Pelvic and sacral osteopathy

The pelvic girdle refers to the combination of the pelvic bones (ilium, ischium, and pubis), sacrum, and coccyx. Because the pelvic girdle is heavily involved in ambulation, respiration, and posture, somatic dysfunction is common in this area. Osteopathic treatment of such conditions includes various articulatory techniques, myofascial release, muscle energy, facilitated positional release, and high-velocity, low-amplitude (HVLA).

Pelvis (innominates)

Bones

• See “Bony pelvis” in the article on the pelvis and hip joint.

Osteopathic landmarks

• Anterior landmarks
  • Anterior superior iliac spine (ASIS)
  • Pubic tubercles
  • Medial malleoli
• Posterior landmarks
  • Iliac crest
  • Posterior superior iliac spine (PSIS)
  • Ischial tuberosity

Motion

• Rotation (inferior transverse axis)

Sacrum

Bones

• See “Sacrum” in the article on the vertebral column.

Osteopathic landmarks

• Superior landmark: Sacral sulci (sacral base)
  • Located superolaterally between the sacrum and PSIS
  • Right and left
  • Can be shallow or deep
• Inferior landmark: Inferior lateral angles (ILA’s)
  • Located on the inferolateral portion of the sacrum
  • Right and left
  • Can be posterior or anterior

Motion

• Ambulatory motion: rotates around either a right or left oblique axis
• Respiratory motion
  • Rotates about a superior transverse axis
  • Inhalation – posterior sacral base
  • Exhalation – anterior sacral base
• Craniosacral motion
  • Occurs at the superior transverse axis of the sacrum
  • Connection between S2 of the sacrum and atlanto-occipital (OA) joint
  • Flexion → counternutation
  • Extension → nutation

Dysfunctions

• Physiologic
  • More common
  • Forward or flexion dysfunctions
  • (‑) Spring and sphinx tests
• Non-physiologic
  • Less common, often a result of trauma
  • Backward or extension dysfunctions
  • (+) Spring and sphinx tests

Trendelenburg sign

• See “Trendelenburg sign” in the article on neurological examination.

Ober test

• Function: evaluates for iliotibial band and tensor fascia lata tightness
• Position: lateral recumbent
• Procedure
  1. Flex knee and abduct and extend the hip.
  2. Slowly allow the hip to fall.
• Positive test: thigh remains abducted or falls with jerking movements

Patrick test (FABERE test)

• Function: evaluates sacroiliac joint
• Position: supine
• Procedure: Flexion, ABduction, External Rotation, Extension
  1. Flex, abduct, externally rotate and extend the hip (figure-4 formation).
  2. Apply pressure on the knee and contralateral anterior superior iliac spine.
• Positive test: reproduction of pain in the hip or sacroiliac joint

Thomas test

See “Thomas test” in the article on osteoarthritis of the hip and knee.

Standing flexion test

• Function: assesses iliosacral motion
• Position: standing
• Procedure
  1. Place both thumbs below the PSIS.
  2. Ask patient to bend forward while standing with both feet firmly on the ground shoulder width apart.
• Positive test: superior thumb motion on one side
• Dysfunction: named after the side of the positive finding

Seated flexion test

• Function: assesses sacroiliac motion
• Position: seated with feet flat on the ground
• Procedure
  1. Place both thumbs below the PSIS.
  2. Ask patient to bend forward slowly.
• Positive test: side of superior thumb motion on one side
• Dysfunction: named after the side of the positive finding

ASIS compression test

• Function: assesses symmetry of sacroiliac joint motion
• Position: supine
• Procedure
  1. Place both palmar surfaces on the ASIS.
  2. Apply a unilateral downward compressive force to evaluate ipsilateral sacroiliac (SI) joint.
• Positive test: side of more resistance
• Dysfunction: named after the side of the positive finding

Sphinx test (Backward bending test)

