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).

Bones

Pelvis (innominate)

• The bony pelvis (pelvic girdle) is composed of two the hip bones, the sacrum, and the coccyx.
• These bones are firmly connected by the pubic symphysis anteriorly and the sacrococcygeal and sacroiliac joints posteriorly.
• Each hip bone consists of three fused bones: the ilium, ischium, and pubis.
• Articulations
  • At the acetabulum: with the femur
  • At the sacroiliac joint (SI joint): with the sacrum
  • The pubic bones articulate with each other at the pubic symphysis.
• For more information, see “Pelvis” in “Pelvis and hip joint.”

Sacrum

• The sacrum is composed of 5 fused vertebrae.
• Lies inferior to the lumbar spine and forms the posterosuperior wall of the pelvis
• Landmarks
  • Anterior portion: sacral promontory
  • Superior portion: sacral base, part of S1
  • Inferior portion: sacral apex, articulates with the coccyx
  • Sacral sulcus (SS)
    • Located at the superior lateral aspect of the sacrum bilaterally; posterior to the sacroiliac joint
    • At the level of S1 and S2
  • Inferior lateral angle (ILA)
    • Bony prominences on the inferior lateral surface of the sacrum
    • At the level of S5
• Articulations
  • Cranially: L5 vertebra
  • Laterally: the ilia
  • Caudally: the coccyx
• The sacral nerves emerge through the anterior and posterior sacral foramina between the central and lateral masses.
• For more information, see “Sacrum” in “Vertebral column.”

Ligaments

• True ligaments
  • Anterior sacroiliac ligament
  • Posterior sacroiliac ligament
  • Interosseous sacroiliac ligament
• Accessory ligaments
  • Sacrospinous ligament
  • Sacrotuberous ligament
  • Iliolumbar ligament
• For more information, see “Joints, ligaments, and foramina of the pelvis” in “Pelvis and hip joint.”

Muscles

• Pelvis
  • Levator ani muscle: can be divided into three separate muscles: pubococcygeus, puborectalis, iliococcygeus
  • Coccygeus muscle
  • For more information, see “Pelvic floor and perineal region” in “Pelvis and hip joint.”
• Sacrum
  • Anterior surface: piriformis, coccygeous, iliacus muscles
  • Posterior surface: erector spinae, multifidus, gluteus maximus

Anatomical landmarks of the pelvis and sacrum

Pelvis

• Anterior landmarks
  • Iliac crest
  • Anterior superior iliac spine (ASIS)
  • Anterior inferior iliac spine (AIIS)
  • Pubic tubercle
  • Medial malleoli
• Posterior landmarks
  • Posterior superior iliac spine (PSIS)
  • Posterior inferior iliac spine (PIIS)
  • Ischial tuberosity

Sacrum

• Superior landmark
  • Sacral sulci (sacral base)
    • Right and left
    • Can be shallow or deep in somatic dysfunctions
  • Palpated to assess for sacral motion
• Inferior landmark
  • Inferior lateral angles (ILAs)
    • Right and left
    • Can be posterior or anterior, superior or inferior in somatic dysfunctions
  • Palpated to assess for sacral motion

Sacrum

• Respiratory motion
  • Occurs at the superior transverse axis of the sacrum
  • Location of the axis: at the level of the S2 vertebra, posterior to the sacroiliac joint
  • During inhalation: the sacral base moves posteriorly
  • During exhalation: the sacral base moves anteriorly
• Craniosacral motion (inherent motion)
  • Occurs at the superior transverse axis of the sacrum
  • Location of the axis: at the level of the S2 vertebra
  • During craniosacral flexion: the sacral base moves posteriorly (counternutates)
  • During craniosacral extension: sacral base moves anteriorly (nutates)
• Postural motion
  • Occurs at the middle transverse axis of the sacrum
  • Location of the axis: at the anterior convexity of the two limbs of the sacroiliac joint
  • During forward bending: the sacral base moves anteriorly
  • During backward bending (terminal flexion): the sacral base moves posteriorly
• Dynamic motion (ambulatory motion)
  • Occurs when the sacrum engages both sacral oblique axes (e.g., during ambulation)
  • Location of the axis
    • Runs diagonally through the opposite sacral sulcus and ILA
    • Named after the side of the sacral sulcus
  • When bearing weight on the left leg (e.g., stepping forward with the right leg), the left sacral axis is engaged.
  • When bearing weight on the right leg (e.g., stepping forward with the left leg), the right sacral axis is engaged.

