FunctionalAnatomyofthePelvisandtheSacroiliacJointAPracticalGuide

JohnGibbons

Chichester,England

NorthAtlanticBooksBerkeley,California

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Title:Functionalanatomyofthepelvisandthesacroiliacjoint:apracticalguide/JohnGibbons.Description:Berkeley,California:NorthAtlanticBooks;Nutbourne,Chichester:LotusPublishing,2017.|Includesbibliographicalreferencesandindex.|DescriptionbasedonprintversionrecordandCIPdataprovidedbypublisher;resourcenotviewed.

Identifiers:LCCN2016020570(print)|LCCN2016019896(ebook)|ISBN9781623171032(ebook)|ISBN9781623171025(pbk.)Subjects:|MESH:Pelvis—anatomy&histology|SacroiliacJoint—anatomy&histology|Movement—physiologyClassification:LCCQM115(print)|LCCQM115

anatomy&histology|Movement—physiologyClassification:LCCQM115(print)|LCCQM115(ebook)|NLMWE760|DDC611/.96—dc23

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Idedicatethisbooktomyson,ThomasRhysGibbons,withallmyloveandbestwishesforahappy,successful,andrewardinglife.

Contents

PrefaceAcknowledgmentsListofAbbreviations

1.AnatomyofthePelvisandtheSacroiliacJoint2.MotionofthePelvisandtheSacroiliacJoint3.SacroiliacJointStability,MuscleImbalances,andtheMyofascialSlings4.TheWalking/GaitCycleandItsRelationshiptothePelvis5.LegLengthDiscrepancyandItsRelationshiptotheKineticChainandthePelvis

6.TheLawsofSpinalMechanics7.MuscleEnergyTechniquesandTheirRelationshiptothePelvis8.TheHipJointandItsRelationshiptothePelvis9.TheGlutealMusclesandTheirRelationshiptothePelvis10.TheLumbarSpineandItsRelationshiptothePelvis11.SacroiliacJointScreening12.AssessmentofthePelvis13.TreatmentofthePelvis

Appendix1:TablesforDysfunctionTestingAppendix2:OuterCoreStabilizationExerciseSheetBibliographyIndex

Preface

I first realized that there weremany areas of the body that still neededmoreattentionwhenIwastryingtoconsolidatethetextforthelastchapterofmyfirstbook, on muscle energy techniques (METs), which focused specifically onpotentialmuscleweaknessesmainlycausedbyshortenedandtightantagonisticmuscles.Inparticular,Iwroteabouttheeffects(possibleweakness/inhibition)oftheshortenedantagonisticmusclesofthehipflexorsontheglutealmusculature.This lastchapterof theMETbook inspiredmesomuch topursue thisavenuethatIdecidedtowriteanentiretextontheglutes.Then,whileIwaswritingthebookontheglutes,Ifoundthattheregionofthepelvicgirdleandsacroiliacjoint(SIJ)keptoncroppingupinonewayoranotherinmostofthechapters,andsoIthoughtitwouldbeamarvelousidea(atthetimeofcourse!)todevoteawholebooktothepelvisandSIJ.

So, aftermanymonths of contemplation and internal debate, I startedwritingthisbookinJuly2014,astheinitialthoughtofwritingmyfourthbookhadtakenme a while to get my head around. Because my book on the glutes haddemandedsuchavastamountofmytimeandeffort,Iwasn’tsureifIactuallywanted to carry onwriting.However, that particularweek in JulywhenVitalGlutes went to the printerswas a huge stepping stone forme. I could finallyfocusallmyattentiononwritinganewbook,thistimeonwhatIfeltwasoneofthemostneglectedareasofthebody—thepelvicgirdleandinparticulartheSIJ.

Havingtaughtcoursesonthespecificareasofthepelvicgirdleandlowerbackformanyyears, I have alwayswanted towrite a bookon theSIJ.The coursenotes each year seem to get thicker and thicker, because of the increasingamount ofmaterial. I thought tomyself: now is the perfect time inmy life tocontinuewriting,anditwouldalsomakeperfectsensetoputpentopaperandwrite an entire book about this specialized and fascinating area of the body. Iwould love to think that, in time, this particular book will be used as a coretextbook by physical therapy students and potentially serve as their mainreferenceguide.

Another reason forwriting thisbookwasbecauseofwhat I remember agoodfriend of mine once saying to me, while he was at university studying for a

physiotherapydegree.Hetoldmethatononeoccasionduringthefirstsemester,ashewasbeingtaughtallthedifferentaspectsofthespecificarearelatingtothehip joint, the tutor of the course announced that in the following semester thefocuswouldbeonthelumbarspine.Myfriendcasuallysaidtothetutor:“Whatabout thebit in themiddle?” (Hewas referring to thepelvisand theSIJ.)Thetutorreplied:“Thatbitinthemiddledoesn’tmove,sodon’tworryaboutit”!

Iampleasedtosaythat thingshavemovedonoverthelastfewyears,andwenowknowthat thefascinatingjoints thatmakeupthepelvicgirdledoactuallyhavesomemovement.

People who have come to know me over the last few years, either throughattendingmy courses or as patients or athletes attending the clinic,will knowthatIamaqualifiedosteopath.IcanhonestlysaywithhandonheartthattheseindividualsnaturallypresumethatallosteopathsspendmanyyearsstudyingthepelvicgirdleandSIJaswellasthelumbarspine,andsoon.Manypatientswhopresent to the osteopathic and chiropractic clinic typically have lower back,neck,orpelvicpain. Ihave taughtamultitudeofosteopathsandchiropractorsover the years, and all of them seem to have encountered different trainingmethodologies, especially when it comes to their core knowledge base andunderstanding of the pelvic girdle, and this appears to reflect the specificinstituteoftrainingtheyattended.

ThereasonIrefertoosteopathsinparticular,andthewaytheyareperceivedintermsoftheirknowledge,isbecauseIwanttomentionsomethingthatshockedand disappointed me. I can recall a time where I was lecturing a four-dayintensivecourseatmyvenueattheUniversityofOxford;thecourseinquestionwas theAdvancedTherapyMaster-Class.Thisparticularcourse isdesigned todeal specificallywith the areas of the pelvis and SIJ.Aswell asmany sportstherapists and physiotherapists, there were four recently qualified osteopathsattendingthecourse.Asthecoursegraduallyprogressedoverthefourdaystheyall mentioned to me (individually) that the specific assessment and treatmenttechniquesIwasshowingthemfortheareaofthepelvis,SIJ,andhip,andeventhe lumbar spine, were new to them and that they had not been taught thosespecific assessment and treatment techniques during their own five-yearintensive training courses. These four osteopaths were from two differenttrainingestablishments;Icouldhaveunderstooditiftheyhadbeenfromasingletrainingcenter,buttohaveallofthemnotbeingtaughtwhatIwouldcallbasicpalpatory, assessment, and treatment techniques not only surprised me but

actually disappointed me as well. I am pleased to say that by the end of thecoursethoseosteopaths,aswellastheothertherapistsattendingthecourse,hada far better understanding of how to assess and treat athletes and patientspresentingwithspecificlowerbackandpelvicpainattheirownclinics.

Hopefully, this textwill answer some (thoughmaybenot all) of the questionsyouhavebeenaskingyourselfwithregardtoyourownathletesandpatients,oritmightevenhelpyougainabetterunderstandingduringyourownstudiesofthepelvisandSIJ.Youmaybereadingthistextnotasaphysicaltherapist,butas someonewhoactuallyhaspain in theareaof the lowerbackorpelvis,andyoumaybetryingtobetterunderstandwhythatmightbeand,moreimportantly,whatyoucandoabout it.Whicheverof theseapplies toyou, I sincerelyhopethatyoufindwhatyouneedinthisbook.

Acknowledgments

The first person I would like to thank is Jon Hutchings of Lotus Publishing.Once again I sincerely thankyou for having the confidence inme to continuewith thedreamofwriting,aswithoutyouallofmybooks, including thisone,wouldnothavebeenwrittenandsubsequentlypublished.Thanksagain,Jon,forhavingthefaithinmetocomeupwiththegoods(sotospeak).MythanksalsotoIanTaylor,whospentavastamountoftimeandefforttakingandeditingthephotographsforthisbook,andtothecopy-editor,SteveBrierley,withoutwhosepatienceandinputthisbookwoulddefinitelynotreadaswellasitdoes!

I would like to include here my recognition of the outstanding work of fourparticularpioneersinthisfieldofmanualtherapy—AndryVleeming,DianeLee,Philip Greenman, and Wolf Schamberger. Without the dedication andparticipation of these individual role models this book would not have beenwritten,andforthatItrulythankyouall.

I am especially grateful to the musculoskeletal physiotherapist GordonBosworth, the person who guided me through my initial osteopathy training.AlthoughIacknowledgedhiminmypreviousbook,Ihavetoincludehimheretoo,becausetheactualfine-tuningwithregardtomyassessmentandtreatmentskillsintheareaofthepelvicgirdleandSIJisalldowntoGordon.Hemademylearningandunderstandingofthisfascinatingbutcomplexareaapleasure,andfor that I thankhimwithallmyheart. Idoconsiderhimtobeoneof thebestphysical therapists—if not the best—I have evermet.Hewas (and still is) aninspiration to me in becoming the person I am today—so thanks a million,Gordon,forallthateffort.Ihopementoringmewasasrewardingforyouasitwasforme!

Fortheir inspirationandmoralsupportduringthecreationofthisbook,Imustthank my sister, Amanda Williams, her husband, Philip Williams, and theirchildren,JamesandVictoria;andmymother,MargaretGibbons.Ialsowishtothankmyson,ThomasRhysGibbons,whowas14atthetimeofwriting,andtowhomIdedicatethisbook.I’vealwayssaidthatTomismylife—Ihopethathecan see the success that I have achieved andwill be inspired to do the same(thoughnotnecessarilyasawriter!). Itgivesmegreatpleasure to include this

brieftributetothesemuch-lovedpeopleinmynewbook.Myonlyregretisthatmyfather,JohnAndrewGibbons,isnotheretoseeorreadmybooks.Iamsure,however,thatheislookingdownonusallwithasmileonhisface.

I always seem to acknowledge a personwho has been inmy life the longest(apartfromfamily)attheendofthissection.Maybethat’sjustthewayitis—you mention one of the most important people in your life at the end. Thatpersonismyfiancée,DeniseThomas;wehavebeentogethersevenyearsatthetimeofwritingof thisbookand Imust say Ihavehad themostamazing timewithher.Thanksforbeing themodel in thephotographs,and thanksamillionforallyoursupport.

JohnGibbons

Abbreviations

AAJatlantoaxialjoint

AHCanteriorhorncell

AIISanteriorinferioriliacspineASISanteriorsuperioriliacspineASLRactivestraightlegraiseCOGcenterofgravity

CT computerized tomography DDD degenerative disc disease DLS deeplongitudinal sling ERS extension, rotation, side bending FABER flexion,abduction, external rotation FAI femoroacetabular impingement FAIRflexion,adduction,internalrotationFRSflexion,rotation,sidebendingGmaxgluteusmaximus

Gmedgluteusmedius

Gmingluteusminimus

GTOgolgitendonorgan

HVThigh-velocitythrustILAinferiorlateralangleITBiliotibialband

LLDleglengthdiscrepancyL-on-Lleft-on-left

L-on-Rleft-on-right

METmuscleenergytechniqueMRmagneticresonance

MRI magnetic resonance imagingMTA middle transverse axis NR neutral,rotation

OAJoccipitoatlantaljointPGPpelvicgirdlepain

PHC posterior horn cellPIIS posterior inferior iliac spinePIR post-isometricrelaxationPLSposteriorlongitudinalslingPSISposteriorsuperioriliacspineQLquadratuslumborum

RIreciprocalinhibitionROMrangeofmotion

R-on-Lright-on-left

R-on-Rright-on-right

SCMsternocleidomastoidSIJsacroiliacjoint

SPDsymphysispubisdysfunctionSPJsymphysispubisjointSTJsubtalarjoint

TFLtensorfasciaelataeTMJtemporomandibularjointTPtransverseprocess

TVAtransversusabdominis

1AnatomyofthePelvisandtheSacroiliacJoint

Thepelvicgirdleiscomposedofthesacrum,thecoccyx,andthethreeso-called“hipbones”—the ilium, ischium, and pubis. The bones of the adult pelvis jointogether to form four joints: the left and right sacroiliac joints (SIJs), thesacrococcygeal joint, and the symphysis pubis joint (SPJ), as shown inFigure1.1.

Figure1.1.Bonesofthepelvicgirdle,formingthefourjoints.

Atbirththeilium,ischium,andpubisbonesareseparatedbyhyalinecartilage;bytheendofpubertytheseboneswillhavenaturallyconjoined(fusedtogether),withcompleteossificationnormallyoccurringbythetimeapersonhasreachedtheageofapproximately20–25.The threebones,oncefusionhas takenplace,are collectively called the innominate bone, or simply the innominate. On thelateral side of the innominate bone is the acetabulum; this area forms thearticulationwith the head of the femur to create the iliofemoral (hip) joint, asshowninFigure1.2.

Figure1.2.Iliofemoral(hip)joint.

InnominateBones

Ilium

The ilium is fan shaped and is themost superior aswell as the largest of thethreehipbones;itmakesupapproximatelytwo-fifthsofthedeep,cuplikesocketofthehipjoint,calledtheacetabulum.Thebodyoftheiliumtogetherwiththesacrum forms the SIJ. This L-shaped articulation is located on the posteriorsuperioraspectoftheiliumandhasavertically(verticalplane)orientated“shortarm”andamorehorizontally(anterioposteriorplane)positioned“longarm,”asshowninFigure1.3.

Figure1.3.Lshapeoftheshort(vertical[1])andlong(horizontal[2])armsoftheilium.

Figure1.4.Anatomicallandmarksoftheiliaccrest:ASIS,AIIS,andPSIS.

Ifyouplaceonehandonyourhip,youcanfeelthecurvedridgeofthesuperioraspectoftheilium:thisisknownastheiliaccrest.Fromthiscrest,ifyoulightlymoveyourfingersdowninferiortotheanterioraspectoftheilium,youshouldfeel a bony projection known as the anterior superior iliac spine (ASIS); thisarea allows the attachment of soft tissues (e.g. the sartorius muscle). If youcontinueslightlyinferiortotheASIS,youwillcometoanotherbonylandmarkcalledtheanteriorinferioriliacspine(AIIS);thisiswhereonepartoftherectusfemorismuscleattaches.Palpatingtheposterioraspectoftheiliumasitcurvesinferiorly, you will feel the bony prominence of the posterior superior iliacspine (PSIS); again this is an attachment for soft tissues. These two bonyprojections (ASIS and PSIS) are commonly used as palpatory landmarks, asshowninFigure1.4,whenoneisassessingthepositionofthepelvicgirdle.

Ischium

Theischiumisnarrowerthantheiliumboneandislocatedinferiortotheiliumand behind the pubis.The ischiumhas an easily palpable landmark called theischialtuberosity,asshowninFigure1.5;itiscommonlycalledthesitboneandprovidesthenecessarylandmarkfortheattachmentofthehamstrings.It isthispartoftheischium(tuberosity),alongwiththecoccyx,onwhichyourestyourbodyweightwhileadoptingasittingposition.Theischiumisthestrongestofthethreebonesandformsapproximatelytwo-fifthsoftheacetabulum(hipsocket).

Figure1.5.Ischiumandischialtuberosity.

Pubis

Thepubis,orpubicbone, is themostanterioraswellasthesmallestofall thethree hipbones andmakes up approximately one-fifth of the acetabulum. Thebodyofthepubisiswide,strong,andflat,andtogetherwiththeoppositepubicbonemakes up the SPJ. This joint is classified as an amphiarthrosis, as it isconnectedcentrallybyabroadpieceof fibrocartilage,as shown inFigure1.6.On the superioraspectof thepubis there is abonyprojectioncalled thepubictubercle;thisstructureallowstheattachmentoftheinguinalligamentandisalsoused as a palpatory landmarkwhenone is assessing the positionof the pelvicgirdle.

Figure1.6.Pubis,pubictubercleandSPJ.

Sacrum

The sacrum (sacred bone) is a large triangular bone located at the base of thelumbarspineandformsthebackpartofthepelviccavity.Thesacrumstartsoutfrombirthasfiveindividualbonesbeforestartingtofusebetweentheagesof16and18; the sacrum isconsidered tohave fully fused intoa singleboneby thetimeyouhavereached34yearsofage.

Considerabledifferencesintheshapeofthesacrumbetweenindividuals,aswellasstructuraldifferencesbetween the leftand right sides,arewelldocumented.

TheconnectionofthesacrumtotheiliumformstheSIJ.

