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Treatment of sacroiliac_joint_dysfunction_nata
The document discusses treatment of sacroiliac joint dysfunction. It describes the axes and movements of the sacroiliac joint, including nutation and counternutation. Physiologic and non-physiologic movements are outlined. Muscle functions related to sacroiliac joint movement are provided. Normal gait mechanics and pelvic girdle function are summarized. Examination techniques including positional tests, motion tests, passive mobility tests, and pain provocation tests are described. Common sacroiliac joint dysfunctions like forward and backward sacral torsion are discussed.
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Treatment of sacroiliac_joint_dysfunction_nata
- 1. Treatment of SacroiliacTreatmentof Sacroiliac Joint DysfunctionJoint Dysfunction Movement of sacrum onMovement of sacrum on iliumilium
- 2. Sacroiliac Joint AxesSacroiliacJoint Axes SuperiorSuperior MiddleMiddle InferiorInferior Right ObliqueRight Oblique Left ObliqueLeft Oblique
- 3. Sacroiliac JointSacroiliac Joint MovementMovement NutationNutation:Anterior: Anterior nutationnutation or flexionor flexion CounternutationCounternutation: Posterior: Posterior nutationnutation oror extensionextension Forward rotation around an obliqueForward rotation around an oblique axisaxis Backward rotation around an obliqueBackward rotation around an oblique axisaxis
- 4. Sacroiliac JointSacroiliac Joint MovementsMovements PhysiologicPhysiologic ––Left sacral torsion on left oblique axisLeft sacral torsion on left oblique axis –– Right sacral torsion on right oblique axisRight sacral torsion on right oblique axis –– Bilateral anterior sacralBilateral anterior sacral nutationnutation –– Bilateral posterior sacralBilateral posterior sacral nutationnutation –– Anterior sacralAnterior sacral nutationnutation with exhalationwith exhalation –– Posterior sacralPosterior sacral nutationnutation with inhalationwith inhalation NonNon--physiologicphysiologic –– Left sacral torsion on right oblique axisLeft sacral torsion on right oblique axis –– Right sacral torsion on left oblique axisRight sacral torsion on left oblique axis –– Left unilateral anteriorLeft unilateral anterior nutationnutation –– Right unilateral anteriorRight unilateral anterior nutationnutation –– Left unilateral posteriorLeft unilateral posterior nutationnutation –– Right unilateral posteriorRight unilateral posterior nutationnutation
- 5. SacralSacral NutationNutation ““Sacral lockingSacrallocking”” Base of sacrum moves into pelvisBase of sacrum moves into pelvis –– InferoposteriorInferoposterior glide ofglide of articulararticular surface of sacrum onsurface of sacrum on iliumilium –– Coronal axis ofCoronal axis of interosseousinterosseous ligamentligament –– Iliac bones approximate,Iliac bones approximate, ischialischial tuberositiestuberosities spreadspread –– Limited byLimited by interosseousinterosseous, ant., ant. sacroiliac,sacroiliac, sacrotuberoussacrotuberous andand sacrospinoussacrospinous liglig BilateralBilateral –– Early trunk extensionEarly trunk extension –– End range trunk flexionEnd range trunk flexion –– ExhalationExhalation UnilateralUnilateral –– Hip flexionHip flexion
- 6. SacralSacral CounternutationCounternutation ““Sacral unlockingSacralunlocking”” Backward motion of base of sacrumBackward motion of base of sacrum out of pelvisout of pelvis –– AnterosuperiorAnterosuperior glide ofglide of articulararticular surface of sacrum onsurface of sacrum on illiumillium –– Coronal axis ofCoronal axis of interosseousinterosseous ligamentligament –– Iliac bones spread,Iliac bones spread, ischialischial tuberositiestuberosities approximateapproximate –– Limited by long post sacroiliacLimited by long post sacroiliac ligament andligament and multifidusmultifidus contractioncontraction BilateralBilateral –– Early trunk flexionEarly trunk flexion –– End of trunk extensionEnd of trunk extension –– InhalationInhalation UnilateralUnilateral –– Hip extensionHip extension