The sacrum has 5 axes of motion: superior, middle, and inferior transverse axes and two oblique axes.

Respiratory and craniosacral motions occur at the superior transverse sacral axis, postural motion occurs at the middle transverse axis, and dynamic motion occurs at the left or right oblique axes.

Innominate

• Occurs at the inferior transverse axis of the sacrum during ambulation
• Location of the axis: at the posteroinferior aspect of the inferior limb of the sacroiliac joint
• Includes anterior innominate and posterior innominate rotation

Innominate motion occurs at the inferior transverse sacral axis.

Pelvic somatic dysfunctions

• Types of pelvic dysfunctions
  • Anterior and posterior innominate
  • Superior and inferior innominate shear
  • Innominate outflare and inflare

The ASIS, PSIS, and standing flexion test need to be evaluated to diagnose pelvic dysfunctions.

Examination

• Position: supine
• Procedure
  1. Perform standing flexion test.
  2. Reset pelvis.
     • Ask the patient to bend their knees and place feet flat on the table.
     • Lift the pelvis off the table and back down.
     • Straighten the legs onto the table.
  3. Compare heights of ASIS.
     • Lay the edge of the thumbs perpendicular to the inferior aspect of each ASIS.
     • Determine the relative position of each side.
  4. Compare heights of PSIS.
     • Lay the edge of the thumbs perpendicular to the inferior aspect of each PSIS.
     • Determine the relative position of each side.
  5. Compare heights of pubic tubercles.
     • 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.
     • Gently place thumb pads over the superior aspect of the pubic tubercles bilaterally to determine relative position.
  6. Compare the heights of the ischial tuberosities
     • Lay the edge of the thumbs on each ischial tuberosity.
     • Determine the relative position of each side.

Sacral somatic dysfunctions

• There are 2 models of sacral dysfunction
  • Sacral motion described in relation to the L5 vertebra
    • Sacral torsion or sacral rotation on an oblique axis
    • Sacral shears (unilateral sacral flexion or extension)
    • Bilateral sacral flexion or extension
  • Sacral motion described in relation to the ilium
    • Anterior sacrum
      • The sacral base rotates forward and sidebends to the opposite side of the rotation
      • Similar to right on right sacral torsion (see sacral torsion/rotation dysfunction)
    • Posterior sacrum
      • The sacral base rotates backward and sidebends to the opposite side of the rotation
      • Similar to a left on right sacral torsion (see sacral torsion/rotation dysfunction)

The PSIS, SS, and ILA need to be evaluated to diagnose sacral dysfunctions.

Examination

• Position: seated
• Procedure
  1. Perform a seated flexion test: Determines the side of the dysfunction
  2. Compare the depth of the sacral sulci: Place each thumb inferolateral to the PSIS of either side.
  3. Compare the position of inferior lateral angles: Place the hypothenar eminences on either side to determine their relative positions.
  4. Diagnose the location of L5 in relation to the sacrum: Determine if torsion or rotation is present.

Standing flexion test

• Function: assesses sacroiliac motion
• Position: standing
• Procedure
  1. Place both thumbs below the PSIS.
  2. Ask the patient to bend forward while standing with both feet firmly on the ground shoulder width apart.
• Positive test: side with superior thumb motion
• 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 the patient to bend forward slowly.
• Positive test: side with superior thumb motion
• 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 the 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 on each sacral sulci.
  2. Ask the patient to lift themselves up on their elbows (sphinx position).
  3. Determine if asymmetry is present: If present, either one side of the sacral base is posterior or the other is anterior.
• Negative test: sulci become more symmetric → anterior component to the sacral base dysfunction
• Positive test: sulci become more asymmetric → posterior component to the sacral base dysfunction

Spring test (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 springs back → forward displacement of the base of the sacrum
• Positive test: sacrum does not spring back → backward displacement of the base of the sacrum

• Trendelenburg test
• FABER test (Patrick test)
• For more information, see “Hip joint examination” in "Orthopedic examination."