Thesuperioraspectofthesacrumiscalledthesacralbaseandisprimarilymadeupofthe1stsacralsegment;thebaseisangledinaforwarddirectiontoformaconcavity.Theoppositeendof thesacrumiscalled thesacralapexandthis ismadeupofthe5thsacralsegment,asshowninFigure1.7.Thenaturalpositionofthesacrumiscalledthesacralangleandisgenerallythoughttobeintherange40–44degrees (Figure1.8), although, asdiscussedby someauthors, the anglecan be anywhere from 30 to 50 degrees.Moreover, a specific type ofmotioncalled nutation (a nodding motion, which will be discussed later) can beresponsibleforanincrease in thisanglebyanywherebetween6and8degreeson standingup (froma sittingposition).The sacral angle increasesbecauseofthechangeinthecurvatureofthelumbarspine,fromaninitialflexioncurvaturewhensitting,toanextensioncurvature(lumbarlordosis)whenstanding,asoneperformsthemotionfromasittingtoastandingposture.Thissacralmovementallowsthewholeofthespinalcolumntoadoptanuprightposition.

Figure1.7.Anatomicallandmarksofthesacrum(posteriorview).

On the lateral sidesof the sacrum locatedbetween the levelsof the first threesacralvertebra(S1–S3)are thealae (wings): theseauricular(earlike)L-shapedareasofthesacrummakeupthearticulationwiththeilium—i.e. theSIJ.Inanearlier paragraph regarding the ilium Imentioned that there is a short verticalarmandalonganteroposterior(horizontal)arm,asshowninFigure1.8,whichwillnaturallydovetailwitheachother,likepiecesofajigsawpuzzle.

Figure1.8.Theshort(vertical[1])andlong(horizontal[2])armofthesacrum,andthesacralangle(lateralview).

Anotherwayoflookingatthesacrumisasacontinuationofthelumbarspine,whiletheSIJsoneithersidearemimickingwhatIgenerallycallatypicalfacetjoints.Youcan thinkof the sacrumasa singlevertebra,and the left and right

SIJsasthearticulatingfacetjoints,withthesuperiorarticularfacetbeingtheiliacomponentandtheinferiorarticularfacetbeingthesacralcomponent(illustratedinFigure1.11).

Coccyx

The coccyx is the continuation and endpoint of the vertebral column and iscommonly referred to as the tailbone. It has between three and five (normallyfour) vertebral segments called the coccygeal vertebrae, and most textbooksstate that these are actually fused; some authors, however, maintain that thecoccygealvertebraeareindeedseparateandindividualentities(Figure1.9).

Figure1.9.Coccyxboneandtheindividualsegments.

Therearemanymuscleswithattachmentsdirectlyonthecoccyx:forexample,the pelvic floor muscles attach to the anterior surface of the coccyx, and thegluteusmaximus (Gmax)muscleand ligamentsattach to theposterior surface.Likewise, some ligaments attach directly to the coccyx, such as thesacrococcygeal ligament and some of the fibers of the sacrospinous andsacrotuberousligaments.Thecoccyxalsoplaysaroleinweightbearing(whilesitting),asitformspartofthetripodstructure,workinginconjunctionwiththeleftandrightischialtuberosities(sitbones).

SymphysisPubisJoint

The symphysis pubis joint (SPJ) is classified as a non-synovialfibrocartilaginousamphiarthrosis,connectingtheleftandrightpubicbones.

Inadultsonly0.08”(2mm)ofmovement(shift)andonedegreeofrotationareconsidered to be possible in this joint; however, these values will increase inwomenduringpregnancyandchildbirth.TheavailablemovementoftheSPJisalsoinfluencedbythenaturalshapeofthejoint,andbymuscularactivationfromtheadductorandabdominalmuscles.

Theendsofeachpubicbonearecoveredbyhyalinecartilagethatconnectstothepiece of fibrocartilage located in the center of the SPJ. The joint has strongsuperiorandinferiorligamentsandathinnerposteriorligament(Figure1.10).

Figure1.10.Symphysispubisjointandassociatedligaments.

One can think of the design of the symphysis pubis as being similar to theintervertebral discs of the spine, with a central disc of fibrocartilage thatcushionsagainstcompressive loads,aswellasprovidingshockabsorptionandcontributingtopassivestabilization.Becauseofthissimilarity,thearticulardiscoftheSPJisalsovulnerabletobothdegenerationandtrauma,particularlywhenthejointissubjectedtotraumaticorrepetitiveshearforces(e.g.osteitispubis).

Functionally, theSPJhelps to resist tension,shearing,andcompressionforces,and remarkably is able to widen during pregnancy. The anatomist AndreasVesalius,whochallenged theHippocraticbelief that thepubicbonesseparated

duringchildbirth,wasthefirsttorecognizethisjointin1543.

SacroiliacJoint

Lowerbackpainandthelinkwiththesacroiliacjoint(SIJ,orSIjoint)datebackto the era of Hippocrates (c.460–377 BC); the medical practitioners(obstetricians) at the time felt that under normal conditions the SIJs wereimmobile.Iamverypleasedtosaythatthingshaveprogressedenormouslyoverthelastfewdecadeswithalltheinformationnowreadilyavailableinrespectofthe general consensus of the role and function of the pelvic girdle, and inparticular of the SIJ. I can guarantee, though, that over time some thingswillneverthelesschange,sothisbookmaywellneedtobeupdatedinthefuture.

Ihavebeenlecturingcoursesonthepelvicgirdle,andontheSIJ inparticular,formanyyearsatmyvenuebasedat theUniversityofOxford,whichmeansIhave come into contact with thousands of physical therapists, ranging fromosteopathsandphysiotherapiststochiropractorsandlotsofsportstherapists,tomentionbutafew.IfIamhonestwithmyself,Ipersonallyconsiderthattheareaof thepelvis isa relativelydifficult subject to try togetacross tomystudents(mainly therapists); this is because I consider the SIJ to be something of a“mystery” to many therapists, and it becomes especially difficult when I amtryingtoexplainthesubjectmattertomyathletesandpatients.

Themajorityofphysicaltherapistsattendingthecourseonthepelvicgirdletellmeatsomepoint that theyseepatientsandathletesonadailybasiswithwhatthey consider to be a presentation of sacroiliac joint dysfunction. In the past,patientswithpresentingSIJ issueshaveevenbeenreferreddirectly to thembythelocalGPoracolleague.

Vleeming et al. (2007) say that mobility of the pelvic joints is difficult tomeasureobjectively,especially in theweightbearingposition,and that feelingmotion at the sacroiliac joint during active and passive motion is difficult toprove.

Bearinginmindtheabovequote,youcanimaginethatteachingaspecificcourseon this fascinating but undoubtedly complex area of the body is not asstraightforwardasonemightthink.

Anatomy

TheSIJ,asshowninFigure1.11, is locatedbetweenthesacrumandthe iliumandisclassifiedasatruesynovialarthrodialjoint,asitcontainsajointcapsule,synovialfluid,articularcartilage,andasynovialmembrane.

The SIJ is unique: on the ilia side, the cartilage is made up mainly offibrocartilage, whereas on the sacral side, the cartilage consists of hyaline, orarticular,cartilage.Thearticular(hyaline)cartilageisthicker(0.04–0.12”,or1–3mm)onthesacralsidethanontheiliaside.KampenandTillman(1998)foundthat in adults the cartilage on the sacral surface of the joint can reach 0.16”(4mm) in thickness, but does not exceed 0.04–0.08” (1–2mm) on the iliacsurface.Thelackofthicknessofthecartilageontheiliasidemightbeoneofthefactorsresponsibleforhardening(sclerosis).

Figure1.11.AnatomyoftheSIJ;a)transversesection;b)lateralview.

The SIJs have an auricular L-shaped appearance, similar to a kidney, with ashort (vertical) upper arm and a longer (horizontal) lower arm (as alreadymentionedearlier).

Regarding the shape of the SIJ, different characteristics between individualshave been clinically proven; moreover, there can be significant structuraldifferencesbetweentheleftandrightsidesofthejointsurfaceswithintheSIJsof the same individual.There is also clear evidenceof the fact that thepairedSIJs, and even the PSISs, are generally asymmetric in appearance,which canalsobethecaseinpatientsandathleteswhopresentwithnosymptomsofpainordysfunction(i.e.areasymptomatic).

In terms ofmotion, the pelvis is capable ofmoving in all three planes of thebody: flexion and extension in the sagittal plane (forward and backwardbending); lateral flexion(sidebending) in thefrontalplane;androtationof the

trunk in the transverse plane. It has been debated that the SIJ can moveanywhere between 2 and 18 degrees, but more recent evidence provided bymanycliniciansdemonstratesthatthereareroughly2–4degreesofrotationand0.04–0.08” (1–2mm) of translation. Studies have shown us that movement ispossible,butonlyinverysmallamounts;thiswasdemonstratedbyEgundetal.(1978)andSturessonetal.(1989,2000a,2000b),whofoundthemotionoftheSIJ to be at best approximately 2–4 degrees in rotation and 0.08” (2mm) intranslation.

Weknowthatwhenwearedevelopingthroughthenaturalagingprocess,theSIJcharacteristicschange.Inearly life theSIJsurfacesare ingeneral initiallyflat,but as we start to walk and progress through puberty, these surfaces developdistinctridgesandgroovesandlose theirnaturallyflattenedappearance.Theseridges and grooves actually fit into one another to some extent; this willpotentiallyaidtheoverallstabilityoftheSIJ,whilestillallowingsomedegreeofmovement.

The text Greenman’s Principles of Manual Medicine (DeStefano 2011)mentions that“during theagingprocess, there isan increase in thegroovesontheopposingsurfacesof thesacrumand iliumthatappears to reduceavailablemotionandenhancestability.”Theauthoralsosaysthat“itisofinteresttonotethattheageatwhichtheincidenceofdisablingbackpainishighest(range:25to45years)isthesameagewhenthegreatestamountofmotionisavailableinthesacroiliacjoints.”

Becauseoftherelationshipofthethreemainpelvicjoints(thetwosacroiliacandthe symphysis pubis), aswell as their relationship to the iliofemoral joint (hipjoint),adysfunctionexistinginanyoneofthesejointscanhaveadirectimpactontheothertwo/threejoints.

LigamentsoftheSIJ

TheSIJhasverystrongligaments,whichincreasethejoint’sstabilityandmakepotentialdislocationsveryrare.

Stability of theSIJ is provided partly through ligamentous attachments.Thesespecific ligamentswillprovide joint integrityaswellas resistance toshearing-type forces.The ligaments that bind the sacrumdirectly to the innominate are(Figure1.12):

Figure1.12.LigamentsrelatingtostabilityoftheSIJ;a)anteriorview,b)posteriorview.

•Sacrotuberous

•Sacrospinous

•Interosseous

•Longdorsal(posteriorsacroiliac)

TheiliolumbarligamentwillalsohaveastabilizinginfluenceontheSIJaswellasonthelumbarspine.

SacrotuberousLigament

ThesacrotuberousligamentattachesfromthePSISandalsohasanattachmenttotheposteriorsacroiliacligaments.Theligamentthencontinuesandattachesontothe ischial tuberosity and splits into three individual bands: the outer (lateral)side attaches from the PSIS to the ischial tuberosity; the inner (medial) bandattachesfromthecoccyxtotheischialtuberosity;andthesuperiorbandconnects

thePSIStothecoccyx.

FourmuscleshaveanattachmentdirectlytothesacrotuberousligamentandwillcontributetotheoverallstabilityoftheSIJ:

•Bicepsfemoris

•Gluteusmaximus(Gmax)

•Multifidus

•Piriformis

Vleemingetal.(1989a)foundthatinapproximately50%ofsubjectsthelowerborderofthesacrotuberousligamentwasdirectlycontinuouswiththetendonoftheoriginofthelongheadofbicepsfemoris;thismusclecouldthereforeacttostabilizetheSIJviathesacrotuberousligament.

Part of the role of the sacrotuberous ligament is to resist the anterior noddingtypeofmotionofthesacrumknownasnutation.Thisligamentwillalsopreventposteriorrotationoftheinnominatebonewithrespecttothesacrum.Ifforsomereasonthereislaxityinthesacrotuberousligament(alongwiththesacrospinousligament), the decreased tension can result in a posterior rotation of theinnominatebone,andalsoleadtoincreasednutationofthesacrum.

SacrospinousLigament

The sacrospinous ligament has an attachment from the lateral aspect of thesacrumandcoccyxandattachestothespineoftheischium,appropriatelynamedtheischialspine.Theligamenthastheappearanceofathintriangleand,togetherwith the sacrotuberous ligament, it modifies the greater sciatic notch in thegreatersciaticforamen.Inonerespect,thefunctionofthesacrospinousligamentissimilartothatofthesacrotuberousligament:itpreventsposteriorrotationofthe innominate bone relative to the sacrum, and also limits nutation (forwardmotion)ofthesacrumrelativetotheinnominatebone.

InterosseousLigament

The interosseous ligamentconsistsof adense, short, thickcollectionof strong

collagenous fibers that run in a horizontal plane and connect the sacraltuberosities of the sacrum to the ilium. This ligament lies deep in the narrowrecess between the sacrum and the ilium, and has deep and superficialcomponentstoit.ThemainfunctionoftheinterosseousligamentistopreventaseparationorabductionoftheSIJbystronglybindingthesacrumtotheilium,asthiswillhelpsecuretheSIJinterlockingmechanism.

LongDorsalLigament(PosteriorSacroiliacLigament)

The long dorsal ligament attaches from the medial and lateral crests of thesacrum and to the PSIS. There is also a connection of this ligament to thethoracolumbarfascia,aswellastothemultifidusanderectorspinaemuscles.

Thelongdorsalligamentmainlyresistscounter-nutationofthesacrum(posteriornutation)aswellasanteriorrotationoftheinnominatebone.Consequently,thisligamentwillnaturallyslackenwhenthesacrumisinastateofnutationand/orifthereisposteriorrotationoftheinnominatebone.

If sacral torsion is present (discussed in later chapters) and the sacral base isfoundtobe“posterior,”thisligamentwillbeunderconstanttensionandmaybetenderwhenpalpated.

Lee (2004, p. 22) mentions that the skin overlying the long dorsal sacroiliacligamentisafrequentareaofpaininpatientswithlumbosacralandpelvicgirdledysfunction, and that tenderness on palpation of the ligament does notnecessarilyincriminatethistissue,giventhenatureofpainreferralfromboththelumbarspineandtheSIJ.

IliolumbarLigament

Theiliolumbarligamentisaverystrongligamentousstructure;itattachesfromthe transverseprocesses (TPs)of the4th and5th lumbarvertebraeand travels totheinnerborderoftheilium.

Thisligament,whichhasfiveindividualbands,isoneofthreevertebrae–pelvisligaments responsible for stabilizing the lumbosacral spine in thepelvis, alongwith the two mentioned already, namely the sacrospinous and sacrotuberous.Themainfunctionoftheiliolumbarligamentisessentiallytolimitthemotionofthe lumbosacral junction by stabilizing the connection between the pelvis and

thelowerlumbarvertebrae(L4andL5).

FunctionoftheSIJs

TheSIJs’primaryresponsibilityistotransfertheweightoftheupperbodytothelowerextremities.Thebodyweightis transferredthroughthevertebralcolumnto the lumbar spine (L5), to the sacrum and across the SIJs to the ischialtuberosities,andthenout to theacetabulaof thehip joints.ThismechanismofbonyattachmentsdemonstratestheSIJs’roleasweight-bearingjoints,asshownin Figure 1.13. The SIJs are also able to transfer the forces in the oppositedirection when one is walking, standing, or sitting: the pressure is directedthroughthelegstotheinnominatesandthesacrum,andthendissipatedupwardthroughthelumbosacraljunction.

Figure1.13.WeighttransferforcesthroughthepelvisandtheSIJs.

Intheirsecondaryrole,theSIJscanbethoughtofasshockabsorbers(mainlyatthepointofheelcontact),astheyhelpcushiontheincreasedstressthatisforcedupon the lumbar spine and in particular upon the lower lumbar intervertebraldiscs.Authorsinthepasthavesuggestedthattheincidenceoflowerlumbardiscdisease/degenerationincreaseswhentheSIJspresentwithpathologicalchanges.

Lee and Vleeming (2007) discussed the analysis of gait mechanics anddemonstratedthattheSIJsprovidesufficientflexibilityfortheintra-pelvicforcestobetransferredeffectivelytoandfromthelumbarspineandlowerextremities.

2MotionofthePelvisandtheSacroiliacJoint

Previousauthorshavesuggestedthatthereareapproximately14individualtypesofdysfunctionpossiblewithinthepelvicgirdlecomplex.Thisinitselfsuggeststomethat,becausetherearesomanytypesofpotentialdysfunctionwhichcanbepresentwithinthepelvicgirdle,therelogicallyhavetobejustasmanytypesofnaturalmotionavailableaswell.

PelvisMotion

Put in a relatively simpleway, there are threemain types ofmotion availablewithinthepelvicgirdle:

• Sacroiliac motion, which comprises the motion of the sacrum on theinnominatebone.

• Iliosacralmotion,whichcomprises themotionof the innominateboneonthesacrum.

•Symphysispubismotion,whichtypicallyrelatestothemotionofthepubicboneononesidewithrespecttotheboneontheotherside.