- 7. Reciprocal Movement atReciprocalMovement at LumbosacralLumbosacral JunctionJunction Flexion of L5S1Flexion of L5S1 –– Sacral base movesSacral base moves posteriorlyposteriorly into extensioninto extension ((counternutatescounternutates)) Extension of L5S1Extension of L5S1 –– Sacral base movesSacral base moves anteriorlyanteriorly into flexioninto flexion ((nutatesnutates)) Right rotation and leftRight rotation and left sidebendingsidebending of L5of L5 –– Sacral base rotates to left and side bends rightSacral base rotates to left and side bends right
- 8. Muscle FunctionsMuscle Functions PiriformisPiriformis ––Anterior tilt and rotate sacrum to opposite sideAnterior tilt and rotate sacrum to opposite side Assisted byAssisted by ipsilateralipsilateral gluteusgluteus maximusmaximus ContralateralContralateral latissimuslatissimus dorsidorsi and gluteusand gluteus maximusmaximus through LDFthrough LDF –– NutationNutation of sacrum and extension of LS junctionof sacrum and extension of LS junction Long head of bicepsLong head of biceps –– Backward tilt and rotate sacrum to same sideBackward tilt and rotate sacrum to same side LongissimusLongissimus andand multifidusmultifidus –– Pull sacral base superiorly andPull sacral base superiorly and posteriorlyposteriorly thruthru dorsal ligamentsdorsal ligaments
- 9. Normal Gait MechanicsNormalGait Mechanics InnominateInnominate –– RightRight innominateinnominate rotatesrotates anteriorlyanteriorly –– Sacrum rotates toward it andSacrum rotates toward it and sidebendssidebends awayaway from itfrom it SacrumSacrum –– Sacrum moves into right forward torsion on rightSacrum moves into right forward torsion on right oblique axis the returns to neutraloblique axis the returns to neutral L5L5 –– As sacrum right rotates and leftAs sacrum right rotates and left sidebendssidebends, L5, L5 left rotates and rightleft rotates and right sidebendssidebends
- 10. Pelvic Girdle FunctionPelvicGirdle Function Form closureForm closure –– Bones, joints, ligamentsBones, joints, ligaments Force closureForce closure –– Muscles, fasciaMuscles, fascia Motor controlMotor control –– Neural patterningNeural patterning EmotionsEmotions –– AwarenessAwareness Lee
- 11. ImpairmentsImpairments ExcessiveExcessive articulararticular compressioncompression ––Fusion (AS)Fusion (AS) –– Capsular fibrosisCapsular fibrosis –– OveractivationOveractivation of globalof global myofascialmyofascial systemsystem –– Joint fixation (underlying instability)Joint fixation (underlying instability) InsufficientInsufficient articulararticular compressioncompression –– LigamentousLigamentous laxitylaxity –– UnderactivityUnderactivity of localof local myofascialmyofascial systemsystem Lee
- 12. Somatic DysfunctionSomatic Dysfunction FunctionFunction ––Stability and motion of SI joints result of shape of jointStability and motion of SI joints result of shape of joint surfaces (form closure) and altering ofsurfaces (form closure) and altering of ligamentousligamentous tension in response to changes of muscle tone (forcetension in response to changes of muscle tone (force closure) (Isaacs &closure) (Isaacs & BookhoutBookhout)) DysfunctionDysfunction –– Imbalance of tension and tone between muscles andImbalance of tension and tone between muscles and ligaments which locks SI joint and prevents normalligaments which locks SI joint and prevents normal function (Isaacs &function (Isaacs & BookhoutBookhout)) ARTTARTT –– Asymmetry of position, restricted motion, tissue texture,Asymmetry of position, restricted motion, tissue texture, tendernesstenderness