Positive Trendelenburg test: pelvic drop on the side of the lifted leg indicates gluteus medius and/or minimus muscle pathology on the opposite leg.

Ober test

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

Anterior innominate dysfunction

• Etiology: tight quadriceps
• Mechanics: : one innominate is rotated anteriorly around a transverse axis
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: inferior on the side of the dysfunction
• PSIS location: superior on the side of the dysfunction
• Additional supportive findings
  • Pubic tubercle is inferior on the side of the dysfunction
  • Ischial tuberosity is superior on the side of the dysfunction
  • ILA tissue texture changes on the side of the dysfunction
  • Iliolumbar ligament tenderness

Posterior innominate dysfunction

• Etiology: tight hamstrings
• Mechanics: one innominate is rotated posteriorly around a transverse axis
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: superior on the side of the dysfunction
• PSIS location: inferior on the side of the dysfunction
• Additional supporting findings
  • Pubic tubercle is superior on the side of the dysfunction
  • Ischial tuberosity is inferior on the side of the dysfunction
  • Sacral sulcus tissue texture changes on the side of the dysfunction
  • Inguinal tenderness
  • Acquired short leg on the side of the dysfunction

Superior innominate shear

• Etiology: trauma (e.g., falling on one buttocks)
• Mechanics: one innominate slips superiorly compared to the other
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: superior on the side of the dysfunction
• PSIS location: superior on the side of the dysfunction
• Additional supporting findings
  • Pubic ramus is superior on the side of the dysfunction
  • Shorter leg on the side of the dysfunction
  • Ischial tuberosity is superior on the side of the dysfunction
  • Medial malleolus is superior on the side of the dysfunction

Inferior innominate shear

• Etiology: trauma
• Mechanics: : one innominate slips inferiorly compared to the other
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: inferior on the side of the dysfunction
• PSIS location: inferior on the side of the dysfunction
• Additional supporting findings
  • Pubic ramus is inferior on the side of the dysfunction
  • Longer leg on the side of the dysfunction
  • Ischial tuberosity is inferior on the side of the dysfunction
  • Medial malleolus is inferior on the side of the dysfunction

Innominate inflare

• Etiology
  • Trauma
  • Muscular imbalances
• Mechanics: the orientation of an innominate flare is determined in relation to the anterior superior iliac spine (ASIS)
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: : medial on the side of the dysfunction (smaller distance between ASIS and umbilicus compared to contralateral side)
• PSIS location: normal or slightly lateral on the side of the dysfunction
• Additional supporting findings
  • Pubic tubercle is medial on the side of the dysfunction
  • Ischial tuberosity is lateral on the side of the dysfunction (larger distance between the ischial tuberosity and midline)
  • Internally rotated leg

Innominate outflare

• Etiology
  • Trauma
  • Muscular imbalances
• Mechanics: the orientation of an innominate flare is determined in relation to the anterior superior iliac spine (ASIS)
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: lateral on the side of the dysfunction (larger distance between ASIS and umbilicus compared to contralateral side)
• PSIS location: normal or slightly medial on the side of the dysfunction
• Additional supporting findings
  • Pubic tubercle is lateral on the side of the dysfunction
  • Ischial tuberosity is medial on the side of the dysfunction (larger distance between the ischial tuberosity and midline)
  • Externally rotated leg

Superior pubic shear

• Etiology
  • Trauma
  • Tight rectus abdominis muscle
  • Pregnancy (due to ligament laxity)
• Mechanics: one pubic bone is displaced superiorly compared to the other
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: at the normal level
• PSIS location: at the normal level
• Additional supporting findings: pubic tubercle is superior on the side of the dysfunction