SacroiliacMotion

Sacroiliacmotion is themovement of the sacrumwithin the innominate bone,andtherearetwomaintypes:(1)anterior/forwardmotion,ornutation(thinkofthis as sacral flexion); and (2) posterior/backwardmotion, or counter-nutation(thinkofthisassacralextension).Bilateralmovementofthesacrumoccurswithforward and backward bending of the trunk; on the other hand, unilateralmovementofthesacrumoccurswithflexionandextensionofthehipjointandlowerlimbs,suchaswhenweinitiatethewalking/gaitcycle.

Nutation

Thewordnutationactuallymeans“nodding”,andthismotionofthesacralbase(top part of the sacrum) is directed anteriorly and inferiorly, while the sacralapex (bottom part of the sacrum)/coccyx moves posteriorly and superiorlyrelativetotheinnominatebone,asillustratedinFigure2.1(a).

Figure2.1.(a)Sacralnutation.(b)Sacralcounter-nutation.

During nutation (which is also known as anterior nutation), the sacrum isconsideredtoglideinferiorlydowntheshort(vertical)armandposteriorlyalongthelong(horizontal)armoftheL-shapedarticularsurface(seeFigure2.2).

Figure2.2.Sacralnutation:thesacrumglidesinferiorlydowntheshortarmandposteriorlyalongthelongarm.

Thenaturalwedgeshapeofthesacrum,aswellastheridgesandgroovesofthearticular surfaces, limits nutation. In addition, the interosseous, sacrotuberous,and sacrospinous ligaments will limit howmuch nutation is possible, as theybecometaughtinthisposition;thisisconsideredtobethemoststableposition.

Vrahasetal. (1995)mention thatnutationrepresentsamovement that tightensmost of the SIJ ligaments, among which are the vast interosseous and dorsalsacroiliac ligaments (with the exception of the long dorsal ligament), therebypreparingthepelvisforincreasedloading.

Counter-Nutation

Incounter-nutation the sacralbasemovesposteriorlyandsuperiorly,while thesacral apex/coccyx moves anteriorly and inferiorly relative to the innominatebone (Figure 2.1(b)). During this type of motion (which is also known as

posteriornutation), thesacrum isconsidered toglideanteriorlyalong the longarmandsuperiorlyuptheshortarmoftheL-shapedarticularsurface,asshowninFigure2.3.

Figure2.3.Sacralcounter-nutation:thesacrumglidesanteriorlyalongthelongarmandsuperiorlyuptheshortarm.

Thelongdorsalligamentlimitsthisspecificmotionofcounter-nutation.Becauseofthelaxityoftheinterosseousandsacrotuberousligaments,thissacralpositionofcounter-nutationisconsideredtobetheleaststable.

IliosacralMotion

Iliosacral motion is the movement permitted by the innominate bone on thesacrum.Bilateralmovement (anterior andposterior rotation)of the innominatebones occurs with forward and backward bending of the trunk; on the otherhand, unilateral movement (anterior and posterior rotation) of the innominate

bone occurs with flexion and extension of the hip joint and lower limbs, forexampleduringthegaitcycle(similartounilateralsacralmotion).

AnteriorInnominateMotion

Whenthehipandlowerlimbareextended,theinnominaterotatesanteriorlyasthe L-shaped articular surface glides inferiorly down the short arm andposteriorlyalongthelongarm,asshowninFigure2.4.Thisanteriormotionoftheinnominateisreminiscentofcounter-nutationofthesacrum.

Figure2.4.Anteriorrotationoftheinnominatebone:theL-shapedarticularsurfaceglidesinferiorlydowntheshortarmandposteriorlyalongthelongarm.

PosteriorInnominateMotion

Whenthehipandlowerlimbareflexed,theinnominaterotatesposteriorlyastheL-shapedarticularsurfaceglidesanteriorlyalongthelongarmandsuperiorlyuptheshortarm,asshowninFigure2.5.Thisposteriormotionoftheinnominateis

reminiscentofnutationofthesacrum.

Figure2.5.Posteriorrotationoftheinnominatebone:theL-shapedarticularsurfaceglidesanteriorlyalongthelongarmandsuperiorlyuptheshortarm.

SymphysisPubisMotion

Anteriorly,thetwohipbonesarejoinedtogethertoformaconnectionknownasthesymphysispubisjoint.Duringnormalwalking,thesymphysispubisjointactsasatypeofpivotpointforthemotionofthetwohipbones.

Although movement is possible at the symphysis pubis joint, it is normallyrestricted because of the attachments of the strong superior and inferiorligaments.Thelimitedmotionthatisavailablemainlyoccursduringthewalkingcycle; however, movement is also possible at this joint when one adopts astabilizedstandingpositionwhilebalancingononeleg.

Symphysis pubis dysfunction (SPD) is generally classified according to theposition in which the joint is fixed—either a superior symphysis pubis or an

inferiorsymphysispubis,asshowninFigure2.6.

Studieshaveshownthatifyouweretomaintainaone-leggedstandingpositionfor a fewminutes, a superiormotion (shear)of the symphysispubiswouldbeseen. If theone-leggedmotion ismaintainedover an extendedperiodof time,recurrentSPDcanresult.

Figure2.6.Superiorandinferiormotionofthesymphysispubisjoint.

SPD is commonly associated with pregnancy and childbirth; it is thought toaffect to varying degrees around one in five women who are pregnant, witharound5–7%ofthemcontinuingtoexperienceongoingpainfulsymptomsafterchildbirth. During pregnancy, and especially during childbirth, the symphysispubis ligamentsbecomemore lax inorder toallowanaturalseparationof thisjoint,sincethisincreasedmovementisneededtowidentheinternaldiameterofthepelvicbowl.

CombinedSacroiliacandIliosacralMotion

We have looked at the individual motion of the sacrum during nutation andcounter-nutation within the innominate bones (sacroiliac) and how theinnominatebone rotatesaround thesacrum(iliosacral).Next,wewillcombinethemotionofthesacroiliac,iliosacral,lumbar,andhipjointsduringforwardandbackwardbendingofthetrunk.

Whenthepelvicgirdle,i.e.thetwoinnominatebonesandthesacrum,rotateasaunit through the hip joint, thismotion is known as ananterior pelvic tilt or aposteriorpelvictilt.

BilateralMotion—ForwardBending

Bilateral (both sides) nutation and counter-nutation are the naturalmovementsthatthesacrumperformswhenweforwardandbackwardbendourtrunkwhileinastablepositionontwolegs.

On the initiation of forward bending of the trunk, the pelvic girdle will shiftposteriorlytocontrolthecenterofgravityinordertomaintainthebalance.Thesacrumwillbe inapositionofnutationandwill stay there throughout the fullrangeofmotion(ROM).Theleftandrightinnominatesrotatesymmetricallyonthefemur inananteriordirection(anteriorpelvic tilt),and thePSISwillmovesymmetricallyinacephalicdirection(superior)asthelumbarspine(L5)flexesonthesacrum.Astrunkflexioncontinues,therewillcomeanaturalpointwhentension is increased within the sacrotuberous ligament, biceps femoris, andthoracolumbarfascia,andapositionwheresacralnutationceases.Atthispointthe innominate bones continue rotating anteriorly; however, because of theincreased tension in the soft tissues (explained earlier), especially thehamstrings, the final position of trunk flexion is that in which the sacrum isconsidered to be in a position of relative counter-nutation, even though thesacrumwillappeartobeinapositionofnutation,asshowninFigure2.7.

Figure2.7.Bilateralmotionduringforwardbending.

Onthereturntoastandingposition,thesacrumremainsinapositionofnutationuntil the erect posture is achieved; at this crucial point, the sacrum slightlycounter-nutates to maintain a suspension between the two innominate bones.(Note that, even though I have mentioned counter-nutation, the sacrum stillmaintainsanoverallpositionofnutation.)

BilateralMotion—BackwardBending

This time, on the initiation of backward bending, the pelvic girdle will shift

anteriorly,while the innominate bones symmetrically rotate posteriorly on thefemur(posteriorpelvictilt); thePSIScanbeseenandfelt torotateinacaudaldirection(inferiorly),whilethethoracolumbarspinecontinuesextensionuntilL5extendsonthesacrum,asshowninFigure2.8.Thesacrumremainsinapositionofnutation throughoutbackwardbending; thisposition is considered tobe themoststablebecauseofthecompressionoftheSIJs.

Figure2.8.Bilateralmotionduringbackwardbending.

Unilateral(OneSide)MotionoftheSacrum

During the walking/gait cycle, the sacrum is required to perform its naturalmotioninawaythatiscompletelyoppositetothatduringforwardandbackwardbendingmovements.Thistimeweneedaspecifictypeofunilateral(one-sided)motion of the sacrum, not a bilateral motion. What I mean by this is thefollowing:aswewalkfrompointAtopointB,weneedonesideofthesacrum(e.g. the left side) tomove forward into nutation, while at the same time theoppositeside(rightsideinthiscase)ismovingbackwardintocounter-nutation(or posterior nutation). This movement gets a little bit more complex, as thenutation/counter-nutationwill naturally induce amovement of sacral rotation.Theproblemweencounternowisthatwhenyouhavearotationofthesacrum(orinfactanyvertebrae),acoupled(combined)motionwithsidebendingalsooccurs; the general rule (according to the current research) is that the sidebendingmotionwillbecoupledtotheoppositesideofthesacralrotation.Thisfollowswhat is typicallyknownasaTypeIorneutralmechanic (explained indetail inChapter6), inwhich the rotationandsidebendingarecoupled to theoppositeside;forinstance,thesacrumcanperformasidebendingmotiontotheleftside,butitwillrotatetotheoppositeside(totherightsideinthiscase).

ConsiderthefollowingexampletoillustratewhatIamtryingtosay.If the leftsideofthesacrumgoesforwardintoanteriornutation,itwillrotatetotherightside(thesacralbasewillpalpatedeeperontheleftside)andwillalsosidebendtotheleft(Figure2.9).However,therightsideofthesacrumwillalsorotatetotherightside,butthistimethesacralbasewillbeinaposteriornutationposition(counter-nutation,asthesacralbasewillnowpalpateshallowontherightside).

Figure2.9.Exampleofaunilateralmotionofthesacrum.

Themovementdiscussedabove,inwhichyouhavearotationtoonesideandasidebendingmotiontotheother,isalsoknownasasacraltorsion;thisspecifictype of sacral movement is considered to occur around an oblique axis (seefigure2.10).

SacralAxis

Thereareapproximatelysixtypesofsacralaxis(Figure2.10):

•Superiortransverseaxis

•Middletransverseaxis

•Inferiortransverseaxis

•Leftobliqueaxis

•Rightobliqueaxis

•Verticalaxis

Figure2.10.(a)Sacralaxis,(b)Leftobliqueaxisandrightobliqueaxis.

It is not within the scope of this book to cover all the different sacral axisvariations.For this text,however, theoneofparticular relevance is themiddletransverse axis (MTA), because sacral dysfunctions are palpated and treatedabout this horizontal axis, according to Mitchell terminology. Moreover, thisaxis is considered to undergo a transformation during the gait cycle into theobliqueaxis,whichisthespecificaxisthatwillbefocusedoninthistext.

ObliqueAxis

Ithasbeensuggestedbysomeauthorsthatthereisaleftobliqueaxisandarightoblique axis (see Figure 2.10(b)). The left oblique axis runs through the leftsacral base and continues through the right inferior lateral thangle (ILA); therightobliqueaxis runs through the right sacralbaseandcontinues through theleftILA.

InChapter3Iwilltakeyouthroughexactlyhowtheobliqueaxisisutilizedincombination with the movements of the kinetic chain as we perform sacralmotionduring thewalking/gait cycle.Fornow,however,wewill focuson thetwonaturalphysiologicalmotionsthatthesacrumiscapableof:“leftrotationonthe left oblique axis,” which is typically called a left-on-left (L-on-L) sacraltorsion,anda“rightrotationontherightobliqueaxis,”commonlyknownasaright-on-right(R-on-R)sacraltorsion.

There are, however, also two non-physiological motions of the sacrum: “leftrotationontherightobliqueaxis,”whichistypicallycalledaleft-on-right(L-on-R) sacral torsion, and a “right rotation on the left oblique axis,” commonlyknownasaright-on-left(R-on-L)sacraltorsion.

When authors mention the word “sacral torsion,” they can mean one of twothings: a naturally occurring motion of the sacrum that is performed, forexample,duringthegaitcycle(Chapter3willexplainthis);oradysfunctionofthesacrum,inthatitbecomesfixedinthisspecifictypeofpositionortorsion.

PhysiologicalMotions(AnteriorMotionFixation/Nutation)

Before we look at sacral torsions, let’s just remind ourselves of the neutralpositionofthesacrum,asshowninFigure2.11(a)andindicatedbythemodelin

Figure2.11(b).

Figure2.11.(a)Neutralpositionofthesacrum.

Figure2.11.(b)Neutralpositionofthesacrum,asindicatedbythemodel.

Left-on-Left(L-on-L)

Let’sdiscussaL-on-Lsacralmotion/torsionabitfurther:itrelatestothesacralbone being in a position of left rotation on the left oblique axis. Thiswill bespecific to thecasewhere the sacrumhas rotated to the left side, so the sacralsulcus(theareathat isnaturallyformedbythejunctionof thesacralbasewiththecorrespondingilium)willpalpateasdeepontheright.Moreover,theILAaswell as the sacral sulcus will palpate as posterior (shallow) on the left side,whichwillindicatethattherightsideofthesacrumhasanteriorlynutatedtotheleft,asshowninFigure2.12(a).

Figure2.12.(a)Left-on-left(L-on-L)sacralmotion/torsion.X=Anteriorordeep. =Posteriororshallow.

ThespecificmotionofaL-on-LsacraltorsionisdemonstratedinFigure2.12(b).

Figure2.12.(b)L-on-Lsacraltorsion,asdemonstratedbythemodel—sacralnutationisshownontherightside.

Right-on-Right(R-on-R)

AR-on-Rsacraltorsionrelatestoarightrotationontherightobliqueaxis.Thiswillbespecifictoasacrumthathasrotatedtotherightside,sothesacralsulcuswillpalpateasdeepontheleftside.TheILAandthesacralsulcuswillpalpateasposterior (shallow)on the right,whichwill indicate that the left sideof thesacrumhasanteriorlynutatedtotheright,asshowninFigure2.13(a).

Figure2.13.(a)Right-on-right(R-on-R)sacralmotion/torsion.X=Anteriorordeep. =Posteriororshallow.

Themodel inFigure2.13(b) isdemonstrating the specificmotionofaR-on-Rsacraltorsion.

Figure2.13.(b)R-on-Rsacraltorsion,asdemonstratedbythemodel—sacralnutationisshownontheleftside.

PhysiologicalSummary

As I have alreadymentioned,L-on-L andR-on-R sacral torsions are naturallyoccurringmotions around the sacrum, although these specificmotions can befixedinapositionofnutation.Forexample,ifyouhaveadysfunctionalposition,say a L-on-L sacral torsion, then the sacrum is capable of performing thismovement, as it is already fixed in this position and is potentially capable ofrotatingbacktoa“neutral”position.However,itisunabletoperforma“R-on-R” sacral torsion due to the fact that the left side of the sacrum is unable tocounter-nutate(posteriornutation),asthisside(left)isheldinafixedpositionofanteriornutation.

You will read in Chapter 3 that most of the activity of our musculoskeletalsystemwillinvolvethewalking/gaitcycle.Ashumans,weespeciallyneedtobeable to maintain ongoing L-on-L and R-on-R sacral (torsion) motions, sincethese are of paramount importance to enable us to ambulate normally through

the gait cycle. If the sacrum cannot perform these naturally occurring sacraltorsions(motion),dysfunctionoccursasaconsequence.

Non-PhysiologicalMotions(PosteriorMotionFixation/Counter-Nutation)

Non-physiologicalmotionsofthesacrumarealittlebitmorecomplextograsp,astheyareconsideredtobeunnaturalmotionsthatoccuraroundanobliqueaxisofthesacrum.Ifyoudohappentofindthistypeofposteriorsacraldysfunctionwithyourpatients, itoften tends tobecausedby the lumbarspine/trunkbeingplacedintoapositionofincreased(forced)flexionwithacombinedmovementof rotation (as in themotion of rotating your body to pick up a heavyweightfromthefloor).

ItmaytakeyouawhiletothinkaboutandunderstandthisnextconceptbutIwilltrymybesttoexplainthisinarelativelysimpleway,eventhoughmanypeoplewillstillhavedifficultyunderstandingwhatitisIamtryingtoportrayduetothenaturalcomplexityofthisfascinatingarea.

Before we start I would like you to think of this motion simply as abackward/posterior torsion, whereas the other two types I mentioned in theearlierparagraphsareforward/anteriortorsions.

Left-on-Right(L-on-R)

AL-on-Rsacral torsion relates toa left rotationon the rightobliqueaxis,andthiswill be specific to the casewhere the sacrum has rotated to the left side.However, because of the posterior motion of the left side of the sacrum, thesacralsulcuswillnowpalpateasshallowontheleft,andtheILAwillpalpateasposterior(shallow)onthe left; thiswill indicatethatthe leftsideofthesacrumhascounter-nutatedorposteriorlynutated,asshowninFigure2.14(a).

