sacroiliac joint

2. SACROILIAC JOINT DYSFUNCTION
AHMED ABDELNASSER BARAKAT (BPT-DPT CAIRO UNIVERSITY)
JABER HOSPITAL

3. Overview
Sacral anatomy
Sacral motions
Sacral somatic
dysfunctions
Special tests for the
sacrum
Diagnosis of sacral somatic
dysfunction

4. OBJECTIVES FOR TODAY LECTURE
.UNDERSTAND THE ANATOMY AND LANDMARKS NECESSARY FOR
SACRAL DIAGNOSIS
.DESCRIBE THE MOTION OF THE SACRUM IN BOTH TRANSVERSE AND
OBLIQUE AXIS
.IDENTIFY THE RELATIONSHIP BETWEEN THE SACRUM , INNOMINATE ,
AND L5
.NAME OF DYSFUNCTION AS SACROILIAC OR LUMBOSACRAL
.EXPLAIN PHYSICAL FINDINGS OF LANDMARKS AND SPECIAL TESTS
TO OBTAIN ACORRECT SACRAL DIAGNOSIS
SCRAL SULCUS , FABER TEST , SEATED FLEXION TEST
.DESCRIBE THREE TYPES OF SACRAL SOMATIC DYSFUNCTION:-
BILATERAL FLEXION AND EXTENSION
UNILATERAL FLEXION AND EXTENSION
TORTION FORWARD AND BACKWARD
.DEFINE PHYSIOLOGIC AND NONPHYSIOLOGIC MOTION OF SACRUM

5. SIJ DYSFUNCTION MOSTLY MISDIAGNOSED OR
NOT EVEN CONSIDERED
SIJ CAN MIMIC DISCOGENIC LOW BACK PAIN OR
RADICULAR PAIN
POTENTIALLY LEADING TO MISDIAGNOSIS AND
UNNECESSARY LUMBAR SURGERY

6. Overview
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
SIJ dysfunction are the fourth common cause of LBP and pelvic pain
6-13% source of LBP OR pelvis PAIN OR referred lower extremity pain
SIJ surface area is greater in males than females AND THIS increased THE biomechanical
loading in males

7. SACRAL STRUCTURE, LIGAMENTS,
MUSCLES AND NERVES

8. 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..
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.

9. Major Pelvic Ligaments
Iliolumbar ligament: from ilia to
5th lumbar vertebrae

10. 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.

12. 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 via
dorsal ligaments

13. COMPLEXITY OF SIJ
INNERVATIONS
!!! INNERVATIONS
The sacroiliac joint receives its
innervation from the ventral rami
of L4 and L5, superior gluteal
nerve, and dorsal rami of L5-S2.
The nerve supply to the SI joint
varies between individuals and
innervation may be almost
derived from the sacral dorsal
rami.

15. 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

16. 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

17. 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

18. 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

20. DIAGNOSIS OF SIJ DYSFUNCTION
HISTORY AND PHYSICAL ASSESSMENT
SIJ INJECTION THE GOLD STANDARD
IMAGING STUDIES USUALLY NOT
HELPFUL

21. HISTORY: POTENTIAL CAUSES
TRAUMATIC
FALL ON THE BUTTOCK
MVA
HEAVY LIFTING
ATRAUMATIC
ADJACENT SEGMENT DISORDER
PRIOR LUMBAR FUSION
L5-S1
L4-L5
SCOLIOSIS
POSTPARTUM
VAGINAL DELIVERY
INFLAMMATORY ARTHROPATHY
E.G ANKYLOSING SPONDYLITIS
INFECTION

22. SIJ PAIN HISTORY
AGGRAVATING FACTOR
TRANSITIONAL MOTIONS
ROLLING ONTO AFFECTED SIDE VS LYING SUPINE
SIT TO STAND
PROLONGED WALKING
UNILATERALWEIGHT BEARING
PUTTING ON PANTS/ SOCKS
CLIMBING STAIRS
PAIN WHILE STATIONARY SITTING WITH WEIGHT
BEARING ON AFFECTED SIDE
PROLONGED STANDING

23. RELIEVING
WEIGHT BEARING ON
UNAFFECTED SIDE
LYING ON UNAFFECTED SIDE
COMPRESSION MANUALLY OR
WITH ABELT TO RELIEVE
HYPERMOBILITY

24. SIJ PAIN HISTORY:-
NEVER BEEN AT MIDLINE
ALWAYS BELOW L5
AT THE LEVEL OF PSIS OR CAUDAL TO
PSIS
OCCASIONALLY PATIENT
COMPLAINING OF GROIN ,POST
LATERAL THIGH OR CALF PAIN
EPICENTER MOST COMMONALY
PATIENT POINTS TO PSIS /SACRAL
SULCUS (FORTIN FINGER TEST )

25. CHIEF COMPLAINT
PATIENT COMPLAIN OF :-
LBP BELOW L5
PELVIC/BUTOOCK PAIN
HIP/GROIN PAIN
POOR SLEEP HABITS
UNILATERAL LEG PAIN
INSTABILITY
SITTING PROBLEMS
LOWER EXTREMITY PAIN

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

27. PHYSICAL EXAMINATION : PAIN
LOCALIZATION
FORTIN FINGER TEST POINT TO PAIN
WHILE STANDING
ABLE TO LOCALIZE PAIN WITH ONE FINGER
WITHIN 1 CM FROM PSIS ( INFEROMEDIAL)
CONSISTENT OVER AT LEAST 2 TRIAL
TENDERNESS OVER SIJ SULCUS
NOT SITTING ON THE AFFECTED SIDE