Inferior pubic shear

• Etiology
  • Trauma
  • Tight adductors\
  • Pregnancy (due to ligament laxity)
• Mechanics: one pubic bone is displaced inferiorly compared to the other
• Standing flexion test or ASIS compression test: positive on the side of the dysfunction
• ASIS location: at the normal level
• PSIS location: at the normal level
• Additional supporting findings: pubic tubercle is inferior on the side of the dysfunction

Overview

• The sacrum rotates on an oblique axis (i.e., an axis that runs from opposite corners of the sacrum and is named after the upper corner).
• Sacral sulci and ILAs are pushed in opposite directions.
  • Deep sacral sulcus and posterior ILA are on opposite sides
  • Shallow sacral sulcus and anterior ILA are on opposite sides
• To determine the type of sacral torsion, three rules can be applied:
  1. Sacrum and L5 are always rotated in the opposite directions.
  2. The oblique axis and sidebending of L5 are on the same side.
  3. Seated flexion test reveals PSIS movement on the side contralateral to the oblique axis.

L5 sidebends in the same direction as the sacral axis and L5 rotates in the opposite direction to the sacrum.

In sacral torsion, an anterior movement of the base of the sacrum indicates forward torsion, meaning that sacral rotation and oblique axis occur on the same side.

Forward sacral torsion

• Description: Rotation occurs on the same side of the axis.
• Left rotation on left oblique axis
  • Seated flexion test: positive on the right
  • Spring test: negative
  • Sacral sulcus: deep (rotated forward) on the right
  • ILA: posterior and inferior (rotated backward) on the left
  • L5: neutral, sidebent left, rotated right (N S_LR_R)
• Right rotation on right oblique axis
  • Seated flexion test: positive on the left
  • Spring test: negative
  • Sacral sulcus: deep (rotated forward) on the left
  • ILA: posterior and inferior (rotated backward) on the right
  • L5: sidebent right, rotated left (N S_RR_L)

Backward sacral torsion

• Description: Rotation occurs on the opposite side of the axis.
• Right rotation on left oblique axis
  • Seated flexion test: positive on the right
  • Spring and sphinx tests: positive
  • Sacral sulcus: deep on the left
  • ILA: posterior and inferior on the right
  • L5: nonneutral, rotated left, sidebent left (F or E R_LS_L)
• Left rotation on right oblique axis
  • Seated flexion test: positive on the left
  • Spring and sphinx tests: positive
  • Sacral sulcus: deep on the right
  • ILA: posterior and inferior on the left
  • L5: nonneutral, rotated right, sidebent right (F or E R_RS_R)

Sacral bilateral dysfunctions

• The entire sacral base moves anterior to the middle transverse axis.
• Common in pregnant women and the postpartum period.

Bilateral sacral flexion

• Seated flexion test: : negative
• Spring and sphinx test: negative
• Sacral sulcus: : deep bilaterally
• ILA: : posterior and inferior bilaterally
• Additional supporting finding: increased lordotic curvature of the lumbar spine

Bilateral sacral extension

• Seated flexion test: : negative
• Spring and sphinx test: positive
• Sacral sulcus: shallow bilaterally
• ILA: anterior and superior bilaterally
• Additional supporting finding: decreased lordotic curvature of the lumbar spine

Sacral unilateral dysfunctions

The sacrum shifts anteriorly or posteriorly around a transverse axis.

Unilateral sacral flexion (physiologic)

• Right unilateral sacral flexion
  • Seated flexion test: positive on the right
  • Spring and sphinx test: negative
  • Sacral sulcus: deep on the right
  • ILA: posterior and inferior on the right
• Left unilateral sacral flexion
  • Seated flexion test: positive on the left
  • Spring and sphinx test: negative
  • Sacral sulcus: deep on the left
  • ILA: posterior and inferior on the left

Unilateral sacral extension (nonphysiologic)

• Right unilateral sacral extension
  • Seated flexion test: positive on the right
  • Spring and sphinx test: positive
  • Sacral sulcus: shallow on the right
  • ILA: anterior and superior on the right
• Left unilateral sacral extension
  • Seated flexion test: positive on the left
  • Spring and sphinx test: positive
  • Sacral sulcus: shallow on the left
  • ILA: anterior and superior on the left

Anterior innominate dysfunction

Muscle energy

• Position: supine
• Procedure
  1. Flex the patient's hip and knee to engage restrictive barrier.
  2. Ask the patient to extend their hip against equal resistance for 3–5 seconds to activate the hamstrings.
  3. Relax for 5 seconds.
  4. Engage new barrier and repeat.
  5. Reassess.