• Function: assesses between physiologic and non-physiologic dysfunction
• Position: prone
• Procedure
  1. Place thumbs in each sacral sulci.
  2. Determine if asymmetry is present.
     • If present, either one side of sacral base is posterior or the other is anterior.
  3. Ask patient to lift him-/herself up onto the elbows (sphinx position).
• Negative test: sulci become symmetric
• Positive test: sulci become more asymmetric → posterior component to the sacral base dysfunction

Lumbosacral spring test

• Function: assesses between physiologic and non-physiologic dysfunction
• Position: prone
• Procedure
  1. Place hypothenar eminence on the lumbosacral junction.
  2. Apply a downward “springing” force.
• Negative test: sacrum does spring back → forward torsion of sacrum
• Positive test: sacrum does not spring back → backward torsion of sacrum

Static examination

• Position: supine
• Procedure
  1. Perform standing flexion test.
  2. Reset pelvis.
     1. Ask patient to bend knees and place feet flat on table.
     2. Lift pelvis off table and back down.
     3. Straighten legs onto the table.
  3. Compare heights of ASIS.
     1. Lay edge of thumbs perpendicular to the inferior aspect of each ASIS.
     2. Determine relative position of each side.
  4. Compare heights of pubic tubercles.
     1. Starting at the level of the umbilicus, gently inch down with the heel of your hand (fingers pointing cephalad) until it meets the bony pubic symphysis.
     2. Gently place thumb pads over the superior aspect of the pubic tubercles bilaterally to determine relative position.
  5. Compare heights of medial malleoli.
     1. Gently add traction inferiorly at both ankles to remove slack.
     2. Place thumb pads just inferior to the medial malleoli bilaterally to determine relative position.
  6. Compare heights of PSIS.
     1. Lay edge of thumbs perpendicular to the inferior aspect of each PSIS.
     2. Determine relative position of each side.

Anterior innominate dysfunction

Diagnostic findings

• Must be present:
  • Ipsilateral inferior ASIS
  • Ipsilateral superior PSIS
• Additional supportive finding: ipsilateral inferior medial malleolus

Treatment

Muscle energy

• Position: supine
• Procedure
  1. Flex the affected hip into its physiologic barrier.
  2. Have patient extend hip against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

High-velocity low-amplitude (HVLA)

• Position: lateral recumbent
• Procedure
  1. Perform myofascial release.
  2. Flex top leg and lock behind extended bottom (non-affected) leg.
  3. Rotate patient to supine position.
  4. Place forearm on hip with elbow between greater trochanter and PSIS.
  5. Have patient take a deep breath.
  6. Apply thrust with forearm downward toward the legs.
  7. Reassess.

Posterior innominate dysfunction

Diagnostic findings

• Must be present:
  • Ipsilateral superior ASIS
  • Ipsilateral inferior PSIS
• Additional supporting finding: ipsilateral superior medial malleolus

Treatment

Muscle energy

• Position: supine
• Procedure
  1. Extend affected hip off the table into its physiologic barrier.
  2. Stabilize contralateral hip.
  3. Have patient flex hip against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

High-velocity low-amplitude (HVLA)

• Position: lateral recumbent
• Procedure
  1. Perform myofascial release.
  2. Flex top leg and lock behind extended bottom (non-affected) leg.
  3. Rotate patient to supine position.
  4. Place forearm on hip with elbow between greater trochanter and PSIS.
  5. Have patient take deep breath.
  6. Apply thrust with forearm upward toward you.
  7. Reassess.

Superior innominate shear

Diagnostic findings

• Must be present:
  • Ipsilateral superior ASIS
  • Ipsilateral superior PSIS
  • Ipsilateral superior medial malleolus
• Additional supporting finding: ipsilateral superior pubic rami

Treatment

Muscle energy

• Position: supine
• Procedure
  1. Grasp leg above ankle or knee.
  2. Abduct leg 10–15 degrees and internally rotate.
  3. Have patient lift hip against equal resistance for 3–5 seconds.
  4. Relax for 5 seconds.
  5. Re-engage barrier and repeat.
  6. Reassess.