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

29. Seated Flexion Test
Performing the Test: The examiner has a hand on
each PSIS. The patient bends forward, while the
examiner is comparing the movement of each PSIS. A
positive test is if greater superior motion is felt on one
PSIS compared to the other

30. Sacral Sulcus Depth
1. Begin by finding the PSISs by following the iliac
crests posteriorly. 2. From the PSISs, move slightly
medial and superior (about 1cm) so that you are now
in It
2. With the patient prone, assess the sacral sulci (bases),
just medial to the PSIS. The sacral sulcus is “deep”
if it is closer to the table (feels more anterior) and
“shallow” if it is farther from the table (feels more
posterior)he sacral sulci.

32. PROVOCATION TESTS

33. Gaenslen's Test
is one of the five provocation tests that can be used to detect musculoskeletal abnormalities and
primary-chronic inflammation of the lumbar vertebrae and Sacroiliac joint (SIJ). The subsequent
tests include; the Distraction Test, Thigh Thrust Test, Compression Test and the Sacral Thrust
Test
The patient lies in supine position near the edge of the table. The RT leg hangs over the edge of
the table. And the other hip and knee are flexed towards the patient's chest

34. FABERS TEST
The FABER test is used to identify the presence of hip pathology
by attempting to reproduce pain in the hip, lumbar spine or
sacroiliac region. The test is a passive screening tool for
musculoskeletal pathologies, such as hip, lumbar spine, or
sacroiliac joint dysfunction, or an iliopsoas spasm

35. FABERS test
The patient is positioned in supine. The leg is placed in position (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 anterior superior iliac spine, 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.

36. FABERS TEST
1.Sarcoiliac Joint Pain on external hip rotation
1. Sacroiliac Joint Dysfunction
2. Sacroiliitis
2.Groin Pain on external hip rotation
1. Iliopsoas Strain or Iliopsoas Bursitis
2. Intraarticular Hip Disorder
1.Hip Impingement (femoral acetabular impingement)
2.Hip Labral Tear[8]
3.Hip loose bodies
4.Hip chondral lesion
5.Hip Osteoarthritis[10]
3.Posterior Hip Pain on external hip rotation
1. Posterior Hip Impingement

38. 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)

39. Gillet test
The Stork test, also known as the Gillet Test, assesses the movement of the SIJ between the
innominate and sacrum through the clinician's palpation, which may be a useful test for clinical
evaluation of a subject's ability to stabilize intrapelvic motion
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

40. 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

41. JUSTIFICATON FOR SIJ INJECTION
POSITIVE HISTORY
POSITIVE FORTIN TEST AND SIJ
PHYSICAL EXAME
POSITIVE PROVOCATIVE TESTS
SIJ DIAGNOSTIC INJECTION

42. DIAGNOSTIC SIJ INJECTIONS
GOLD STANDARD
CONFIRM OR DENY SIJ AS THE
SOURCE OF PAIN
20-30 MIN AFTER PROCEDURE PAIN
SHOULD HAVE SUBSIDED (AT LEAST
80% BETTER

43. IASP : SIJ PAIN DIAGNOSTIC
CRITERIA
PAIN IS PRESENT IN THE
REGION OF SIJ
PROVOCATIVE TESTS
REPRODUCES PATIENTS
PAIN
SIJ INJECTION RELIEVE THE
PAIN OF PATIENT

44. THANK YOU

45. THANK YOU

49. SACROILIAC JOINT DYSFUNCTION
AHMED ABDELNASSER BARAKAT (BPT-DPT CAIRO UNIVERSITY)
JABER HOSPITAL

50. Overview
Sacral anatomy
Sacral motions
Sacral somatic
dysfunctions
Special tests for the
sacrum
Diagnosis of sacral somatic
dysfunction

53. MANAGEMENT
• Soft Tissue Techniques
• Myofascial Release Techniques
• Counterstrain Techniques
• Muscle Energy Techniques
• High-Velocity, Low-Amplitude Techniques
• Facilitated Positional Release Techniques

54. 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"

55. 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.

56. . 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 lumbar
paravertebral musculature. 9. This technique may also be performed using deep,
sustained pressure. 10. Tissue tension is reevaluated to assess the effectiveness
of the technique.

57. 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.

58. 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

59. Bilateral Thumb Pressure,
Prone
1. Patient and therapist/physician position same as before technique
2. 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. 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. 4. This stretch is held for several seconds, is slowly released, and is then
repeated in a gentle, rhythmic, and kneading fashion.
5. 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 lumbar paravertebral musculature.
6. 6. This technique may also be performed using deep, sustained pressure. 7.
Tissue tension is reevaluated to assess the effectiveness of the technique.

60. 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.

61. 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

62. 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

63. 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.

64. 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.

65. 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)

66. 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

67. 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

68. 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.

69. 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.

70. Posterior Lumbar Tender Point
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. 2. The physician extends the patient's thigh and hip until the
dysfunctional segment is engaged.
3. 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. 4. The physician fine-tunes through small arcs of motion (hip flexion
and extension, external and internal rotation, and adduction and
abduction).

71. 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).

72. 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"

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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

79. 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.

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81. THANK YOU

82. THANK YOU