- 13. Sacroiliac SomaticSacroiliac Somatic DysfunctionsDysfunctions Forwardsacral torsionForward sacral torsion Backward sacral torsionBackward sacral torsion Bilateral sacral anteriorBilateral sacral anterior nutationnutation Bilateral sacral posteriorBilateral sacral posterior nutationnutation Unilateral sacral anteriorUnilateral sacral anterior nutationnutation Unilateral sacral posteriorUnilateral sacral posterior nutationnutation
- 14. SymptomsSymptoms Stiffness and painwith walkingStiffness and pain with walking Pain opposite side with walkingPain opposite side with walking –– SISI Pain same side with walkingPain same side with walking –– ISIS Unilateral pain below L5Unilateral pain below L5 Pain with sit to standPain with sit to stand CoccydyniaCoccydynia (torsions)(torsions) Groin painGroin pain
- 15. ExaminationExamination Positional testsPositional tests MotiontestsMotion tests Passive mobility testsPassive mobility tests Pain provocation testsPain provocation tests PalpationPalpation
- 16. Positional TestsPositional Tests LandmarksLandmarks ––ASISASIS –– PSISPSIS –– SacralSacral sulcussulcus –– ILAILA –– MedialMedial malleolimalleoli (prone)(prone) –– L5L5 –– Pubic tuberclePubic tubercle PositionsPositions –– Neutral, extended andNeutral, extended and flexedflexed
- 17. Active Motion TestsActiveMotion Tests Standing flexionStanding flexion testtest Stork testStork test –– GilletGillet’’ss testtest Seated flexion testSeated flexion test –– PiedalluPiedallu’’ss testtest
- 18. Passive Mobility TestingPassiveMobility Testing OsteokinematicOsteokinematic –– Nutation/counternutationNutation/counternutation ProneProne –– Anterior/posteriorAnterior/posterior innominateinnominate rotationrotation SidelyingSidelying ArthrokinematicArthrokinematic –– InferoposteriorInferoposterior glideglide AnteriorAnterior innominateinnominate rotationrotation –– SuperoanteriorSuperoanterior glideglide PosteriorPosterior innominateinnominate rotationrotation –– Horizontal translationHorizontal translation Squish testSquish test –– Vertical translationVertical translation Lumbar spring testLumbar spring test
- 19. PalpationPalpation Tension (ligaments)Tension (ligaments) ––SacrotuberousSacrotuberous –– Long dorsal ligamentLong dorsal ligament Tone (muscles)Tone (muscles) –– PiriformisPiriformis –– Psoas/IliacusPsoas/Iliacus –– CoccygeusCoccygeus –– GluteusGluteus maximusmaximus –– LatissimusLatissimus dorsidorsi –– MultifidusMultifidus –– ErectorErector spinaespinae TendernessTenderness
- 20. TendernessTenderness L5S1L5S1 –– yellowyellow LumbarLumbar–– blackblack SI jointSI joint -- blueblue
- 21. Pain Provocation TestsPainProvocation Tests Anterior gappingAnterior gapping (Distraction)(Distraction) Posterior gappingPosterior gapping (Compression)(Compression) GaenslenGaenslen’’ss Thigh thrustThigh thrust Sacral thrustSacral thrust
- 22. StandingStanding Anatomic landmarksAnatomic landmarks Standingflexion testStanding flexion test –– Symmetrical superior movement ofSymmetrical superior movement of PSISPSIS’’ss Stork test (Stork test (GilletGillet’’ss march test)march test) –– PSIS should drop (also move laterally after 90PSIS should drop (also move laterally after 90°°)) Hip drop testHip drop test –– AnteriorAnterior nutationnutation on side of bent knee, rotateon side of bent knee, rotate toward lumbar concavitytoward lumbar concavity Side bendingSide bending –– AnteriorAnterior nutationnutation on side of convexity, rotateon side of convexity, rotate toward lumbar concavitytoward lumbar concavity –– AnteriorAnterior innominateinnominate rotation (side of concavity),rotation (side of concavity), posteriorposterior innominateinnominate rotation (side of convexity)rotation (side of convexity)