High-velocity low-amplitude (HVLA)

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

Posterior innominate dysfunction

Muscle energy

• Position: supine
• Procedure
  1. Extend the patient's hip off the table to engage restrictive barrier.
  2. Ask the patient to flex their hip against equal resistance for 3–5 seconds to activate the quadriceps.
  3. Relax for 5 seconds.
  4. Engage new barrier and repeat.
  5. Reassess.

High-velocity low-amplitude (HVLA)

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

Superior innominate shear

Muscle energy

• Position: supine
• Procedure
  1. Grasp the affected leg above the ankle or knee.
  2. Abduct the leg 10–15 degrees and internally rotate.
  3. Have the patient lift the 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 the affected leg above the ankle or knee.
  3. Abduct the leg 10–15 degrees and internally rotate.
  4. Apply thrust inferiorly.
  5. Reassess.

Inferior innominate shear

Muscle energy

• Position: prone
• Procedure
  1. Place the affected hip off the side of the table.
  2. Flex and abduct the patient's hip.
  3. Place the hand on the ipsilateral ischial tuberosity.
  4. Ask the patient to inhale and apply a superior and lateral force on the ischial tuberosity.
  5. Ask the patient to take a deep breath:
     1. During inhalation, attempt to straighten their leg against resistance.
     2. During exhalation, relax their leg for 5 seconds.
  6. Re-engage barrier and repeat.
  7. Reassess.

Innominate inflare

Muscle energy

• Position: supine
• Procedure
  1. Stand on the same side as the dysfunction.
  2. Flex the patient's hip and knee, and let the ankle rest across the opposite knee, while abducting and externally rotating the hip.
  3. Stabilize the contralateral ASIS with the other hand.
  4. Further abduct and externally rotate toward the restrictive barrier.
  5. Ask the patient to adduct and internally rotate the hip against equal resistance for 3–5 seconds.
  6. Relax, maintaining the same hip position for 1–2 seconds.
  7. Re-engage the barrier and repeat.
  8. Repeat for a total of 3–5 times.
  9. Return the patient to a neutral position.
  10. Reassess.

Innominate outflare

Muscle energy

• Position: supine
• Procedure
  1. Stand on the same side as the dysfunction.
  2. Flex the patient's hip and knee, and let the ankle rest across the opposite knee using one hand
  3. With the other hand, use the fingers to find and hook medially to the ipsilateral PSIS and further flex the patient's knee.
  4. Adduct and internally rotate the hip engaging the restrictive barrier.
  5. Ask the patient to abduct and externally rotate the hip against equal resistance for 3–5 seconds.
  6. Relax, maintaining the same hip position for 1–2 seconds.
  7. Re-engage the barrier and repeat.
  8. Repeat for a total of 3–5 times.
  9. Return the patient to a neutral position.
  10. Reassess.

Superior pubic shear

Muscle energy

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

Inferior pubic shear

Muscle energy

• Position: supine
• Procedure
  1. Place the hand on the ipsilateral ASIS.
  2. Flex and abduct the patient's hip.
  3. Place the hand on the ipsilateral ischial tuberosity.
  4. Posteriorly rotate the hip (superior and medial force) while maintaining pressure on the ASIS, ischial tuberosity, and the knee.
  5. Ask the patient to straighten their leg against resistance.
  6. Relax their leg for 5 seconds.
  7. Re-engage barrier and repeat.
  8. Reassess.

Forward sacral torsion

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 torsion

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.

Forward sacral torsions are treated with the patient's Face down. BACKward sacral torsions are treated with the patient's BACK down.

Bilateral sacral flexion

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

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

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

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.