Figure2.14.(a)Left-on-right(L-on-R)sacraltorsion.X=Anteriorordeep. =Posteriororshallow.

ThisspecificmotionofaL-on-RsacraltorsioncanbeseeninFigure2.14(b),asdemonstratedbythemodel.

Figure2.14.(b)L-on-Rsacraltorsion,asdemonstratedbythemodel—sacralcounter-nutationisshownontheleftside.

Right-on-Left(R-on-L)

ItfollowsthataR-on-Lsacral torsionmustbetheoppositeofaL-on-Rsacraltorsion; thus, the sacral torsion this time relates to a right rotation on the leftobliqueaxis,andthiswillbespecific to thesacrumhavingrotated to therightside.Becauseof theposteriormotionof therightsideof thesacrum,however,the sacral sulcuswill nowpalpate as “shallow”on the right, and the ILAwillpalpateasposterior(shallow)ontheright.Thiswillindicatethattherightsideof the sacrumhas counter-nutated, or (if easier to understand) that the sacrum

hasposteriorlynutated(thinkofthissimplyasabackwardmotion),asshowninFigure2.15(a).

Figure2.15.(a)Right-on-left(R-on-L)sacraltorsion.X=Anteriorordeep. =Posteriororshallow.

Figure 2.15(b) illustrates the specific motion of a R-on-L sacral torsion, asdemonstratedbythemodel.

Figure2.15.(b)R-on-Lsacraltorsion,asdemonstratedbythemodel—sacralcounter-nutationisshownontherightside.

Non-PhysiologicalSummary

WhatIwouldliketodonowisgiveabriefreviewofthemainpointsdiscussedabove,sothatyoucanbetterunderstandthesespecifictypesofdysfunction.Weknow that L-on-R and R-on-L sacral torsions are unnatural motions of thesacrum,hencetheirbeingtermednon-physiological.Thesespecificmotionscanbefixedinapositionofcounter-nutationorabackwardtorsion.Forexample,ifyou have a dysfunctional position of a L-on-R sacral torsion, the sacrum iscapableofperformingthisbackwardtypeofmovement,asitisalreadyfixedin

that position. The sacrum is, however, unable to perform the normalphysiologicalmotionofaL-on-LoraR-on-Rsacraltorsion,becauseofthefactthat the left side of the sacrum is unable to nutate, since it is held in a fixedposition.Anotherwayof thinkingabout this is that the left sideof thesacrumcannotperformthemotionofanteriornutation,orsimplygoforwardontheleft,as it is held backward in a fixed position of counter-nutation or posteriornutation.

SacralTorsionsSummary

Tables2.1and2.2summarizethephysiologicalandnon-physiologicalmotionsofthesacrum.Youwillnoticethatthetablescontainextracomponents,namelythe position of the 5th lumbar vertebra, seated flexion test, lumbar spring test,sphinxtest,lumbarlordosiscurvature,andpositionofthemedialmalleolus.Allofthesewillbeexplainedinmoredetailinlaterchapters,especiallyChapter12,buthavebeenmentionedherebecausemyaim in this chapter is towhetyourappetite tocontinuereading.Fornow,I justwantedyoutobeawareofall thedifferenttypesofphysiologicalandnon-physiologicalmotionthatthesacrumiscapableofbeforeweprogressthroughtherestofthechapters.

L-on-LsacraltorsionForward/nutation

R-on-RsacraltorsionForward/nutation

Deepsacralsulcus(neutral) Right Left

Shallowsacralsulcus(neutral)

Left Right

ILAposterior Left Right

L5rotation Right—ERS(R) Left—ERS(L)

Seatedflexiontest Right Left

Lumbarspring Negative Negative

Sphinxtest Sacralsulcilevel Sacralsulcilevel

Lumbarlordosis Increased Increased

Medialmalleolus(leglength) Shortleft Shortright

Table2.1.Normalphysiologicalmotion:anterior/forwardsacraltorsions.

L-on-RsacraltorsionBackward/counter-nutation

R-on-LsacraltorsionBackward/counter-nutation

Deepsacralsulcus(neutral) Right Left

Shallowsacralsulcus(neutral)

Left Right

ILAposterior Left Right

L5rotation Right—FRS(R) Left—FRS(L)

Seatedflexiontest Left Right

Lumbarspring Positive Positive

Sphinxtest Leftsacralsulcusshallow(rightsacralsulcusdeeper)

Rightsacralsulcusshallow(leftsacralsulcusdeeper)

Lumbarlordosis Decreased Decreased

Medialmalleolus(leglength) Shortleft Shortright

Table2.2.Non-physiologicalmotion:posterior/backwardsacraltorsions.

3SacroiliacJointStability,MuscleImbalances,andtheMyofascialSlings

As the incidenceof pelvic and lower backpain continues to increase,wewillneedtolookatandunderstandthemuscularrelationshipsthataffectthecoreandlumbo–pelvic–sacral stability.Wewill thenhave todecidehow to incorporatethisknowledgeintoanassessmentandtreatmentplan,especiallyforpatientsandathleteswhopresentwithpainassociatedwiththeareaofthepelvicgirdleandlowerback.

Thereare twomainfactors thataffect thestabilityof thepelvis(or tobemoreprecise the sacroiliac joint (SIJ)): form closure and force closure. These twomechanisms collectively assist in a process known as the self-lockingmechanism.

Form closure arises from the anatomical alignment of the bones of theinnominateandthesacrum,wherethesacrumformsakindofkeystonebetweenthewingsofthepelvis.TheSIJtransferslargeloadsanditsshapeisadaptedtothis task. The articular surfaces are relatively flat, which helps to transfercompressionforcesandbendingmovements.However,a relatively flat joint isvulnerabletoshearforces.TheSIJisprotectedfromtheseforcesinthreeways.First,thesacrumiswedge(triangular)shapedandthusisstabilizedbetweentheinnominatebones,similarlytoakeystoneinaRomanarch,andiskeptinastateof “suspension” by the ligaments acting upon it. Second, in contrast to othersynovial joints, the articular cartilage is not smooth but rather irregular (thinkbacktoChapter1).Third,afrontaldissectionthroughtheSIJrevealscartilage-covered bone extensions protruding into the joint—the so-called “ridges” and“grooves.” They seem rather irregular, but are in fact complementary to eachother,andthisunusualirregularityisveryrelevantasitservestostabilizetheSIJwhencompressionisapplied.

AccordingtoVleemingetal.(1990a),afterpubertymostindividualsdevelopacrescent-shaped ridge running the entire length of the iliac surface with a

corresponding depression on the sacral side; this complementary ridge andgroovearenowbelieved to lock the surfaces togetherand increase stabilityoftheSIJ.

If thearticularsurfacesof thesacrumand the innominatebonesfitted togetherwithperfect formclosure,mobilitywouldbepractically impossible.However,form closure of theSIJ is not perfect andmobility—albeit small—is possible,and therefore stabilization during loading is required. This is achieved byincreasingcompressionacrossthejointatthemomentofloading;theanatomicalstructures responsible for this compression are the ligaments, muscles, andfasciae.ThemechanismofcompressionoftheSIJbytheseadditionalforcesiswhatiscommonlycalledforceclosure.WhentheSIJiscompressed,frictionofthejointincreasesandconsequentlyreinforcesformclosure,asshowninFigure3.1.AccordingtoWillardetal.(2012),forceclosurereducesthejoint’s“neutralzone,”therebyfacilitatingstabilizationoftheSIJ.

Forceclosureisaccomplishedasfollows.Thefirstmethodisbynutationofthesacrum, which is achieved either by anterior motion of the sacral base or byposteriorrotationoftheinnominatebone.Thesetwotypesofmotionresultinatightening of the sacrotuberous, sacrospinous, and interosseous ligaments; thistighteningassists inactivating theforceclosuremechanism, therebyincreasingthecompressionof theSIJ.Counter-nutation,on theotherhand,decreases thestability of the SIJ because of the reduced tension in the above-mentionedligaments.

Cohen (2005) states that because the ilium and sacrum only meet atapproximately one-third of their surfaces, the associated ligaments provide therestofthestabilitybetweenthesebones.

In thesecondmethod, forceclosure isassistedby theactivation/contractionoftheinnerandoutercoremuscles(localandglobalmusclesystems),asyouwillreadlateroninthischapter.

Figure3.1.Therelationshipbetweenform/forceclosureandsacroiliacstability.

The terms form closure and force closure delineate the active and passivecomponents of this self-locking mechanism and were first identified byVleemingetal. (1990a,1990b).BelowisaquotefromVleemingetal. (1995)thatIpersonallybelieveexplainstheabovetext.

“Shear in the sacroiliac joints is prevented by the combination of specificanatomical features (form closure) and the compression generated bymusclesandligamentsthatcanbeaccommodatedtothespecificloadingsituation(forceclosure).Ifthesacrumwouldfitthepelviswithperfectformclosure,nolateralforces would be needed. However, such a construction would make mobilitypracticallyimpossible.”

SacroiliacStability

Severalligaments,muscles,andfascialsystemscontributetoforceclosureofthepelvis: these are collectively referred to as the osteo-articular-ligamentoussystem. Recall that when the body is working efficiently, the shear forcesbetween the innominate bones and the sacrum are adequately controlled, andloadscanthenbetransferredbetweenthetrunk,pelvis,andlegs.

Vleeming and Stoeckart (2007) mention that various muscles are involved inforce closure of the SIJ, and that even muscles such as the rectus femoris,sartorius, iliacus,Gmax,andhamstringshaveadequate leverarms to influencemovementintheSIJ.Theeffectofthesemusclesisdependentonopenorclosedkinematicmovements,andwhetherthepelvisissufficientlybraced.

As you will read shortly, and also in later chapters, there is one muscle inparticularthatplaysahighlysignificantroleinstabilizingtheSIJs—thismuscleistheGmax.SomeoftheGmaxfibersmergeandattachontothesacrotuberousligament as well as onto a connective tissue structure known as thethoracolumbar fascia. Vleeming et al. (1989a) demonstrated this fact on 12cadaverdissections; they found that theGmaxmusclewasdirectlyattached tothesacrotuberousligamentinallcases.

TheGmaxconnects,viathethoracolumbarfascia,tothecontralaterallatissimusdorsi to form what is known as the posterior oblique myofascial sling (seesection“TheOuterCoreUnit:TheIntegratedMyofascialSlingSystem(GlobalSystem)” later in thischapter). Ithasbeenshown thatweakness,orpossiblyamisfiringsequence,oftheGmaxwillpredisposetheSIJtoinjurybydecreasingthefunctionofthis(posterioroblique)myofascialsling.Aweaknessormisfiringof the Gmax is a potential cause of a compensatory overactivation of thecontralateral latissimus dorsi; walking and running (gait cycle, explained inChapter4)imposehighloadsontheSIJ,sothisweight-bearingjointwillneedtobe self-stabilizing in order to reduce the effect of the altered compensatorymechanism.

Research has shown that sacral nutation (a nodding type ofmovement of thesacrumbetweentheinnominatebones)isthebestpositionforthepelvicgirdletobeatitsmoststable.AsIhavealreadyexplainedinearlierchapters,nutationoccurswhenmoving(forexample)fromasittingpositiontostanding,andfullnutationoccursduringforwardorbackwardbendingofthetrunk.Thismotionofsacral nutation tightens themajor ligaments (sacrotuberous, sacrospinous, andinterosseous) of the posterior pelvis, and the resulting tension increases thecompressive force across the SIJ. The increased tension provides the requiredstabilitythat isneededbytheSIJduringthegaitcycleaswellaswhensimplyrisingfromasittingtoastandingposition.

Vleeming et al. (1989b) showed how load application to the sacrotuberousligament, either directly to the ligament or through its continuations with thelong head of biceps femoris or the attachments of the Gmax, significantlydiminishes forward rotation of the sacral base. They demonstrated that thisincreases the coefficient of friction, thus decreasing movement of the SIJ byforceclosure.

SacralNutationandCounter-Nutation

SacralNutationandCounter-Nutation

Ifinditverybeneficialatcertain times,especiallyforyouthereader, to try todiscussalternativewaysofexplaininga relativelycomplexmotion. I thereforethoughtIwouldintroduceanopinionbyanotherauthor,EvanOsar(2012),whostates that nutation is the anterior inferior motion of the sacral base, whilecounter-nutation istheposteriorsuperiormotionofthesacralbase.NutationisnecessaryforthelockingoftheSIJduringunilateralstance,asshowninFigure3.2(a).Theinabilitytonutatethesacrumisaleadingcauseofunilateralstanceinstability and one of the causes of the classic Trendelenburg gait. Counter-nutation, on the other hand, is necessary in order to unlock the SIJ to allowanterior rotationof the innominate and extensionof thehip joint, as shown inFigure 3.2(b). The inability to unlock or counter-nutate the sacrum leads tocompensatory increases in lumbopelvic flexion, which in turn lead to andperpetuatelumbarinstability.

Figure3.2.(a)Posteriorpelvicrotationandsacralnutation.(b)Anteriorpelvicrotationandsacralcounter-nutation.

ForceClosureLigaments

Themainligamentousstructuresthatinfluenceforceclosure(Figure3.3)are:(1)the sacrotuberous ligament,whichconnects the sacrum to the ischiumandhasbeentermedthekeyorleadligament;and(2)thelongdorsalsacroiliacligament,whichconnectsthe3rdand4thsacralsegmentstothePSISandisalsoknownastheposteriorsacroiliacligament.

Figure3.3.Sacrotuberousligament(key)andthelongdorsalsacroiliacligament.

Ligaments can increase articular compression when they are tensed orlengthenedbythemovementofthebonestowhichtheyattach,orwhentheyaretensedbythecontractionofmusclesthatinsertontothebones.

Tensioninthesacrotuberousligamentcanbeincreasedinoneofthreeways:

1.Posteriorrotationoftheinnominatebonerelativetothesacrum.

2.Nutationofthesacrumrelativetotheinnominatebone.

3. Muscular contraction of any one of the four muscles that have a directattachment to the sacrotuberous ligament, namely biceps femoris,piriformis,Gmax,andmultifidus.

The main ligamentous tissue to restrain counter-nutation of the sacrum, oranterior rotation of the innominate, is the long dorsal sacroiliac ligament(posteriorsacroiliacligament).Thisisalessstableposition(comparedwiththeposition of nutation) for the pelvis to resist horizontal and/or vertical loading,since theSIJ isunder lesscompressionand isnotself-locked.The longdorsalligamentiscommonlyasourceofpainandcanbepalpatedjustbelow(inferiorto)thelevelofthePSIS.

Bythemselves,ligamentscannotmaintainastablepelvis—theyrelyonseveralmusclesystemstoassist them.Thereare twoimportantgroupsofmuscles that

contribute tostabilityof the lowerbackandpelvis:collectively theyarecalledtheinnerunit(core)andtheouterunit(myofascialslingsystems).Theinnerunitconsists of the transversus abdominis (TVA), multifidus, diaphragm, andmuscles of the pelvic floor—also collectively known as the core, or localstabilizers. The outer unit consists of several “slings,” or systems of muscles(global stabilizers and mobilizers that are anatomically connected andfunctionallyrelated).Theinnerandouterunitswillbediscussedlateroninthischapter.

ForceCouple

Definition: A force couple is a situationwhere two forces of equalmagnitude,but acting inoppositedirections, areapplied toanobjectandpurerotationresults,asmentionedbyAbernethyetal.(2004).

Anyalteredpositioningofthepelviscausedbypotentialmuscleimbalanceswillsubsequentlyaffecttherestofthekineticchain.Thereareseveralforcecouplesresponsibleformaintainingproperpositioningandalignmentofthepelvis.TheforcecouplesresponsibleforcontrollingthepositionofthepelvisinthesagittalandfrontalplanesareshownschematicallyinFigures3.4(a–f)and3.5.

Figure3.4.(a)Sagittalplane(anterior)pelvicforcecouple.(b)Anteriortilt:musclesheldinashortenedposition.(c)Anteriortilt:musclesheldinalengthenedposition.

Figure3.4.(d)Sagittalplane(posterior)pelvicforcecouple.(e)Posteriortilt:musclesheldinashortenedposition.(f)Posteriortilt:musclesheldinalengthenedposition.

Figure3.5.Frontalplane(lateral)pelvicforcecouples.

Posture

Definition:Postureistheattitudeorpositionofthebody,asdiscussedbyThomas(1997).

AccordingtoMartin(2002),postureshouldfulfillthreefunctions:

1. Maintain the alignment of the body’s segments in any position: supine,prone,sitting,allfours,andstanding.

2. Anticipate change to allow engagement in voluntary, goal-directedmovements,suchasreachingandstepping.

3.Reacttounexpectedperturbationsordisturbancesinbalance.

Fromtheabove,itcanbeseenthatpostureisanactiveaswellasastaticstate,andthatitissynonymouswithbalance.Optimalposturemustbemaintainedatall times,notonlywhenholding staticpositions (e.g. sittingand standing)butalsoduringmovement.