- 23. SeatedSeated Seated forward flexiontestSeated forward flexion test –– Symmetrical superior/anterior movement ofSymmetrical superior/anterior movement of PSISPSIS’’ss –– Positive seated flexion test indicates sacroiliacPositive seated flexion test indicates sacroiliac dysfunctiondysfunction –– Indicates dysfunctional sideIndicates dysfunctional side PalpationPalpation –– ILAILA’’ss Symmetrical in upright, flexed and extended positionsSymmetrical in upright, flexed and extended positions –– LumbarLumbar laminaelaminae (L5) and transverse processes(L5) and transverse processes SymmetricalSymmetrical
- 24. Seated Flexion TestSeatedFlexion Test IfIf ILAILA’’ss become symmetricalbecome symmetrical –– Rule outRule out Unilateral anterior or posterior sacralUnilateral anterior or posterior sacral nutationsnutations Forward sacral torsionForward sacral torsion If positive on leftIf positive on left –– Rule outRule out Bilateral anterior or posteriorBilateral anterior or posterior nutationsnutations –– Could beCould be Left unilateral anteriorLeft unilateral anterior nutationnutation ROR forward sacral torsionROR forward sacral torsion LOR backward sacral torsionLOR backward sacral torsion
- 25. SupineSupine PalpatePalpate –– ASISASIS’’ss, pubictubercles, medial, pubic tubercles, medial malleolimalleoli Helps define etiologyHelps define etiology Is it purely sacral or mixed problem (iliac and pubicIs it purely sacral or mixed problem (iliac and pubic dysfunction)dysfunction) Squish testSquish test –– Symmetrical resistanceSymmetrical resistance Pain provocation testsPain provocation tests –– GaenslenGaenslen’’ss testtest –– SI compression/distractionSI compression/distraction Compression inCompression in sidelyingsidelying –– Thigh thrustThigh thrust ASLR (Active SLR test)ASLR (Active SLR test)
- 26. ProneProne PalpationPalpation –– Sacral baseandSacral base and ILAILA’’ss Prone and proneProne and prone--on elbows positionson elbows positions –– MalleoliMalleoli positionposition –– Long dorsal sacroiliac joint ligamentLong dorsal sacroiliac joint ligament –– SacrotuberousSacrotuberous ligamentligament –– MusclesMuscles PiriformisPiriformis,, glutealgluteal,, paraspinalparaspinal MobilityMobility –– Spring testSpring test LumbarLumbar Sacral (transverse axis & oblique axis)Sacral (transverse axis & oblique axis) Pain provocation testPain provocation test –– Sacral thrustSacral thrust
- 27. Forward Sacral TorsionForwardSacral Torsion Forward rotation around oblique axisForward rotation around oblique axis –– 85% LOL (common in R handed people)85% LOL (common in R handed people) Imbalance betweenImbalance between piriformispiriformis and hip rotatorand hip rotator muscles. Aftermuscles. After posterolateralposterolateral disc.disc. SymptomsSymptoms –– No low back pain, unless associated with ERSNo low back pain, unless associated with ERS –– PiriformisPiriformis symptoms,symptoms, glutealgluteal painpain –– Occasional sciaticaOccasional sciatica –– Standing, walking and stair climbingStanding, walking and stair climbing –– Little or no pelvic restriction with gaitLittle or no pelvic restriction with gait In gait, on R heel strike, sacrum turns L and L5 turns RIn gait, on R heel strike, sacrum turns L and L5 turns R At R midAt R mid--stance, sacrum rotates right on ROA, L5 rotates Lstance, sacrum rotates right on ROA, L5 rotates L and SB Rand SB R Must treat lumbar nonMust treat lumbar non--neutral dysfunctions firstneutral dysfunctions first