High-velocity low-amplitude (HVLA)

• Position: supine
• Procedure
  1. Perform myofascial release.
  2. Grasp leg above ankle or knee.
  3. Abduct leg 10–15 degrees and internally rotate.
  4. Apply thrust inferiorly.
  5. Reassess.

Inferior innominate shear

Diagnostic findings

• Must be present
  • Ipsilateral inferior ASIS
  • Ipsilateral inferior PSIS
  • Ipsilateral inferior medial malleolus
• Additional supporting finding: Ipsilateral inferior pubic rami

Inflare of the innominate

Diagnostic findings

• Both must be present:
  • Ipsilateral medial ASIS (smaller distance between ASIS and umbilicus compared to contralateral side)
  • Ipsilateral lateral ischial tuberosity (larger distance between ischial tuberosity and midline)

Outflare of the innominate

Diagnostic findings

• Both must be present:
  • Ipsilateral lateral ASIS (larger distance between ASIS and umbilicus compared to contralateral side)
  • Ipsilateral medial ischial tuberosity (smaller distance between ischial tuberosity and midline)

Static examination

• See step 4 in the pelvic static examination

Pubic shears

Superior pubic shear

Diagnostic findings

• Both must be present:
  • Ipsilateral superior pubic bone
  • ASIS and PSIS are level

Treatment

Muscle energy

• Position: supine with knees at 90 degrees
• Procedure
  1. With knees closed, ask patient to abduct knees against equal resistance for 3–5 seconds.
  2. Relax for 5 seconds.
  3. Repeat.
  4. With knees open, ask patient to adduct knees against equal resistance for 3–5 seconds.
  5. Relax for 5 seconds.
  6. Gradually increase distance between knees and repeat.
  7. Reassess.

Inferior pubic shear

Diagnostic findings

• Both must be present:
  • Ipsilateral inferior pubic bone
  • ASIS and PSIS are level

Treatment

• Same as superior shear

Overview

• Sacral motion is typically described in relation to the L5 vertebrae
• Four types of dysfunction
  • Rotation
    • Occurs on an oblique (right or left) axis
    • Deep sacral sulcus and posterior ILA are opposite
    • L5 rotates in the same direction
  • Torsion
    • Occurs on an oblique (right or left) axis
    • Deep sacral sulcus and posterior ILA are opposite
    • L5 rotates in the opposite direction
  • Unilateral flexion or extension
    • Can be physiologic or non-physiologic
    • Deep sacral sulcus and posterior ILA are on the same side
  • Bilateral flexion or extension
    • Either deep sacral sulci or posterior ILA's are present on both sides
    • Typically found in pregnant women

Static examination

• Position: seated
• Procedure
  1. Perform diagnostic tests (seated flexion, sphinx, or lumbosacral spring test).
     • Seated flexion test is only used as a guide.
     • Sphinx and lumbosacral spring test determine posterior component to diagnoses.
  2. Compare depth of sacral sulci.
     • Place each thumb inferolaterally to the PSIS of either side.
  3. Compare position of inferior lateral angles (ILAs)
     • Place the hypothenar eminences on either side to determine their relative positions.
  4. Diagnose L5 vertebral dysfunction.
     • Determines if torsion or rotation is present.

Forward sacral rotation/torsion

Diagnostic findings

• Left rotation on a left oblique axis
  • All must be present
    • Right deep sacral sulcus
    • Left posterior inferior ILA
    • L5:
      • Rotation: rotated to the left
      • Torsion: rotated to the right
• Right rotation on a right oblique axis
  • All must be present
    • Left deep sacral sulcus
    • Right posterior inferior ILA
    • L5:
      • Rotation: rotated to the right
      • Torsion: rotated to the left

Treatment

Muscle energy

• Position: lateral sims position (axis side down)
• Procedure
  1. Flex hip until motion at lumbosacral junction.
  2. Have patient hug table (sims position)
  3. Place legs off table to induce side bending.
  4. Ask patient to lift legs against equal resistance for 3–5 seconds.
  5. Relax for 5 seconds.
  6. Re-engage barrier and repeat.
  7. Reassess.

