Type 1 is 45 degrees away from that of Type 2, with no overlap of spring test findings. The most distal compensation for Type I Inflare and Outflare is a counter rotation at C1, which can spontaneously resolve after successful treatment of the SIJ/pelvis. The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and external rotation of the hip, as described by DonTigny.9 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would primarily occur in the sagittal plane, less so in the frontal, and only slightly in the transverse plane. In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named Upslip. The presence of an Upslip PMD could be validated or negated with the client in prone. A superior spring to the ischial tuberosity and inferior spring to the posterior iliac shelf would both be blocked with Upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As Upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as Vaughn and Nitsch1 noted with passive testing. Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD, than I do clients with symptomatic SIJ/pelvic dysfunction.10,11 Treating the clients who present with asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention, and reducing the suboptimal biomechanical influence on proximal and distal structures. The Ostgaard test is a special test (provocative), which was described in the article.1 the test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, it seems that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide. I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions and empiricism on the subject.   Jerry Hesch J Hesch, PT, MHS, Manager Hesch Seminars and Physical Therapy, LLC Address all correspondence to Mr Hesch at: jerryhesch@cox.net.   References   1 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590. 2 Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368. 3 Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165. 4 Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis.  Spine. 1998;23:1124–1128; discussion 1129. 5 Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997. 6 Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Vleeming A, Mooney V, Dorman T, et al, eds. Movement, Stability and Low Back Pain: The Essential Role of the Pelvis. London, United Kingdom: Churchill Livingstone; 1997: chap 42. 7 Hesch J. Course Workbook: The Hesch Method of Treating Sacroiliac Joint Dysfunction: Integrating the SI, Symphysis Pubis, Hip and Lumbar Spine. Henderson, NV: Hesch Seminars; 2009. 8 Hesch J. Manual therapy evaluation of the pelvic joints using palpatory and articular spring tests. Presented at the First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint; November 6, 1992; San Diego, California. 9 DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44. 10 Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California. 11 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7.

6.  Sacrum:  Key Concepts

KEY CONCEPTS REGARDING THE SACRUM:

See section on Key Concepts which comes below the following 3 sacral images. 

POSTERIOR VIEW OF THE SACRUM

RIGHT SIDE VIEW OF THE SACRUM

TOP VIEW OF THE SACRUM

 God bless Wikipedia and the fine folks that make it possible. I took these images from Wikipedia: The sacrum.

Additional images can be found at the bottom of this page.

KEY CONCEPTS REGARDING THE SACRUM:

Rules of physiological motion dysfunction. A dysfunctional structure i.e. left sacral rotation fixation, can move further into the pattern in which it is stuck, it cannot move out of it.

1. A sacral torsion has blocked P-A at only one quadrant

2. Left sacral rotation (more common than torsions, typically occur on left) about a vertical axis has both left quadrants blocked

3. Posterior glide sacral fixation has all 4 quadrants blocked

4. The rare forward bending sacral fixation has blocked P-mobility at the apex, S4-5 bilaterally

5. A backward bent sacrum (rare) has blocked P-A at the base S1 bilaterally

6. A side bent sacrum has blocked motion on the side bent side of sacroiliac dysfunction. Testing superior glide motion at the ILA that is lower, (ILA=inferior lateral angle), reveals stuck mobility.

7. So-called "Unilateral Flexion or Unilateral Extension" as described by the Osteopathic and Muscle Energy paradigms, does NOT exist. Details provided upon request. To "find and treat' them requires profound suspension of belief, belief that only a few landmarks and a few GROSS MOTION tests with very poor inter/intra tester reliability can evanesce this problem.

8. Sacral Side Glide is physiologically impossible, or at least in over 25 years of search, never has found it. I suspect that the interosseous ligament is quite unyielding.

9. Whatever happens at the sacrum influences motion at the symphysis pubis, so you much recheck both after you treat one. The reverse of course is also true.

10. The best position to evaluate the sacrum is Yoga child's Pose/Muslim Prayer Position, of course screen it in prone neutral and prone extension also; the latter so rarely if ever has dysfunctional patterns.

11. Of the above sacral patterns, only #3 is non-physiological motion and all directions of motion are blocked.

12. The Osteopathic terminology lexicon online has more than 12 different names for sacral torsion about a vertical axis. Confusion anybody?

13. Sacral rotation About a Vertical Axis is much more common that Sacral Torsions About an Oblique Axis, yet I believe that nearly all Muscle Energy Seminars emphasize the torsion and do not even teach the pure rotations, and even though Posterior Glide Sacral Fixations are part and parcel of Osteopathic Theory, it is not taught at MET seminars. No wonder many still feel somewhat confused after taking seminars on SIJ dysfunction, see #7.

14. Sacrum means "sacred thing" because the ancients believed it to be the seat of the soul. 

15. the most distal compensation for a sacral rotation is at the Occiput-C1-C2.

16. Some seminars (some I have attended) use a matchbook to represent the sacrum when describing torsion about

 a vertical axis. Real plastic sacral models can be purchased for about $10.00m each. matchbooks cost perhaps 10 cents.

ANTERIOR AND POSTERIOR VIEW OF SACRUM AND COCCYX

LATERAL VIEW OF SPINE WITH SACRUM AND POSTERIOR IMAGE OF SCRUM

1.                                                                                2.

1.  LATERAL CUT VIEW OF SACRUM from www.back.com/anatomy-sacral.html                                                                

2. POSTERIOR VIEW from www.back.com/anatomy-sacral.html

FRONT VIEW OF THE BONY PELVIS WITH SACRUM COLORED GREEN

Please look at other sources to see the sacrum in relationship to the muscles, nerves, vessels, fascia, organs, etc.