- 28. Backward Sacral TorsionBackwardSacral Torsion Backward rotation around oblique axisBackward rotation around oblique axis –– 85% LOR85% LOR LumbarLumbar sidebendingsidebending and rotation to same side whileand rotation to same side while fully flexed. Locks with attempt to return to uprightfully flexed. Locks with attempt to return to upright position.position. –– Left L/S SB/ROT in F will cause right sacral rotation on LOALeft L/S SB/ROT in F will cause right sacral rotation on LOA –– ““the well bent over and the cripple stood upthe well bent over and the cripple stood up”” syndromesyndrome Symptoms:Symptoms: –– Testicle pain, heel burning, lateral knee pain, back of legTesticle pain, heel burning, lateral knee pain, back of leg numb; cannumb; can’’t lie side of torsion; cant lie side of torsion; can’’t lie prone; morningt lie prone; morning stiffness; inability to cross legs; inability to sweep orstiffness; inability to cross legs; inability to sweep or vacuum; pain with walking; sitvacuum; pain with walking; sit--toto--stand; rising from FBstand; rising from FB positionposition Must treat nonMust treat non--neutral lumbar dysfunction firstneutral lumbar dysfunction first
- 29. Sacral Torsion DiagnosisSacralTorsion Diagnosis SulcusSulcus deep and ILA posterior on opposite sidesdeep and ILA posterior on opposite sides SulcusSulcus determines torsiondetermines torsion –– LeftLeft sulcussulcus deep is RSTdeep is RST Axis and direction determinationAxis and direction determination –– PiriformisPiriformis Left tight creates ROALeft tight creates ROA Positive left seated flexion test indicates tight leftPositive left seated flexion test indicates tight left piriformispiriformis –– Spring test positive in backward, negative in forwardSpring test positive in backward, negative in forward –– Forward torsions become asymmetric in flexion andForward torsions become asymmetric in flexion and symmetric in extension (symmetric in extension (ILAILA’’ss)) –– Backward torsions become asymmetric in extension andBackward torsions become asymmetric in extension and symmetric in flexion (symmetric in flexion (ILAILA’’ss)) Normal lumbar adaptationNormal lumbar adaptation –– ROT in direction of deepROT in direction of deep sulcussulcus, SB away, SB away
- 30.
- 31. Bilateral Anterior SacralBilateralAnterior Sacral NutationNutation Also known as bilaterally flexed sacrum or bilateralAlso known as bilaterally flexed sacrum or bilateral inferior sacral shearinferior sacral shear Forward rotation on MTAForward rotation on MTA –– RareRare Jumping from a height and landingJumping from a height and landing Symptoms:Symptoms: –– PersistentPersistent lumbosacrallumbosacral andand glutealgluteal painpain –– Lumbosacral/glutealLumbosacral/gluteal pain worse with forward bending,pain worse with forward bending, walking, standing, down stairswalking, standing, down stairs –– Prefers to lie pronePrefers to lie prone –– Stands with accentuatedStands with accentuated lordosislordosis –– Uncomfortable sittingUncomfortable sitting –– LumbosacralLumbosacral flexion limitedflexion limited
- 32. Bilateral Posterior SacralBilateralPosterior Sacral NutationNutation Also known as bilaterally extended sacrumAlso known as bilaterally extended sacrum or bilateral superior sacral shearor bilateral superior sacral shear Backward sacral rotation on MTABackward sacral rotation on MTA Lifting heavy load in midline positionLifting heavy load in midline position Symptoms:Symptoms: –– ConstantConstant lumbosacrallumbosacral painpain –– LumbosacralLumbosacral pain worse with backward bending,pain worse with backward bending, sitsit--toto--stand, walking down stairs, patient prefersstand, walking down stairs, patient prefers to sit slumped with arms on thighs, lie supine orto sit slumped with arms on thighs, lie supine or fetal position, stands with flat backfetal position, stands with flat back –– LumbosacralLumbosacral extension limitedextension limited
- 33. Bilateral SI DysfunctionsBilateralSI Dysfunctions