If optimal posture and postural control are to be encouraged during exerciseperformance, the principles of good static posture must be fully appreciated.Once these are understood, poor posture can be identified and correctivestrategiesadopted.

•Goodpostureisthestateofmuscularandskeletalbalancethatprotectsthesupporting structures of the body against injury or progressive deformity,irrespectiveoftheattitude(e.g.erect,lying,squatting,orstooping)inwhichthesestructuresareworkingorresting.

• Poor posture is a faulty relationship of the various parts of the body,producingincreasedstrainonthesupportingstructures,andresultinginlessefficientbalanceofthebodyoveritsbaseofsupport.

PoorPosture

Poorposturemaybea resultofmanydifferent contributing factors. Itmaybecaused by trauma suffered by the body, some form of deformity within themusculoskeletal system, or even faulty loading. Because sitting has become apositionmaintainedbyourbodiesforlongperiodsoftime(possibly8+hours),mostpeople in today’s society are losing the fight againstgravity andalteringtheir centerofgravity (COG).With correct posture, yourposturalmuscles arefairlyinactiveandenergyefficient,onlyrespondingtodisruptionsinbalanceinorder to maintain an upright position. As you move away from an idealalignment, postural muscle activity therefore increases, thus leading to higherenergyexpenditure.

PainSpasmCycle

Ischemiawillbeaprimarysourceofpain in the initial stagesofpoorposture.The blood flow through a muscle is inversely proportional to the level ofcontraction or activity, reaching almost zero at 50–60% of contraction. Somestudieshaveindicatedthat thebodyisnotable tomaintainhomeostasiswithasustainedisometriccontractionofover10%.

Considerthefollowingexample:theweightoftheheadisapproximately7%oftotalbodyweight (shouldersandarmsarearound14%).Thismeans that forapersonweighing176lbs(80kg),theheadwillweigharound11–13lbs(5to6kg).Iftheheadandshouldersmoveforward,outofidealalignment,theactivationoftheneckextensorswillincreasedramatically,resultinginrestrictedbloodflow.Previous authors have stated that for every inch of forward head posture, theweightoftheheadonthespinecanincreasebyapproximately10lb(4.5kg).Forexample, if the weight of the head is normally 10lb (4.5kg), it will nowpotentially weigh 20lb (9kg) for just a 1” (2.5cm) increase in forward headposture,30lb(13.5kg)fora2”(5cm)increase,andanunbelievable40lb(18kg)iftheheadtranslates3”(7.5cm),asshowninFigure3.6(a).

Figure3.6.(a)Theresultofaforwardheadposture.

This prolonged isometric contraction will force the muscles into anaerobicmetabolismandincreaselacticacidandotherirritatingmetaboliteaccumulation.Ifadequaterestisnotgiven,areflexcontractionofthealreadyischemicmusclesmaybeinitiated.Thispersonwillhavenowenteredthepainspasmcycle(Figure3.6(b)).

Figure3.6.(b)Painspasmmodel.

The neuromuscular system, as we know, is made up of slow-twitch and fast-twitchmusclefibers,eachhavingadifferentroleinthebody’sfunction.Slow-twitch fibers (Type I) are active in sustained low-level activity, such asmaintaining correct posture, whereas fast-twitch fibers (Type II) are used forpowerful,grossmovements.Musclescanalsobebrokendownintotwofurthercategories—tonic(orpostural)andphasic.

Tonic(Postural)andPhasicMuscles

Janda(1987)identifiedtwogroupsofmusclesonthebasisoftheirevolutionanddevelopment. Functionally, muscles can be classified as tonic or phasic. The

tonic system consists of the flexors, which develop later on to become thedominantstructure.Umphredetal. (2001) identified that the tonicmusclesareinvolvedinrepetitiveorrhythmicactivityandareactivatedinflexorsynergies,whereas the phasic system consists of the extensors and emerges shortly afterbirth.Thephasicmusclesworkeccentricallyagainsttheforceofgravityandareinvolved in extensor synergies. The division of muscles into predominantlyphasicandpredominantlyposturalisgiveninTable3.1.

Predominantlyposturalmuscles Predominantlyphasicmuscles

Shouldergirdle

Pectoralismajor/minor

Levatorscapulae

Uppertrapezius

Bicepsbrachii

Neckextensors:ScalenesCervicalerectorsSternocleidomastoid

Rhomboids

Lowertrapezius

Midtrapezius

Seratusanterior

Tricepsbrachii

Neckflexors:Supra-andinfrahyoid/Longuscolli

Lowerarm

Wristflexors Wristextensors

Trunk

Lumbarandcervicalerectors

Quadratuslumborum

Thoracicerectors

Abdominals

Pelvis

Bicepsfemoris/Semitendinosus/Semimembranosus

Iliopsoas

ITB

Rectusfemoris

Adductors

Piriformis/Tensorfasciaelatae

Vastusmedialis

Vastuslateralis

Gluteusmaximus

Gluteusminimusandmedius

Lowerleg

Gastrocnemius/Soleus Tibialisanterior/Peroneals

Table3.1.Phasicandposturalmusclesofthebody.

Previousauthorshavesuggestedthatmuscleswhichhaveastabilizingfunction(postural) have a natural tendency to shorten when stressed, and that othermuscles which play a more active/moving role (phasic) have a tendency tolengthen and can subsequently become inhibited (seeTable 3.2). Themusclesthattendtoshortenhaveaprimaryposturalroleandarerelatedtothepotentialinhibitionweaknessoftheglutealmuscles(whichyouwillreadaboutlater).

Postural Phasic

Function Posture Movement

Muscletype TypeI TypeII

Fatigue Late Early

Reaction Shortening Lengthening

Table3.2.Lengtheningandshorteningofmuscles.

Thereare someexceptions to the rulewhichstates thatcertainmuscles followthe pattern of becoming shortened while others become lengthened—somemuscles are capable of modifying their structure. For example, some authorssuggestthatthescalenemusclesareposturalinnature,whileotherssuggestthattheyarephasic.Weknowfromspecifictesting,dependingonwhatdysfunctionispresentwithinthemuscleframework,thatthescalenescanbefoundtobeheldinashortenedpositionandtight,butatothertimestheycanbeobservedtobelengthenedandweakened.

There is a distinction between postural and phasic muscles; however, manymusclescandisplaycharacteristicsofbothandcontainamixtureofTypeIandTypeIIfibers.Thehamstringmuscles,forexample,haveaposturalstabilizingfunction, yet are polyarticular (crossmore than one joint) and are notoriouslypronetoshortening.

PosturalMuscles

Alsoknownastonicmuscles,theposturalmuscleshaveanantigravityroleandarethereforeheavilyinvolvedinthemaintenanceofposture.Slow-twitchfibers

aremoresuitedtomaintainingposture:theyarecapableofsustainedcontractionbutgenerallybecomeshortenedandsubsequentlytight.

Posturalmusclesareslow-twitchdominantbecauseoftheirresistancetofatigue,and are innervated by a smaller motor neuron. They therefore have a lowerexcitability threshold, which means the nerve impulse will reach the posturalmusclebeforethephasicmuscle.Withthissequenceofinnervation,theposturalmusclewill inhibit thephasic (antagonist)muscle, thus reducing itscontractilepotentialandactivation.

PhasicMuscles

Movement is themain function of phasic muscles. Thesemuscles, which areoftenmore superficial than postural muscles and tend to be polyarticular, arecomposed of predominantly Type II fibers and are under voluntary reflexcontrol.

A shortened, tight posturalmuscle often results in inhibition of the associatedphasicmuscle,whosefunctionbecomesweakenedasaresult.Therelationshipbetweena tightness-pronemuscle andanassociatedweakness-pronemuscle isone way. As the tightness-prone muscle becomes tighter and subsequentlystronger,thiscausesaninhibitionoftheweakness-pronemuscle,resultinginitslengthening and consequentweakening: think about how thismight affect therelationship, for example, between the iliopsoas and the gluteal muscles, orbetweenthepectoralismajor/minorandtherhomboids.

Figure3.7.Posturalandphasicmuscles:(a)anteriorview;(b)posteriorview.Thebluemusclesarepredominantlypostural,andtheredmusclespredominantlyphasic.

MuscleActivityBeforeandAfterStretching

Let’s take a look at some electromyography (EMG) studies of trunk muscleactivitybefore andafter stretchinghypertonicmuscles, in this case the erectorspinae. InTable3.3 thehypertonicerectorspinaeare indicatedasbeingactiveduringtrunkflexion.Afterstretching,thesemusclesaresuppressedbothintrunkflexion (which allows greater activation of the rectus abdominis) and in trunkextension(dorsalraise).

Muscle

Firstrecording Secondrecording

Rectusabdominis

Erectorspinae

Table3.3.EMGrecordingsofmuscleactivity.

(Source:Hammer1999)

EffectsofMuscleImbalance

TheresearchresultsofJanda(1983)indicatethattightoroveractivemusclesnotonly hinder the agonist through Sherrington’s law of reciprocal inhibition asstatedbySherrington(1907),butalsobecomeactiveinmovementsthattheyarenotnormallyassociatedwith.This is the reasonwhy,when trying tocorrectamusculoskeletal imbalance,youwouldencourage lengthening of anoveractivemuscle by using a muscle energy technique (MET), prior to attempting tostrengthenaweakelongatedmuscle(METswillbeexplainedinChapter7).

Thinkaboutthefollowingwordsbeforeyoucontinuereading:

“A tightmusclewill pull the joint into a dysfunctional position and theweakmusclewillallowthistohappen.”

One possible way to address this, therefore, is to simply apply the followingrule:“lengthenbeforeyoustrengthen.”

If muscle imbalances are not addressed, the body will be forced into acompensatoryposition,whichincreasesthestressplacedonthemusculoskeletalsystem, eventually leading to tissue breakdown, irritation, and injury.You arenow in a vicious circle of musculoskeletal deterioration as the tonic musclesshortenandthephasicmuscleslengthen(Table3.4).

Muscle imbalances are ultimately reflected in posture. As mentioned earlier,posturalmusclesareinnervatedbyasmallermotorneuronandthereforehavealowerexcitabilitythreshold.Sincethenerveimpulsereachestheposturalmusclebeforethephasicmuscle,theposturalmusclewillinhibitthephasic(antagonist)muscle,thusreducingthecontractilepotentialandactivation.

Whenmuscles are subject to faulty or repetitive loading, the posturalmusclesshorten and the phasic muscles weaken, thus altering their length–tension

relationship.Consequently,postureisdirectlyaffectedbecausethesurroundingmusclesdisplacethesofttissuesandtheskeleton.

Table3.4.Theviciouscircleofmusculoskeletaldeterioration.

CoreMuscleRelationships

InnerCoreUnit(LocalSystem)

Definition:Staticstabilityistheabilitytoremaininonepositionforalong timewithout losinggood structural alignment, asmentionedby

Chek(1999).

Staticstabilityisalsooftenreferredtoasposturalstability,althoughthismightbesomewhatmisleading,sinceasMartin(2002)states:“…postureismorethanjust maintaining a position of the body such as standing. Posture is active,whether it is in sustaining an existing posture ormoving from one posture toanother.”

Theinnercoreunit(Figure3.8)consistsof:

•Transversusabdominis(TVA)

•Multifidus

•Diaphragm

•Musclesofthepelvicfloor

OnlytheTVAandmultifiduswillbecoveredinthisbook,asthesemusclesarespecificallyrelatedtoposturalandphasicimbalancesandareeasilypalpatedbythephysical therapist.Since thediaphragmandmusclesof thepelvic flooraredifficulttopalpate,theywillnotbediscussedhere.

Figure3.8:Theinnercoreunit.

TransversusAbdominis

TransversusAbdominis

The transversus abdominis (TVA) is the deepest of the abdominalmuscles. Itoriginates at the iliac crest, inguinal ligament, lumbar fascia, and associatedcartilageoftheinferiorsixribs,andattachestothexiphoidprocess,lineaalba,andpubis.

ThemainactionoftheTVAistocompresstheabdomenviaa“drawing-in”ofthe abdominal wall. This drawing-in is observable as a movement of theumbilicus(bellybutton)towardthespine.Themuscleneitherflexesnorextendsthe spine. Kendall et al. (2010) also state that “this muscle has no action inlateralflexionexceptthatitactsto…stabilizethelineaalba,therebypermittingbetteractionbyanterolateraltrunkmuscles[internalandexternalobliques].”

The TVA appears to be the key muscle of the inner unit. Richardson et al.(1999) found that inpeoplewithoutbackpain, theTVA fired30millisecondspriortoshouldermovementsand110millisecondsbeforelegmovements.Thiscorroborates the key role of the TVA in providing the stability necessary toperformmovementsoftheappendicularskeleton.AstheTVAcontractsduringinspiration itpulls thecentral tendon inferiorlyand flattens, thereby increasingtheverticallengthofthethoraciccavityandcompressingthelumbarmultifidus.

Multifidus

Themultifidus is themost medial of the lumbar backmuscles, and its fibersconverge near the lumbar spinous processes to an attachment known as themammillary process. The fibers radiate inferiorly, passing to the TPs of thevertebraethatlietwo,three,four,andfivelevelsbelow.Aswellassomefibersunitingdistallywith thesacrotuberous ligament, thosefibers thatextendbelowthelevelofthelastlumbarvertebra(L5)anchortotheiliumandthesacrum.

Themultifidusisconsideredtobeaseriesofsmallermuscles,whicharefurtherdividedintosuperficialanddeepcomponents.Thereismoremusclemassofthemultifidus near the base of the sacrum than at the apex, especially filling thespacebetweenthePSISsratherthantheILAs.

The role of the multifidus in producing an extension force is essential to thestabilityofthelumbarspine,aswellasfunctioningtoresistforwardflexionofthe lumbar spine and the shear forces that are placed upon it. Themultifidusmuscle also functions to take pressure off the intervertebral discs, so that the

bodyweight is evenly distributed throughout thewhole vertebral column.Thesuperficial muscle component acts to keep the vertebral column relativelystraight,whilethefibersofthedeepmusclecomponentcontributetotheoverallstabilityofthespine.

Richardsonetal.(1999)identifiedthelumbarmultifidusandtheTVAasthekeystabilizers of the lumbar spine. Both muscles link in with the thoracolumbarfasciatoprovidewhatRichardsonetal.refertoas“anatural,deepmusclecorsettoprotectthebackfrominjury.”

Morerecently,Richardsonetal.(2002)investigatedhowthesemusclesimpacttheSIJusingtheEchoDoppler(adiagnosticultrasounddevice,whichcanshowifspecificmusclesarecontracting).TheywereabletodemonstratethatwhentheTVA and multifidus co-contract, the stiffness of the SIJ increases, therebyproving that thesemusclesare essential to compressing theSIJ and stabilizingthe joint under load (force closure) and also that it is critical that thiscompressionoccursatjusttherighttime.

HydraulicAmplifier

Described by Osar (2012), the hydraulic amplifier effect occurs with thecontractionofmuscleswithin their fascial envelopes.Allmuscles are investedinside fascia and, as they contract, push out into the fascia, thus creating astiffeningeffectaroundthejoint.Inthespine,contractionofthelumbarerectorspinaeandmultifiduswithinthethoracolumbarfasciacreatesanextensionforce,assistingextensionofthespine.Osarsaysthatwhenthelumbosacralmultifiduscontracts, it broadens posteriorly into the lumbodorsal fascia (Figures 3.9 and3.10).

Figure3.9.Asthemultifiduscontracts,itpushesintothethoracolumbarfasciaand,alongwithcontractionoftheTVA,providesintersegmentalstability.

Figure3.10.(a)Therelaxedmultifidusmuscleintransversesection.(b)Co-contractionoftheTVAandmultifiduscreatesastiffeningtensiononthethoracolumbarfascia,therebyprovidingintersegmentalstability.

Thiseffect isaidedbycontractionof theTVA,whichpulls the thoracolumbarfascia tight around the contracting erector spinae and multifidus, therebycreatingastablecolumn(Figure3.11).

Figure3.11.(a)AstheTVAcontracts,ittensesthethoracolumbarfascia,whichallowsthemultifidusandlumbarerectorspinaetocontractagainstitandaidspinalelongationandstiffness.(b)Contractionofthepyramidalistensesthelineaalba(centraltendon),creatingastablebaseforcontractionoftheTVA.

OuterCoreUnit(GlobalSystem)

The force closure muscles of the outer core unit consist of four integratedmyofascialslingsystems(Figures3.12–3.15):

•Posterior(deep)longitudinalsling

•Lateralsling

•Anteriorobliquesling

•Posteriorobliquesling

Thesemyofascial slings provide force closure and subsequent stability for thepelvic girdle; failure or evenweakness of any of these slings to secure pelvicstabilitycanleadtolumbopelvicpainanddysfunctions.Althoughthemusclesoftheouter coreunit canbe trained individually, effective force closure requiresspecificcoactivationandreleaseofthesemyofascialslingsforoptimalfunctionandperformance.

Figure3.12.Posterior(deep)longitudinalsling.

Figure3.13.Lateralsling.

Figure3.14.Anteriorobliquesling.

Figure3.15.Posteriorobliquesling.