High-velocity low-amplitude (HVLA)

• Position: supine
• Procedure
  1. Perform myofascial release.
  2. Stand on side of deep sacral sulcus.
  3. Side bend torso slightly away.
  4. Place contralateral leg over ipsilateral leg and side bend slightly away.
  5. Ask patient to clasp hands behind their neck.
  6. Ask patient to inhale.
  7. Stabilize opposite PSIS.
  8. Place hand through patient's arm and rotate upper torso toward you.
  9. Ask patient to exhale throughout motion.
  10. Apply a downward thrust.
  11. Reassess.

Backward sacral rotation/torsion

Diagnostic findings

• Right rotation on a left oblique axis
  • All must be present:
    • Left deep sacral sulcus
    • Right posterior inferior ILA
    • L5:
      • Rotation: rotated to the right
      • Torsion: rotated to the left
• Left rotation on a right oblique axis
  • All must be present:
    • Right deep sacral sulcus
    • Left posterior inferior ILA
    • L5:
      • Rotation: rotated to the left
      • Torsion: rotated to the right

Treatment

Muscle energy

• Position: lateral recumbent position (axis side down)
• Procedure
  1. Rotate torso of patient up.
  2. Flex hip until motion at lumbosacral junction.
  3. Place legs off table to induce side bending.
  4. Ask patient to lift legs against equal resistance for 3–5 seconds.
  5. Relax for 5 seconds.
  6. Re-engage barrier and repeat.
  7. Reassess.

The L5 vertebral diagnosis determines whether a sacral rotation or torsion is present!

Bilateral sacral flexion

Diagnostic findings

• Both must be present:
  • Right and left deep sacral sulcus
  • Right and left posterior inferior ILA
• Additional supporting finding: increased lordotic curvature of the lumbar spine

Treatment

Muscle energy

• Position: supine with knees flexed at ∼90 degrees
• Procedure
  1. Monitor lumbosacral junction and hyperflex knees.
  2. Ask patient to push knees against equal resistance for 3–5 seconds.
  3. Relax for 5 seconds.
  4. Re-engage barrier and repeat.
  5. Reassess.

Bilateral sacral extension

Diagnostic findings

• Both must be present:
  • Right and left shallow sacral sulcus
  • Right and left anterior superior ILA
• Additional supporting finding: decreased lordotic curvature of the lumbar spine

Treatment

Muscle energy

• Position: prone
• Procedure
  1. Ask patient to prop up onto their elbows to extend the lumbar spine.
  2. Place thenar eminence on sacral base.
  3. Apply anterior pressure to bring sacral base into its barrier.
  4. Ask patient to inhale while resisting the posterior motion of the sacral base.
  5. Follow sacral base anteriorly as patient exhales.
  6. Re-engage barrier and repeat.
  7. Reassess.

Unilateral sacral flexion (physiologic)

Diagnostic findings

• Right unilateral flexion
  • Both must be present:
    • Right deep sacral sulcus
    • Right posterior inferior ILA
• Left unilateral flexion
  • Both must be present:
    • Left deep sacral sulcus
    • Left posterior inferior ILA

Treatment

Muscle energy

• Position: prone
• Procedure
  1. Place hypothenar eminence on affected ILA.
  2. Ask patient to inhale and hold.
  3. Apply anterior force for 3–5 seconds.
  4. Ask patient to exhale while you resist posterior inferior motion.
  5. Re-engage barrier and repeat.
  6. Reassess.

Unilateral sacral extension (nonphysiologic)

Diagnostic findings

• Right unilateral extension
  • Both must be present:
    • Right shallow sacral sulcus
    • Right anterior superior ILA
• Left unilateral extension
  • Both must be present:
    • Left shallow sacral sulcus
    • Left anterior superior ILA

Treatment

Muscle energy

• Position: prone
• Procedure
  1. Place hypothenar eminence on affected sacral base.
  2. Ask patient to exhale and hold.
  3. Apply anterior force for 3–5 seconds.
  4. Ask patient to inhale while you resist posterior motion.
  5. Re-engage barrier and repeat.
  6. Reassess.