- 34. Unilateral AnteriorUnilateral Anterior SacralSacralNutationNutation Also known as inferior sacral shear, unilateral flexed sacrumAlso known as inferior sacral shear, unilateral flexed sacrum or side bent lesionor side bent lesion Usually traumaticUsually traumatic –– Land on one leg with spine extended (volleyball/basketball)Land on one leg with spine extended (volleyball/basketball) Superior transverse axisSuperior transverse axis Associated with posteriorAssociated with posterior innominateinnominate rotation and nonrotation and non--neutralneutral L5 dysfunction (LL5 dysfunction (L innominateinnominate posterior rotation with L5 ERSL)posterior rotation with L5 ERSL) –– Treat L5 dysfunction firstTreat L5 dysfunction first Less common than torsions 3:2, left flexion most commonLess common than torsions 3:2, left flexion most common SymptomsSymptoms –– Pain usually in sacral andPain usually in sacral and glutealgluteal areas, unilateralareas, unilateral –– IpsilateralIpsilateral sciaticasciatica –– Gait problem, pain opposite sideGait problem, pain opposite side –– Worse with standing (<20 min)Worse with standing (<20 min) –– Relieved by sittingRelieved by sitting Tests for sacralTests for sacral sulcisulci andand ILAILA’’ss definitivedefinitive
- 35. Unilateral PosteriorUnilateral Posterior SacralSacralNutationNutation Also known as superior sacral shear or unilateral sacralAlso known as superior sacral shear or unilateral sacral extensionextension Superior transverse axisSuperior transverse axis Rare, most common on rightRare, most common on right May be associated with anteriorMay be associated with anterior innominateinnominate dysfunctiondysfunction May be confused with R on L torsionMay be confused with R on L torsion Caused by bending and twisting followed by forceful extensionCaused by bending and twisting followed by forceful extension with load.with load. HypertonusHypertonus ofof ipsilateralipsilateral longissimuslongissimus thoracisthoracis asas result ofresult of thoracolumbarthoracolumbar area strainarea strain Often treating source ofOften treating source of hypertonushypertonus (TL junction) fixes(TL junction) fixes problemproblem Sometimes must treat L5 (FRSR)Sometimes must treat L5 (FRSR)
- 36. Unilateral SacralUnilateral SacralNutationNutation DiagnosisDiagnosis SulcusSulcus deep and ILA inferior/posterior ondeep and ILA inferior/posterior on same side (anteriorsame side (anterior nutationnutation)) Flexed and extended positionsFlexed and extended positions –– ILAILA’’ss never become symmetric with unilateralnever become symmetric with unilateral nutationsnutations Seated flexion testSeated flexion test –– Positive on left with left anteriorPositive on left with left anterior nutationnutation Normal lumbar adaptationNormal lumbar adaptation –– ROT in direction of deepROT in direction of deep sulcussulcus, SB away, SB away
- 37. Unilateral SI DysfunctionsUnilateralSI Dysfunctions
- 38. TreatmentTreatment Muscle energyMuscle energy JointmobilizationJoint mobilization Joint manipulationJoint manipulation Muscle stretchingMuscle stretching Trunk stabilizationTrunk stabilization
- 39. Correction of ForwardCorrectionof Forward Sacral TorsionSacral Torsion Lie axis side downLie axis side down Rotate trunk to rightRotate trunk to right with right arm off tablewith right arm off table Flex knees and hips toFlex knees and hips to localize forces at L/Slocalize forces at L/S junctionjunction Resist bottom heelResist bottom heel lifting toward ceilinglifting toward ceiling ROR
- 40. Correction of BackwardCorrectionof Backward Sacral TorsionSacral Torsion Lie axis side downLie axis side down Extend lower leg toExtend lower leg to induce some sacralinduce some sacral flexionflexion Flex upper hip so legFlex upper hip so leg off tableoff table Extend trunk to L/SExtend trunk to L/S junctionjunction Rotate trunk left to L/SRotate trunk left to L/S junctionjunction Resist lifting upper legResist lifting upper leg toward ceilingtoward ceiling LOR