Theintegratedmyofascialslingsystemrepresentsmanyforcesandiscomposedof severalmuscles.Amusclemay participate inmore than one sling, and theslingsmayoverlapand interconnect,dependingon the task inhand.Thereareseveral slings ofmyofascial systems in the outer unit, including (but probablynotlimitedto)acoronalsling(havingmedialandlateralcomponents),asagittalsling (having anterior and posterior components), and an oblique spiral sling.Thehypothesisisthattheslingshavenobeginningorend,butratherconnectasnecessarytoassistinthetransferenceofforces.Itispossiblethattheslingsareall part of one interconnectedmyofascial system, and a sling that is identifiedduring any particular motion could merely be a result of the activation of

selectivepartsofthewholesling(Lee2004).

The identification and treatment of a specific muscle dysfunction (such asweakness, inappropriate recruitment, or tightness) is important when restoringforceclosure(secondcomponentofstability)andforunderstandingwhypartsofa slingmay be restricted inmotion or lacking in support. Note the followingpoints:

•Thefoursystemsoftheoutercoreunitaredependentupontheinnercoreunit for the joint stiffness and stabilitynecessary for creatinganeffectiveforcegenerationplatform.

•Failureoftheinnerunittoworkinthepresenceofouterunitdemandoftenresultsinmuscleimbalance,jointinjury,andpoorperformance.

• The outer unit cannot be effectively conditioned by the use of modernresistance machines, as the specific training provided by these types ofmachinegenerallydoesnotrelatetoday-to-dayfunctionalmovements.

•Effectiveconditioningoftheouterunitshouldincludeexercisesthatrequireintegrated function of the inner and outer units, usingmovement patternscommontoanygivenclient’sworkorsportenvironment(Chek1999).

InChapter 4 Iwill discuss thewalking cycle (gait cycle); if youhave a goodunderstandingof the information regarding themyofascial sling systems, then,hopefully, it shouldmakeperfect sensehow these slingsarenow incorporatedintothiscycle.Itrulyhopethatasyoureadthatparticularchapter,thepiecesofthe jigsawpuzzlewillslowlybegin to formarecognizablepicture.Mygoal isfor you to come back to each specific chapter time and time again, to try tounderstandanddigestwhat Ihavewritten.More importantly,however, Iwantyoutobeabletousethisinformationinyourownclinicalsettingtoassessandtreatyourownathletesandpatients.

ExercisingtheOuterCore

I personally believe that when most people go to the gym to exercise, theygenerallyperformroutinesthataretypicallyfrontal-planeorsagittal-planetypesofexercise:theyeitherliftaweighttothesides(frontalplane)oftheirbodyortothefront(sagittalplane).Ifoneweretoasktheseindividualstodemonstratean

exercise to train their core, and also to perform that specific exercise in thetransverseplane, Iamsure thataftersome thought theywouldprobably lieontheirbackandperformanabdominalcrunchtypeofmotionwitharotation; inother words, their elbow would be directed toward their opposite knee whileperformingthecrunchmovement,asshowninFigure3.16(a).

Figure3.16.(a)Abdominalcrunchinthetransverseplane.

Let’sbealittlerealistichere.Apartfromwhenwegetoutofbedinthemorning,whendoweeverperformthattypeofmotiononadailybasis?Whendowelieon our back and rotate the elbow toward the opposite knee? Iwould call thisexercise non-functional, even though the majority of gym users routinelyperformthisexercisefortheircoremuscleseverydayintheirpersonalexerciseroutines.

Ifyouthinkaboutit,mostsportingmovements,orsimplywalkingcometothat,normallyinvolvesometypeofactioninthetransverseplane(movementacrossthe body) of motion. Does it not make perfect sense, therefore, to trainspecificallywithin theparametersof the transverseplane, in combinationwithtraininginthesagittal(coronal)andfrontalplanes?

Movement-BasedExercise

Theinnercoreunitmusculatureisgenerallymadeupofpostural(tonic)muscletypes that functionmainly as stabilizers. These inner coremuscles effectivelystabilize the spine and SIJ at low levels of muscular contraction, with a lowsusceptibility to fatigue. Coordination of the inner core is critical for properstabilization,whichthenallowsacoordinatedrecruitmentofthemusclesoftheouter core unit. The ability of the inner core unitmuscles to contract prior toforceproductionby thephasicmuscles (biased towardmovements) is actuallyconsideredmoreimportantthantheirinherentstrength.

Theoutercoreunitismainlyaphasicsystem,withlargemusclesthathavetheability,becauseofthefactthattheyareverywellorientated,toproduceenoughforcetosubsequentlypropelthebodyforward.Theoutercore,consistingofthefourmyofascial slings, also plays a very important role in stabilization of thepelvis,asallof thefour individualslingsmentionedearliercross thisareaandnaturallyassistinforceclosureoftheSIJ.

With regard to functional types of exercise, movement patterns must beidentifiedandresistanceappliedtothosepatternsinaspecificway.Thisiswhatresistancetrainingisallabout…resistingmovements!

Ifspecificmovementsperformedbyathletesandpatientsonadailybasiscanbeidentified, these can be replicated by using some form of resistance training,thereby creating a stability protocol. This stability protocol will be furtherenhanced if thesemovements can be performed at a speed of contraction thatmimicstheirdailyfunctions.Thiswillnotonlyimprovelevelsofoverallfitnessbutalsopromoteforceclosureofthepelvis,andsubsequentlypromoteastablefoundation.Eachexercisewillnowhaveadirectpurposeandfunction, insteadofjustincreasingthesizeofthecross-sectionalareaofaparticularmuscle.

Before embarking on a training program for the outer and inner core, it isimportanttounderstandthemeaningsofthewords“rep”and“set.”

RepetitionsandSets

Definition: A repetition (or rep) is one complete motion of anexercise.Asetisagroupofconsecutiverepetitions.

Youmayhaveheardsomeonecommentthattheyperformed,forexample,threesets of 12 reps on the bench press machine. This means that they did 12consecutive bench presses, had a break (rest), and then repeated the process afurthertwotimes.

There is no simple answer to the question of how many repetitions and setsshould be performed, as the number of repetitions required depends onmanyfactors, includingwhere thepatient/athlete is in theircurrent trainingandwhattheir individual goals are. Remember, the purpose of this book/chapter is toimprovetheoptimumfunctionalityofthepelvisthroughactivationoftheoutercore unit so that your patient/athlete can perform the activities needed foreverydaylife,aswellasparticipateinanysports-relatedactivities.Isuggestweaimforbetween10and12repsandbetweenoneandtwosetsofeachexercise,atleasttostartwith.

Pleasealsorememberthat,aswithanytrainingprogram,theworkoutswillneedto be progressive. For example, let’s say the patient/athlete startswith two orthreeexercises that Ihavechosen from theaboveprimarymovementpatterns,andtheyperformtwosetsof10repsforeachexercise;whenthepatientgetstothestagewheretheyfindtheseexercisestoberelativelyeasy,itisthentimetoprogress. This might happen after one week or it might take longer, perhapsthreeorfourweeks.Theexercisecanbemademoredifficultbysimplychangingthe number of repetitions, reducing the rest period between sets, adding inanother exercise, or changing the resistance of the band (another color), asshowninFigure3.16(b).Forexample,thegreenbandislevel1(easy),thebluebandislevel2(moderate),andtheblackbandislevel3(hard).

Figure3.16.(b)Colorofbandindicatesthelevelofresistance.

To progress in the program, you could, for example, ask the patient to eitherincreasethenumberofrepetitions,i.e.performtwosetsof12reps(insteadof10reps), or rest for only 30 seconds (instead of 45 seconds) between the sets. Ihighlyrecommendthateverythingbewrittendown,as it isveryeasytoforgetwhat was done in the previous training session—trust me on this! I canguarantee thatwithinafewweeks thepatient/athletewilleasilybedoingthreesetsof12–15repsforsixorsevendifferenttypesofoutercoreexercise.

Thefollowingexercisesdonotspecifythenumberofrepetitionsandsetsnexttothe exercise diagram, as Iwant to demonstrate how to perform the individualexercisescorrectly.RefertoAppendix2attheendofthebookforan“ExerciseStabilizationSheet”fortheoutercoremuscles;ithasbeendesignedspecificallyforyoutophotocopyandgiveouttoyourathletesandpatients(orevenforyourown personal use). The blank boxes allow you to record the number ofrepetitionsandsetsforyourpatient’srehabilitationprogramforthepelvis.

Unfortunately, there are a multitude (indeed, an almost infinite number) ofmovements that are performed in everyday life, making it near impossible toensurethattheyareallincludedineverygym-basedtrainingprogram.However,

Ihaveselectedthefollowingsixexercises,whichcanbeincorporatedintoanystrengthandstability trainingregime,as theywillspecifically target theglobalmusclesoftheoutercoreslingsystem.

PrimaryMovementPatterns

The following exercises are what I consider to be the primary movementpatterns,andoneormoreofthesedemonstratedexercisescanbeincludedinanyfunctional, strength, or stability training program. The therapist/trainer shouldnevertheless be able to modify and adapt these primary movement exercisepatterns accordingly (I will explain later in this chapter). This adaptabilityprotocol will make the exercises far more functional, as well as being moreinterestingandspecifictotheneedsanddemandsofyourathletesandpatients.

Some of the exercises I mention will activate one particular sling more thananother;remember,however,thatthereisanaturalcross-overoneachexercise,so it isdifficult toexerciseandtargetonlyonespecificslingata time.This isbecauseallofthefourslingsIhavementionedhavetobeinvolvedinonewayoranother,dependingontheparticularmovementoneisperforming.Forexample,the anterior and posterior oblique sling will be classified as agonist andantagonist (opposite to each other); however, I consider them to be alsosynergists (helpers toeachother),becausewhenyouwalkor run ina forwarddirection,therightarmmovesinaforwardmotion,subsequentlyactivatingtheanterior oblique sling, but at the same time the left armmoves in a backwardtype ofmotion, activating the posterior oblique sling.Hence the opposite andsynergistictheory!

Ibelievethetheoryaboveisexplainedverywellbythefollowing:

“Whenwalking or running, every forwardmotion of the right limb elicits anautomatic backwardmotion of the left limb, and vice versa.You cannot haveonemovementwithouttheother.”

Thesixprimarymovementpatternexercisesare:

1.Push

2.Pull

3.Squat—BendtoExtend

4.BendtoExtendwithRotation

5.Single-LegStance

6.Rotation

Eachofthesemovementpatternscanbereproducedinagymenvironmentusingspecific exercisemachines (e.g. cablemachine) or resistance bands; they can,however, also be performed practically anywhere, as the majority of theexercisesthatIdemonstrateinthischaptersimplyinvolveusingasinglepieceofresistance exercise band, a core ball, and some dumbbells. Examplemovement/exercises for incorporating sling patterns are presented in thefollowingsections.

Figure3.17.AnteriorObliqueSling:(a)startposition;(b)finishposition.

1.Push

The first exercise I propose is very effective at utilizing the anterior obliquesling.IfyoulookatthestartpositioninFigure3.17(a),youwillnoticethattheexercise band (alternatively a cable machine can be used) is held with theathlete’srighthandatshoulderheight,andtheirleftarmandleftlegareplacedin a forward position. The exercise motion is shown in Figure 3.17(b): theathlete pushes the band forward across their body, using their stance legadductors,internaloblique,andcontralateralexternaloblique.Atthesametime,the leftarmcomesbackward,as this inducesa rotationof the trunk to the left

side,subsequentlyworkingtheanteriorobliqueslingin the transverseplaneofmotion.

All day-to-day movements will work this muscle sling, but particularly goodexamplesaretheactionsofwalking,running,andthrowing.

Note:Itisveryimportantthattheathletecontrolthemotioninbothphases,i.e.theconcentric(shortening)phaseandtheeccentric(lengthening)phase,andnotletthebandcontrolthemovement.Moreover,onehastobeveryawareoftheactivationoftheinnercoremusculatureinordertoprovidethenecessarystabilitytoperformallof theseexercises Idescribe. Ifyouareunsureaboutperforming theseexercises,pleaseseekprofessionaladvicebeforeyoubeginanytypeofresistancetraining.

Ialwayssaythefollowingtomyathletesandpatientsduringthedemonstrations,asIconsiderittoberelevanttoalloftheslingexercises:

“Youcontrolthemovement—don’tletthemovementcontrolyou.”

2.Pull

Thisparticularexerciseisoneofmypersonalfavorites,asitisveryeffectiveinutilizing theposterior oblique sling. If you look at the start position inFigure3.18(a),youwillseethattheexerciseband/cableisheldwiththeathlete’srighthandatshoulderheight,andtheirleftlegandleftarmareplacedinabackwardposition.The exercisemotion is shown inFigure3.18(b): using the latissimusdorsi, thoracolumbar fascia, and contralateralGmax, the athletepulls thebandbackwardacrosstheirbodywiththeirrightarm.Atthesametime,theleftarmcomes forward, as this induces a rotation of the trunk to the right side,subsequently working the posterior oblique sling in the transverse plane ofmotion.

I often say the following when teaching a class, or even to my athletes andpatients, as it I consider it reinforcesperfectly themotion in the twoexercisesoutlinedabove:

“Everypullisapushandeverypushisapull—youcannothaveonewithouttheother.”

Figure3.18.PosteriorObliqueSling:(a)startposition;(b)finishposition.

3.Squat—BendtoExtend

Anyexerciseormotionthatincorporatesabend-to-extendtypeofmotion,suchasatypicalsquatoradeadlift,willincorporatetheposterior(deep)longitudinalslingaswellasinvolvingtheposteriorobliquesling.

CoreBallSquat

Acore ball is placed against thewall, and the patient positions themselves sothat thecoreball is locatednear their lowerback, as shown inFigure3.19(a).

Fromthisposition,thepatientstepsforwardslightly,withtheirkneesshoulder-widthapart.Thepatientisthenaskedtoactivatetheinnercoreandslowlysquat(eccentric phase) until they reach a position of approximately 90 degrees, asshowninFigure3.19(b).Thetherapistmakessurethatthetrackingofthepatellaistowardthepatient’ssecondtoeandthatthepatelladoesnotpassbeyondthelevelofthetoes,asindicatedbythearrowsinFigure3.19(b).Thepatientistheninstructedtostanduponthereturn(concentricphase)foracountof two; theyarealsoinstructedtosqueezetheirglutesjustbeforetheendphaseofthesquat.

Figure3.19.CoreBallSquat:(a)startposition;(b)full-squatposition.

Progression1:WithWeight

TheCoreBallSquatexerciseisperformedasexplainedabove,exceptthepatientnowholdsalightweightineachhand,asshowninthestartpositioninFigure3.20(a).TheconcentricphaseofthesquatisshowninFigure3.20(b).

Figure3.20.CoreBallSquatwithWeight:(a)startposition;(b)concentricphase.

Progression2:WithWeightandWithoutaCoreBall

The start position of this progression is shown in Figure 3.21(a): the athleteholdsadumbbellineachhand,withtheirkneesshoulder-widthapart.Thesquatisthenperformedtoreachaknee-bendofapproximately90degrees,asshowninFigure3.21(b).

Pleaserememberthatthepatellafollowsanimaginarylinetothesecondtoeanddoesnotpassthelevelofthetoes.Fromthe90-degreeposition,theathletethenrises to return to the start position. (This exercise can be performed with or

withoutdumbbells.)

Figure3.21.SquatwithWeight:(a)startposition;(b)finishposition.

4.BendtoExtendwithRotation

A bend-to-extend type of movement with a rotation is an excellent way ofincorporating the posterior (deep) longitudinal sling as well as the posteriorobliquesling,allatthesametime.InthestartpositionshowninFigure3.22(a),the athlete’s right hand holds the exercise band/cable at shoulder height in aforwardposition,andtheirleftarmisplacedinabackwardposition.Noticethat

the athlete has adopted a type of squat position, which can vary in terms ofdepth;theathleteherehasadoptedanangleof45degrees,butonecanchoosetostartatasmallerorgreaterangle,dependingonrequirements.

The exercise motion is shown in Figure 3.22(b): the athlete pulls the bandbackward across their body, using both of their posterior slings. At the sametime, the left arm comes forward as the athlete returns to the erect position.Figure 3.22(c) shows an alternative end position for the right arm, as somepatientsfindthismovementeasier.WhatIsometimessuggestisthatmyathletesvaryoralternatethetwomovementsdescribedabove.

Figure3.22.Posterior(deep)LongitudinalandPosteriorObliqueSling:(a)startposition;(b)finishposition;(c)alternativepositionforthearmattheendofmotion.