7. Email:  Sacral Rotation Dialogue

10.  The righting Reflex, Pelvis and Neck

THE RIGHTING REFLEX, TYPE 1 PELVIC FLARING AND THE UPPER CERVICAL ADAPTATION

Jerry Hesch, MHS, PT

The righting reflex is a powerful reflex that responds to asymmetries in the   body. The purpose is to symmetrically allign the eyes and the brain in all 3 planes of the body and to allow symmetrical circulation to the brain. A very common transverse plane rotational pattern in the pelvis is named type 1 right inflare/left outflare. This is distinctly different from the rare type 2 inflare/outflare described by the Osteopathic Muscle Energy paradigm. This pattern is common in our society perhaps due to the fact that; we live and function in a right-handed environment, thus both right-hand and left-hand dominant individuals; often present with this pattern.  The type 1 flare pattern has a discernable movement dysfunction in the A-P/P-A directions using spring tests as utilized in the Hesch Method of treating SI joint dysfunction.  The type 2 flare pattern is not evaluated in the same manner as it has a greater motion dysfunction in the medial-lateral/lateral-medial directions. The type 1 pattern remains after treatment for a right anterior ilum and left posterior ilium SI dysfunction.  The evaluation and treatment of type 1 inflare/outflare will be demonstrated.  Prior to doing so, the craniocervical counterrotation will be demonstrated. After resolving the pelvic flare pattern the craniocervical rotation will be reevaluated.  Typically, the craniocervical response is to reflexively, immediately released while the "client" is still lying supine.  This demonstrates the reflexogenic effect and the fact that this reflex is not an anti-gravity muscular response.  This demonstration will highlight the value of screening the pelvis for type 1 flare patterns in the presence of a cranicervical counter-rotational pattern, and it reinforces the paradigm of treating the bottom first-top last.  The craniocervical response is not just rotational, however; rotation is the greatest response. The other accessory motion responses will be elaborated upon, briefly addressing evaluation of each, and treatment as relevant; when not a reflexogenic response.  Right anterior ilium/left poterior ilium with type 1 flare pattern Dysfunction are part of the Most Common Pattern of SI Joint Dysfunction (Hesch) and all 7 components will be described, with evaluation and treatment explained.  Other transverse plane patterns in the lower body will be mentioned as relevant to a craniocervical counter-rotation.

11.  Coccyx

Dear Group,
just a few thoughts re coccyx. All posts have been thought provoking to me.
At an appropriate juncture such as past 1st trimester, one could screen the
coccyx for a side bent fixation which would tend to cause pain to be
unilateral. These, when present, are easily corrected by pushing directly
onto the lateral coccyx towards midline while at the same time pushing on
the opposite side laterally to enhance tension on the sacrospinous and
sacrotuberous ligaments, holding for about 2 minutes. I understand the
client had a long road trip and I do think we tend to weight bear
asymmetrically in cars, due to gas and brake pedals and pre-existng pelvic
asymmetry.
If mid line, a pure inferior glide force could be applied externally, and
the distraction it induces might provoke a "self correction". I have also
compressed both ischial tuberosities medially to slacken the sacrotuberous
and sacrospinalis ligaments. This is difficult as a one person technique, easier
with one person on each side, again that magic creep thing of 2 minutes
seems ideal.
Shannon's post re treating other areas a helpful reminder, and sometimes a
midline disc bulge will be culpable. I agree that anything that can reduce
positional faults along the entire spine and rib cage is worthy of
intervention.
Just a few thoughts.
Best Reards
JH

Coccyx Screen

A mid line disc bulge at the thoraco-lumbar region and several segments below can cause coccygeal pain. Any post-op imaging to evaluate canal, discs - such as Ct or MRI?
Check the lateral allignment of the ischial tuberosity on both sides in relation to the midline gluteal crease. Check the ischia with respect to A-P, P-A relationships. Also test mobility with medial to lateral, lateral to medial at ischial tuberosity, P-A just above the ischial tuberosity on the ishium (bilaterally). If positive, contact me via my e-mail. There are 4 unilateral patterns that could be at work here, but invariably both sides require treatment. You will not find these described in the literature, someday I will publish.
The coccyx needs to be evaluated mechanically for forward/backward motion dysfunction and side-bending also.
It is relevant to palpate the Sacrotuberous ligament. Open your palms fully so that thumbs are nearly 90 degrees away from digits. Bring thumb tips and tips of index fingers together so that they form a triangle. Place the tip of index fingers on the coccyx and the thumbs should then be on the creases on top of the thighs. The index fingers then lie on top of the Sacrotuberous ligaments. Now with tip of thumbs push into the ligament, you will have to depress the gluteal fat ands muscle several centimeters. You can strum the ligament like guitar string or simply depress it - just like taking up the slack and performing a mobility test at a joint. Compare the tone side to side. Asymmetry of tone coupled with bony palpation and passive mobility testing should be informative, and can guide treatment.
It would be worthwhile to read up on Dr Maigne who has some excellent work on thoracolumbar junction mobility dysfunction. More often than not T12-L1 is in hyperextension and a foam roller placed below it with progressive flexion to isolate force at the junction is helpful, say for at least 5 minutes. Be creative, there are several ways to accomplish this. More details upon request.
Sitting on rolled towels in front of the ischial tuberosities will unweigh the coccyx, helpful if it is suffering from sitting compression. Mulligan has a sitting wedge, though I was making these in 1983 (Albuquerque, New Mexico, USA), just never did market properly. Best Regards Jerry Hesch, MHS, PT jerryhesch@cox.net

12. Abstract: Downslip Ilium with Paradoxical Upslip Appearance