- 41. Correction of BilateralCorrectionof Bilateral AnteriorAnterior NutatedNutated SacrumSacrum Patient seatedPatient seated Feet apart and legsFeet apart and legs internally rotatedinternally rotated Patient flexes forwardPatient flexes forward ATC hands on sacralATC hands on sacral apex and thoracic spineapex and thoracic spine Maintain pressure onMaintain pressure on sacral apex (sacral apex (ILAILA’’ss) and) and resist trunk extensionresist trunk extension with full inhalationwith full inhalation
- 42. Correction of BilateralCorrectionof Bilateral PosteriorPosterior NutatedNutated SacrumSacrum Patient seatedPatient seated Feet together and legsFeet together and legs externally rotatedexternally rotated Arms crossedArms crossed ATC hands on sacral baseATC hands on sacral base and across anterior chestand across anterior chest Maintain pressure onMaintain pressure on sacral base and resistsacral base and resist trunk flexion with fulltrunk flexion with full exhalation or have patientexhalation or have patient arch back by pushingarch back by pushing abdomen to kneesabdomen to knees
- 43. Correction of UnilateralCorrectionof Unilateral Anterior SacralAnterior Sacral NutationNutation Patient pronePatient prone Abduct (15Abduct (15°°) and) and internally rotate left leginternally rotate left leg ATCATC’’ss right hand on leftright hand on left ILAILA Apply and maintainApply and maintain anterior and superioranterior and superior pressure on left ILA aspressure on left ILA as patient inhales and holdspatient inhales and holds breathbreath ATC maintains pressureATC maintains pressure as patient exhalesas patient exhales Left Unilateral Anterior Nutation
- 44. Correction of UnilateralCorrectionof Unilateral Posterior SacralPosterior Sacral NutationNutation Patient pronePatient prone Abduct (15Abduct (15°°) and externally) and externally rotate right legrotate right leg Trunk extended via prone onTrunk extended via prone on elbow positionelbow position ATCATC’’ss right hand on right sacralright hand on right sacral basebase Apply and maintain anterior andApply and maintain anterior and inferior pressure with right handinferior pressure with right hand as patient exhalesas patient exhales ATCATC’’ss left hand applies posteriorleft hand applies posterior pressure to right ASISpressure to right ASIS After exhalation, patient pullsAfter exhalation, patient pulls ASIS toward tableASIS toward table Return to prone lying positionReturn to prone lying position while maintaining pressurewhile maintaining pressure Right Unilateral Posterior Sacral Nutation
- 45. Treatment SequenceTreatment Sequence Lumbarspine, pubes,Lumbar spine, pubes, innominateinnominate shears, sacroiliacshears, sacroiliac dysfunction,dysfunction, iliosacraliliosacral dysfunction, muscledysfunction, muscle imbalances (imbalances (GreenmanGreenman)) Pubes,Pubes, innominateinnominate shears, lumbar spine, sacroiliacshears, lumbar spine, sacroiliac dysfunction,dysfunction, iliosacraliliosacral dysfunction (dysfunction (IssacsIssacs && BookhoutBookhout)) Leg muscles, pubes,Leg muscles, pubes, iliosacraliliosacral (flares,(flares, innominateinnominate shears, rotations), sacroiliac, lumbar (unless L5,shears, rotations), sacroiliac, lumbar (unless L5, then before sacrum) (Rex)then before sacrum) (Rex) Pubes,Pubes, iliosacraliliosacral (rotations,(rotations, innominateinnominate shears,shears, flares) sacroiliac (Mitchell)flares) sacroiliac (Mitchell)
- 46. ReferencesReferences IssacsIssacs ER,ER, BookhoutBookhoutMR.MR. BourdillonBourdillon’’ss SpinalSpinal Manipulation (6Manipulation (6thth Ed.). ButterworthEd.). Butterworth-- Heinemann:BostonHeinemann:Boston, 2002, 2002 GreenmanGreenman PE. Principles of Manual MedicinePE. Principles of Manual Medicine (3(3rdrd Ed.).Ed.). LippincottLippincott Williams &Williams & Wilkins:PhiladelphiaWilkins:Philadelphia, 2005, 2005 Lee D. The Pelvic Girdle (3Lee D. The Pelvic Girdle (3rdrd Ed.). ChurchillEd.). Churchill Livingstone:EdinburghLivingstone:Edinburgh, 2004, 2004 Rex L.Rex L. UrsaUrsa Foundation, Edmonds, WA.Foundation, Edmonds, WA.