5.Single-LegStance

Thelateralslingsystemhelpstostabilizethebodyinthefrontalplane.Duringany type of single-leg stance the hip abductors—gluteus medius (Gmed) andgluteus minimus (Gmin)—and the adductors of the supporting leg work inconjunction with the contralateral (opposite) quadratus lumborum (QL) tostabilize the pelvis. The internal and external oblique abdominal musculaturealsoworkssynergisticallytosecureastablespineandpelvis.Dysfunctionofthelateralslingsystemisacommonsourceofinjurytotheback,theSIJ,andalso

thesupportingleg.Ifyouthinkaboutit,mostsportsaresingle-legdominantinnature. During walking, but especially running and sprinting, the body ispropelledforwardthroughpowerfulsingle-legactions,sotheneedforastrongand functional lateral sling system is of paramount importance. This specificslingsystemwillhelpimproveoverallathleticperformanceandconserveenergyexpenditure, as well as reducing the possibility of sustaining musculoskeletaltypesofinjury.

Anyexerciseswhichincorporateamovementthatreliesonbeinginasingle-legstancepositionwillactivatethemusclesofthelateralsling.ThelastchapterofTheVitalGlutes:ConnectingtheGaitCycletoPainandDysfunction(Gibbons2014) specifically targets exercises that are biased toward a single-leg stanceposition in order to activate theGmedmuscle in particular of the lateral slingsystem.ForthistextIwillthereforeincludeanexercisethatisdemonstratedonone leg; however, I am also going to simultaneously target the anterior andobliqueslingswhileperformingapushandapullmotionasdescribedearlier.

Note: If you have difficulty standing on one leg, possibly because of weakness of the lateral sling, Irecommend that you read the vital glutes book (Gibbons 2014) first, so that you will have a betterunderstanding of why and how to initiate the strengthening of the Gmed/lateral sling system beforeembarkingontryingtoperformthefollowingexercise.

LateralSlingandAnteriorObliqueSling

Figure 3.23(a) shows the athlete in a single-leg stance position (lateral sling),whileatthesametimeholdingtheexercisebandwiththeirrighthand,withthearmraisedto90degrees;theleftarmisheldinaforwardpositionandthebodyis rotated to the right.Theathlete thenpushes the rightarmforwardwhile theleftarmmovesbackward;thiswillinducearotationofthetrunktotheleftside,asshowninFigure3.23(b),subsequentlyactivatingtheanteriorobliquesystemandatthesametimeutilizingthelateralslingmusculature.

Figure3.23.LateralSlingandAnteriorObliqueSling:(a)startposition;(b)finishposition.

LateralSlingandPosteriorObliqueSling

Figure3.24(a)showstheathletestandingononeleg(lateralsling),whileatthesametimeholdingtheexercisebandwiththeirrighthand,withthearmraisedto90degrees;theleftarmisheldinabackwardpositionandthebodyisrotatedtotheleft.Theathletethenpullstherightarmbackwardwhiletheleftarmmovesforward; thiswill induce a rotation of the trunk to the right side, as shown inFigure3.24(b),causinganactivationoftheposteriorobliquesystemandatthesametimeutilizingthelateralslingmuscles.

Figure3.24.LateralSlingandPosteriorObliqueSling:(a)startposition;(b)finishposition.

6.Rotation

Thelastmotionoftheprimarymovementpatternsisrotation,whichwillutilizemainlytheinternalandexternalobliquesaswellastheglutealmuscles.

AnteriorRotation

Figure3.25(a) shows the athlete standingwith their legs shoulder-width apart,holding the exercise bandwith their right hand, and stabilizing the inner coremuscles.Theathleterotatestheirbodytotheleft,whichwillutilizetheoblique

muscles,asshowninFigure3.25(b).Thearmshouldberelativelyfixed,sincethemotionisfromthetrunkandnotfromthemovementofthearm.

Figure3.25.ObliqueSling—AnteriorRotation:(a)startposition;(b)finishposition.

PosteriorRotation

Figure3.26(a) shows the athlete standingwith their legs shoulder-width apart,holding the exercise band with their left hand, and stabilizing the inner coremuscles.Theathleterotatestheirbodytotheleft,whichwillutilizetheobliquemuscles,asshowninFigure3.26(b).Thearmshouldberelativelyfixed,sincethemotionisfromthetrunkandnotfromthemovementofthearm.

Figure3.26.ObliqueSling—PosteriorRotation:(a)startposition;(b)finishposition.

ExerciseVariations

Ihavedemonstratedandexplained sixprimarymovementpatterns that canbeincludedinanoutercorestabilizationprogram.WhenIseeathletesandpatientsforthefirsttimeInormallysuggestthatonlytwoinitialexercisesareperformedtostartwith,namelyapullmotionandapushmotion.Irecommendthattheydobetween10and12repsonbothsides(pushexerciseontheleftandpushontheright,thenthesameforthepullexercise)andrepeatfortwo/threesets(10–12×2/3).Isuggeststartingwith10repsinitially,foroneortwosets(onceperday),andprogressto15repsforthreesetsperdayoveracoupleofweeks.

When patients visit me for their second and third sessions, I will personallychecktheirtechniquebeforeIgivethemanotherexercise;thiswayIcanmakesurethatwhatIshowedtheminitiallyisbeingreiteratedintheirdemonstrationback tome.When Iamhappywithwhat theyhaveshownme, then,andonlythen,will Igive themanotherone (orpossibly two)of theprimarymovementexerciseslistedabove.

Onceallofthesixexerciseshavebeenincorporatedintotheirexerciseregime,wecan thenstart toaddabitofvarietyandadapt theexercisesaccordingly tomake them more specific and tailored to the athlete, depending on theirindividualsportingrequirements.Althoughthefollowingexercisesareexplainedand demonstrated for only one side of the body, they would of course beincorporatedinaprogramforbothsides(anexerciseperformedontheright isrepeatedontheleft,andsoon).

CombinedPush–Pull

TheathleteinFigure3.27(a)holdsapieceofexercisebandwiththeirlefthandand another piece of exercise band with their right hand. They are asked tocombinethemotionofapushfromtherightarmandapullfromtheleftarm,asindicated inFigure3.27(b). It is recommended that the inner coremuscles areactivated,tomakesurethattheyarestablewhileperformingthismotion.

Figure3.27.CombinedPush–Pull:(a)startposition;(b)finishposition.

CombinedPush–PullonOneLeg

Thisisthesameexerciseasabove,butthistimetheathleteadoptsasingle-legstancepositionwhilegrasping the exercisebands, as shown inFigure3.28(a).Themotionisacombinationofapushfromtherightarmandapullfromtheleftarmwhilestandingononeleg,asindicatedinFigure3.28(b).

Figure3.28.CombinedPush–PullonOneLeg:(a)startposition;(b)finishposition.

PushwithLunge

InthestartpositionshowninFigure3.29(a),theathleteisholdingtheexercisebandwith the right hand at shoulder height, and the left arm and left leg areplacedinaforwardposition.TheexercisemotionisshowninFigure3.29(b):theathletepushesthebandforwardacrosstheirbody,whileatthesametimetheleftarmmovesbackwardastheleftkneebendstoperformalungetypeofmotion.(Note:theleftkneedoesnotpastthelevelofthetoes,andthepatellafollowsthesecondtoe.)

Figure3.29.PushwithLunge:(a)startposition;(b)finishposition.

PullwithLunge

In the start position shown inFigure3.30(a)youwill notice that this time theathlete is holding the exercise bandwith their right hand placed in a forwardpositionatshoulderheight;theleftarmisheldinabackwardposition,withtheleft leg forward. The exercise motion is shown in Figure 3.30(b): the athletepulls thebandbackwardacross theirbody,whileat thesametimethe leftarmmovesforwardastherightkneebendstoperformalungetypeofmotion.(Note:the right knee does not pass the level of the toes, and the patella follows thesecondtoe.)

Figure3.30.PullwithLunge:(a)startposition;(b)finishposition.

PushonUnstableBase

In the start position shown in Figure 3.31(a), the exercise band is held in therighthandat shoulderheight, and the left arm isplaced ina forwardposition.Overleaf,theexercisemotionisshowninFigure3.31(b):theathletepushestheband forward across their body, and at the same time the left arm movesbackwardwhilemaintainingstabilityontheunstablebase.

Figure3.31.PushonUnstableBase:(a)startposition.

Figure3.31.PushonUnstableBase:(b)finishposition.

PullonUnstableBase

InthestartpositionshowninFigure3.32(a),theathleteholdstheexercisebandin the right hand at shoulder height, and the left arm is placed in a backwardposition.The exercisemotion is shown inFigure3.32(b): the athletepulls theband backward across their body, and at the same time the left arm movesforwardwhilemaintainingstabilityontheunstablebase.

Figure3.32.PullonUnstableBase:(a)startposition;(b)finishposition.

BendtoExtendwithRotationonUnstableBase

InthestartpositionshowninFigure3.33(a),theathleteholdstheexercisebandwiththeirrighthandatshoulderheightandplacestheirleftarminabackwardposition, while adopting a squat position on the unstable base. The exercisemotion is shown inFigure3.33(b): the athletepulls thebandbackwardacrosstheirbody,andatthesametimetheleftarmmovesforwardastheyreturntotheerectpositionwhilemaintainingstabilityontheunstablebase.

Figure3.33.BendtoExtendwithRotationonUnstableBase:(a)startposition;(b)finishposition.

BendHightoLow(WoodChop)

In the start position shown in Figure 3.34(a), the athlete holds the bandsimultaneouslywiththeirrightandlefthandsatapointaboveshoulderheight.TheexercisemotionisshowninFigure3.34(b):theathletepullsthebandacrosstheir body to a low position, while at the same time performing a squattingmotion.Thismovementissimilartochoppingwood.

Figure3.34.BendHightoLow:(a)startposition;(b)finishposition.

BendLowtoHigh(ReverseWoodChop)

InthestartpositionshowninFigure3.35(a),theathletesquatsdownandholdsthe band simultaneously in the right and left hands at a point below shoulderheight. The exercise motion is shown in Figure 3.35(b): the athlete pulls thebandacrosstheirbodytoahighposition,whileatthesametimerisingfromthesquattoanerectposition.

Figure3.35.BendLowtoHigh:(a)startposition;(b)finishposition.

BendLowtoHigh(SingleArm)

Acombinationof a bend-low-to-high typeofmovementwith a rotation and asquatisanexcellentwayofincorporatingtheposteriorlongitudinalslingaswellastheposteriorobliquesling,bothatthesametime.InthestartpositionshowninFigure3.36(a),youwillseethattheathleteisholdingtheexerciseband/cableata lower levelwith their righthand ina forwardposition,and the leftarmisplaced inabackwardposition; the trunkadoptsapositionof left rotation.Theathletehasalsoadoptedasquatposition,whichcanvaryintermsofdepth:heretheathletehassquattedtoanangleof45degrees,butthisanglecanbesmaller

orgreater,dependingonrequirements.OverleaftheexercisemotionisshowninFigure3.36(b):theathletepullsthebandbackwardandhighacrosstheirbody,usingbothoftheirposteriorslings.Atthesametime,theleftarmcomesforwardwhilethetrunkrotatestotherightastheathletereturnstotheerectposition.

Figure3.36.BendLowtoHigh(SingleArm):(a)startposition.

Figure3.36.BendLowtoHigh(SingleArm):(b)finishposition.

ObliqueSling—AnteriorRotationonUnstableBase

In thisdemonstrationshowninFigure3.37(a), theathletestartswith their legsshoulder-width apart, and holds the exercise bandwith their right handwhilestabilizing their inner coremuscles. The athlete then rotates their body to theleft,whilemaintainingstabilityontheunstablebase,asshowninFigure3.37(b).Thearmshouldbe relatively fixed,since themotion is fromthe trunkandnotfromthemovementofthearm(thesameexercisecanberepeatedforaposteriorrotation;seeObliqueSling—PosteriorRotation).

Figure3.37.ObliqueSling—AnteriorRotationonUnstableBase:(a)startposition;(b)finishposition.

ObliqueSling—AnteriorRotationonOneLeg

Figure 3.38(a) shows the athlete standingwith their legs shoulder-width apartandholding theexercisebandwith their righthand,whilestabilizing the innercoremuscles.Theathletethenrotatestheirbodytotheleftwhileperformingtheexercise in a single-leg stance position, as shown in Figure 3.38(b). The armshouldberelativelyfixed,since themotion is fromthe trunkandnot fromthemovementofthearm(thesameexercisecanberepeatedforaposteriorrotation;seeObliqueSling—PosteriorRotation).

Figure3.38.ObliqueSling—AnteriorRotationonOneLeg:(a)startposition;(b)finishposition.

RotationWhileKneeling

Forananteriorrotation,theathleteinFigure3.39(a)kneelsonanexercisemat,withtheirkneesshoulder-widthapart,andholdstheexercisebandwiththeirlefthandwhilestabilizingtheinnercoremuscles.Theathletethenrotatestheirbodyto the rightwhile performing the exercise in a kneeling position, as shown inFigure3.39(b).Thearmshouldberelativelyfixed,sincethemotionisfromthetrunkandnotfromthemovementofthearm.

Figure3.39.ObliqueSling—AnteriorRotationWhileKneeling:(a)startposition;(b)finishposition.

Thesameexercisecanberepeatedforaposterior rotation,asshowninFigure3.40.

Figure3.40.ObliqueSling—PosteriorRotationWhileKneeling:(a)startposition;(b)finishposition.

Conclusion

Weneedtheinnerandoutercoreunitstofunctionsynergisticallyto:(1)stabilizethe body; and (2) create powerful and economicmovement.Without efficientfunctioningoftheinnerunitthereisnostabilityofthespineandSIJs.Moreover,thecorewillnotbeable toprovidea stablebaseof contraction for thephasicmuscles(outercore)tocontract,whichcanresultinalossoflimbpowerandareducedeconomyofmovementpatterns,aswellasanincreasedsusceptibilitytomusculoskeletalinjuries.

Awell-conditioned innercoreunit isverydependentonstrongoutercoreunitsystems,andviceversa, inorder toprotect the smaller innerunitmuscles, thespinalligaments,andtheassociatedjointsofthespineandpelvis.

Let me try to explain this concept with the following example. I have beenfortunatetoworkwiththeOxfordUniversityBoatTeamformanyyears.Whentheyhavebeenrowingonveryflatandcalmlakesandrivers,Ihavementionedtothemmanytimes(mainlyduringtrainingsessions)thattheoutercoreunit(i.e.the phasicmuscles) is doingmost of thework to propel the boat through thewater,andtheinnercoreunitisrelativelyrelaxed(bycomparison),especiallyoncalmwater.

I amcurrently the sportsosteopath for the team, sowhen they finish rowing Ialwaysaskthemhowtheyfeel(intermsoftheirlowerbackandpelvis,etc.);Icanhonestly say thatmost of the time there areno reports ofmusculoskeletalissues. However, when the team row on the “tideway” (the River Thames inLondon) in preparation for the annual Boat Race, it is a completely differentstory; thisrivercanbeveryunpredictable—oneminutetheriver isparticularlychoppy and the next it is calm. The River Thames is tidal fed from the sea,which alters the tone of the water; in addition, passing motorboats producewaves thatcanalsoaffect the flowandmannerof thewater.Becauseof thesevariablecircumstances, if the riverappears rougher thanusual, then Iconsiderthe inner core unit to be working a lot harder than normal, because it has tostabilize eachof the individual rowers in their seats.Moreover, the inner coreunitistryingtostabilizetherowingboattopreventitfromtiltingfromsidetoside,whileatthesametimetheoutercoreunitisstillbeingutilizedtopropeltheboat forward. At the end of the training session, I ask the rowers the samequestion (relating to any issues with the lower back); in this case, probablyaroundhalfofthemsaythattheyneedtoseemefortreatmenttohelpreducethesymptomsthattheyareexperiencing.

Inordertohaveastrongoutercoreunit,itisparamountthattheinnercoreunitbe stabilized first, as the most susceptible area in a rower’s musculoskeletalsystemisthelowerlumbarspine—usuallydiskinjuriesoccurtoL4/5(4thand5th

lumbarvertebrae)ortoL5/S1(5thlumbarvertebra/1stsacralvertebra).

Mostoftherowersknowabitaboutcorestabilitytraining,andsomehavedoneone or two exercises before, mainly abdominal trunk curls and planks (twoexercises that I typically classify asnon-functional anddefinitelynot effective

for the inner core—hence not recommended). During the times I have beeninvolved in their training, I have tried tomake the inner core training fun, astheseexercisesaregenerallynotappealingtoabunchoffityoungrowerswhoareusedtodoingonlybenchpresses,squats,andlunges.

Forexample, Iwouldgetall the team(eight in thiscase,ornine including thecox)tositongymballsinastraightline,onebehindtheother,facingthesameway—exceptforthecoxattheend,whowouldsitfacingthem.Whilesittingontheball,theywouldthenplacetheirfeetontheballinfrontandtrytomaintainstability by using their inner coremuscles,which is especially challenging, asthefeetarenowliftedoffthefloor.

The idea of this exercise was to mimic sitting in a boat on water. From thisposition,eachteammemberhadtokeepthelineofeightrowers(nineincludingcox)stablebyactivatingtheirinnercoremuscles.Oncethishadbeenachieved,wewouldthentrytomimicthemotionofrowingwhilestillsittingonthegymballs. Apart from being fun, this is a great way of activating the inner coremuscleswithouthavingtothinkabouttheprocessesinvolved.

Thisexercise is justoneexample thatemphasizes to the teamwhy training theinner core unit is every bit as important as training the outer core unit. ThementalityofmanyathleteswhoIhavecomeintocontactwithistotrainonlythemusclestheycanseeandnottheonesthattheycannot.

Note:Ihaven’tincludedmanyinnercoreexerciseexplanations/demonstrations,asIfeelitisnotwithinthescope of this book. The reason for this is mainly that I wanted to focus my attention on training andstabilizingtheoutercoremusclesinthistext,becauseIfeelthatthisparticularareahasbeenneglectedinthepast.Therearenumerousbooksontheshelvesthatofferspecificinnercoreactivationexercises,somayIsuggestyouconsultoneofthem.IhavediscussedhereonlybrieflysomeoftheinnercoreexercisesthatIincorporateintherowingtrainingprogram—mystrategyistotraintherowers’innercoremuscles,withoutthemactuallybeingawarethattheyaretrainingthem!

4TheWalking/GaitCycleandItsRelationshiptothePelvis

Mostofus,Iwouldsay,takewalkingforgranted—itissomethingthatwejustdo without understanding what exactly is going on … until we suffer painsomewhere in our body, and then the simple action ofwalking becomes verypainful.WhatIwouldliketodointhischapterisexamineindetailwhatexactlytakes place when we walk (you might want to go through some of themovementsyourselfastheyaredescribed)andtherelationshipofthegaitcycletoboththepelvisandthekineticchain.

GaitCycle

Definition:Agaitcycleisasequenceofeventsinwalkingorrunning,beginning when one foot contacts the ground and ending when thesamefootcontactsthegroundagain.

Thegaitcycleisdividedintotwomainphases:thestancephaseandtheswingphase. Each cycle begins at initial contact (also known as heel-strike) of theleadingleginastancephase,proceedsthroughaswingphase,andendswiththenext contact of thegroundwith that same leg.The stancephase is subdividedintoheel-strike,mid-stance,andpropulsionphases.

Humangait isaverycomplicated,coordinatedseriesofmovements.Aneasierwayofthinkingaboutthegaitcycleistobreakitdownintophases.Thestancephaseistheweight-bearingcomponentofeachcycle;itisinitiatedbyheel-strikeandendswithtoe-offfromthesamefoot.Theswingphaseisinitiatedwithtoe-off and ends with heel-strike. It has been estimated that the stance phaseaccountsforapproximately60%ofasinglegaitcycle,andtheswingphaseforapproximately40%,asshowninFigure4.1.

Figure4.1.Stanceandswingphasesofthegaitcycle.

Heel-Strike

Ifyouthinkaboutthepositionofyourbodyjustbeforeyoucontactthegroundwithyourrightlegduringthecontactphaseofthestancephase,therighthipisinapositionof flexion, theknee isextended, theankle isdorsiflexed,and thefoot is inapositionofsupination,asshowninFigure4.2.Thetibialisanteriormuscle,withthehelpofthetibialisposterior,workstomaintaintheankle/footina position of dorsiflexion and inversion (inversion is one part of the motionreferredtoassupination).

Innormalgait,thefootstrikesthegroundatthebeginningoftheheel-strikeinasupinated position of approximately 2 degrees.A normal footwill thenmovethrough 5–6 degrees of pronation at the subtalar joint (STJ) to a position ofapproximately3–4degreesofpronation,asthiswillallowthefoottofunctionasa“mobileadaptor.”

Figure4.2.Thepositionofthelegjustbeforeheel-strike.

AMyofascialLink

As a result of the ankle and foot being in a position of dorsiflexion andsupination, the tibialis anterior (which is themainmuscle responsible for thisanatomicalposition,withaninsertiononthemedialcuneiformand1stmetatarsalonthefoot)isnowpartofalinksystemthatwewillcallamyofascialsling(seeChapter 3). This sling, starting from the initial origin of the tibialis anterior,continues as the insertion of the peroneus longus (onto the 1st metatarsal andmedialcuneiform,asinthecaseofthetibialisanterior)toitsmuscularoriginon

the lateral side and head of the fibula. This bony landmark is alsowhere thebicepsfemorismuscleinserts.

Theslingnowcontinuesas thebiceps femorismuscle toward itsoriginon theischial tuberosity, where the muscle attaches to the tuberosity via thesacrotuberous ligament; often the biceps femoris directly attaches to thisligamentratherthantotheischialtuberosity,andsomeauthorshavementionedthatpotentially30%ormoreofthebicepsfemorisattachesdirectlytotheILAofthe sacrum. If you think back to Chapter 1, Imentioned thatVleeming et al.(1989a) found that in50%of subjects, part of the sacrotuberous ligamentwascontinuouswiththetendonofthelongheadofthebicepsfemoris.

Figure4.3.Apersonwalking,withtheposterior(deep)longitudinalslingmuscleshighlighted.

The sling then carries on as the sacrotuberous ligament,which attaches to theinferior aspect of the sacrum at the ILA and fascially connects to thecontralateral(oppositeside)multifidiandto theerectorspinae,whichcontinuetothebaseoftheoccipitalbone.Thismyofascialslingisknownastheposteriorlongitudinalsling(PLS)orthedeeplongitudinalsling(DLS),asshowninFigure4.3.

Even before you initiate the contact to the ground through heel-strike,dorsiflexion of the ankle (by the contraction of the tibialis anterior) initiates acoactivationofthebicepsfemorisandperoneuslongusjustpriortoheel-strike.Studies have shown that the biceps femoris communicates with the peroneuslongus at the fibular head, transmitting approximately 18% of the contractionforceofthebicepsfemoristhroughthefascialsystemintotheperoneuslongusmuscle. This co-contraction therefore serves to “wind up” the thoracolumbarfasciamechanismasameansof stabilizing the lowerextremity; this results inthe storage of the necessary kinetic energy that will subsequently be releasedduringthepropulsivephaseofthegaitcycle.

Theposterior(deep)longitudinalslingasdescribedisbeingfasciallytensioned;the increased tension is focused on the sacrotuberous ligament via theattachment of the biceps femoris, as shown in Figure 4.4(b). This connectionwillassisttheforceclosuremechanismprocessoftheSIJ;insimpleterms,thiscreates a self-locking and stable pelvis for the initiation of theweight-bearinggait cycle. You may also notice that the right ilium (see Figure 4.4(a–c))undergoesposteriorrotationduringtheswingphase,whichwillassisttheforceclosureoftheSIJbecauseoftheincreasedtensioninthesacrotuberousligament.

You can also see from Figure 4.4(c), overleaf, that there is now tensiondevelopingwithintherightsacrotuberousligamentbecauseofthecontractionofthebicepsfemorisaswellastheposteriorrotationoftherightinnominate;atthesametime,theleft innominateisrotatinganteriorlyandthesacrumhasrotatedon the left oblique axis (L-on-L).This specificmotionof the lumbopelvic hipcomplexoccursallatthesametimeastherightheel-strike.

Figure4.4.(a)Rightiliuminposteriorrotation—sacrotuberousligamenttensioned.

Figure4.4.(b)Positionofthelegjustbeforeheel-strike,withthebicepsfemorisandsacrotuberousligamenttensioned.

Figure4.4.(c)Rightiliuminposteriorrotation—leftiliuminanteriorrotationandsacrumrotatedontheL-on-Laxis.

Forthenextphase,youmightwanttostandandslowlygothroughthefollowingmovementssothatyoucangetasenseofwhathappenswithyourbodyin thenormalwalkingcycle.Asexplainedabove,justbeforetheheel-strikephaseyourhipwillbeflexed,yourkneeextended,andyourankledorsiflexedwiththefootsupinated.Thetibialisanteriorandtibialisposteriormaintainthispositionoftheankleandfoot,andasyoucontacttheground,thesetwomusclesareresponsibleforcontrollingtherateofpronationthroughtheSTJbycontractingeccentrically.

As your right legmoves fromheel-strike to toe-off (stance phase), your bodyweightbeginstomoveoveryourrightleg,causingyourpelvistoshiftlaterallyto the right. As the movement continues toward toe-off, your right pelvic

innominate bone begins to rotate anteriorly while your left innominate bonebeginstorotateposteriorly.

Asyouproceed through thegaitcycle,younowenter themid-stancephaseofgait. This is where the hamstrings should reduce their tension because of thenatural anterior rotation of the pelvis and the slackening of the sacrotuberousligament.Formclosureatthispointisgraduallylostduringthelatterpartofthestance phase, so that stability at this point is chieflymaintained through forceclosure.This is thepoint during themid-stancephasewhere theGmaxon theright side should take the role of the continued movement of lower limbextension, aswell asworking inconcertwith thecontralateral latissimusdorsi(leftside).Theactivecontractionofthesetwomusclesincreasesthetensioninthethoracolumbarfascia(posteriorobliquesling), thusprovidingthenecessaryforceclosurestabilitytotherightSIJduringthemid-stancephaseofgait.

Iwouldliketoelaboratealittlemoreonthisprocess.PhasiccontractionoftheGmaxoccurs in themid-stancephase; theGmaxsimultaneouslycontractswiththe contralateral latissimus dorsi—it is this muscle that will extend the armthrough what is known as counter-rotation, to assist in propulsion. Thethoracolumbar fascia,which isa sheetofconnective tissue, is locatedbetweentheGmaxandthecontralaterallatissimusdorsi;thisfascialstructureisforcedtoincreaseitstensionbecauseofthecontractionsoftheGmaxandlatissimusdorsi.ThisincreasedtensionwillassistinstabilizingtheSIJofthestancelegthroughtheforceclosuremechanism.

In Figure 4.5 you can see that just before heel-strike, the Gmax will reachmaximumstretchasthelatissimusdorsiisbeingstretchedbytheforwardswingoftheoppositearm.Heel-strikesignifiesatransitiontothepropulsivephaseofgait, at which time the Gmax contraction is superimposed on that of thehamstrings.

Figure4.5.Apersonrunning,withtheposteriorobliqueslingmuscleshighlighted.

As explained in the previous paragraphs, activation of the Gmax occurs inconcert with contraction of the contralateral latissimus dorsi, which is nowextendingthearminunisonwiththepropellingleg.Thesynergisticcontractionof the Gmax and the contralateral latissimus dorsi creates a state of tensionwithinthethoracolumbarfascia,whichwillbereleasedinasurgeofenergythatwill assist the muscles of locomotion. This stored energy within thethoracolumbarfasciahelps toreduce theoverallenergyexpenditureof thegaitcycle. Janda (1992, 1996)mentions that poorGmax strength and activation ispostulated to decrease the efficiency of gait. The posterior oblique sling alsocontains a lower component (consisting of the continuations of the Gmax),

which acts to increase the tension of the iliotibial band (ITB); this helps tostabilizethekneeduringthestancephaseofgait.

Asweprogress from themid-stancephase toheel-liftandpropulsion, the footbeginstore-supinateandpassesthroughaneutralpositionwhenthepropulsivephasebegins;thefootcontinuesinsupinationthroughtoe-off.Asaresultofthefoot supinating during themid-stance propulsive period, the foot is convertedfrom a “mobile adaptor” (which is what it is during the contact period) to a“rigidlever”asthemid-tarsaljointlocksintoasupinatedposition.Withthefootfunctioningasarigidlever(asaresultofthelockedmid-tarsaljoint)duringthetime immediately preceding toe-off, theweight of the body is propelledmoreefficiently.

PelvisandSIJMotion

Nextwewilltakealookatthepelvisandhowitfunctionsduringthemid-stancephase of the walking cycle. As the right innominate bone starts to rotateanteriorly from an initial posteriorly rotated position, the tension of the rightsacrotuberous ligament is reduced, and the sacrum will be forced to move(passively) into a right torsion on the right oblique axis (R-on-R) (recall, themotion of the pelvis and sacroiliac joint in Chapter 2). In other words, thesacrumrotatestotherightandsidebendstotheleft,becausetheleftsacralbasemoves into an anterior nutation position (this is also known as Type I spinalmechanics,as therotationandsidebendingarecoupledtooppositesides—seeChapter6);themotionisillustratedinFigure4.6(a).

Figure4.6.(a)Sacralrotationandlumbarcounter-rotation.

Wealsoneedtomentionandconsiderthat,astheleftsideofthesacrummovesforwardintonutation,therightsideofthesacralbasewillmovebackwardintocounter-nutation(R-on-R); this ismainlybecauseof theslackeningof therightsacrotuberous ligament and the continual anterior rotational movement of therightinnominateboneduringmid-stance.

Owingtothekinematicsofthesacrum,thelumbarspinerotatesleft(oppositetothesacrum)andsidebendstotheright(TypeImechanics),asshownisFigure4.6(b).The thoracicspine rotates right (sameas thesacrum)andsidebends tothe left, and the cervical spine rotates right and side bends to the right. The

cervical spine coupling is opposite to that of the other vertebrae, since itsspecificspinalmotionisclassifiedasTypeIIspinalmechanics(TypeIImeansthatrotationandsidebendingarecoupledto thesameside—seeChapter6formoredetails).

As the left legmoves fromweight bearing to toe-off, the left innominate, thesacrum,and the lumbarand thoracicvertebraeundergosacral torsion, rotation,and side bending in a similar manner to that described above, but withmovementsintheoppositedirections.

Figure4.6.(b)Sacralrotationandlumbarcounter-rotationsuperimposedonthepelvicgirdle.

The anterior oblique alsoworks in conjunctionwith the stance leg adductors,ipsilateralinternaloblique,andcontralateralexternalobliquemuscles,asshowninFigure 4.7.These integratedmuscle contractions help stabilize the body on

top of the stance leg and assist in rotating the pelvis forward for optimumpropulsioninpreparationfortheensuingheel-strike.

Theabdominalobliquemuscles,aswellastheadductormusclegroup,servetoprovidestabilityandmobilityduringthegaitcycle.

WhenlookingattheEMGrecordingsoftheobliqueabdominalsduringgaitandsuperimposingthemonthecycleofadductoractivityingait,BasmajanandDeLuca(1979)foundthatbothsetsofmuscles(obliquesandadductors)contributetostabilityattheinitiationofthestancephaseofthegaitcycle,aswellastotherotationofthepelvisandtheactionofpullingthelegthroughduringtheswingphaseofgait.(ThiswasalsodemonstratedbyInmanetal.(1981).)Asthespeedof walking increases to running and sprinting speeds, the activation of theanteriorobliquesystembecomesmoreprominentaswellasanecessity.

Figure4.7.Apersonrunning,withanteriorobliqueslingmuscleshighlighted.

Theswingphaseofgaitutilizesthelateralslingsystem,aswehavenowenteredthe single-leg stance position. This sling connects theGmed andGmin of thestance leg, and the ipsilateral (same side) adductors, with the contralateral(opposite)QL.ContractionoftheleftGmedandadductorsstabilizesthepelvis,andactivationof thecontralateralQLwillassist inelevationof thepelvis; thiswill allow enough lift of the pelvis to permit the leg to go through the swingphaseofgait.Thelateralslingplaysacriticalrole,asitassistsinstabilizingthespine and hip joints in the frontal plane and is a necessary contributor to theoverallstabilityofthepelvisandtrunk.

Notonlydoesthelateralslingsystemprovidestabilitythatprotectstheworkingspinalandhipjoints,butitisalsoanecessarycontributortotheoverallstabilityof the pelvis and trunk. Should the trunk become unstable, the diminishedstability will compromise one’s ability to generate the forces necessary formoving the swing leg quickly, as required in many work and sportsenvironments. Attempts to move the swing leg, or to generate force with thestancelegduringgaitandotherfunctionalactivities,caneasilydisrupttheSIJsand symphysis pubis and cause kinetic dysfunction in joints throughout theentirekineticchain(Chek1999).

Figure4.8.Anexampleoftheswingphaseofgait,withlateralslingmuscleshighlightedonthesingle-stanceleg.

Maitland (2001) mentions that proper body movement while walking isinfluenced by the ability of the sacrum to cope with left torsion on the leftobliqueaxis(L-on-L)andrighttorsionontherightobliqueaxis(R-on-R).Sincemostwalking isaccomplishedwith thevertebralcolumnrelativelyuprightand

vertical, for thepurposeof thisdiscussionwewill assume thatyour spineandsacrumareinneutralwhileyouwalk.

The way our axial skeletal system alternately undulates in side bending androtation aswewalk is very interesting and extremely important to our overallwell-being. It is amovement that is reminiscent of the undulating action of asnakeasitslithersthroughthegrass.Thebigdifferencebetweenasnakeandahuman,ofcourse,isthatoursnakelikespinehasendedupbeinggiventwolegsonwhichtowalk.

SummaryoftheSacrumandtheGaitCycle

To summarize the gait cycle and the specific motion of the sacral spine, thesacrumiscapableofleftrotationontheleftobliqueaxis(L-on-L),fromwhichitthen returns to a neutral position. From this neutral position the sacrum thenrotates to the right on the right oblique axis (R-on-R) and again returns toneutral.Themovementofthesacrumisanteriorinitsnatureasitundergoestheearlier-describedmotion of nutation.The forward nutationalmovement duringwalking is anterior on one side, followed by a return to the neutral position;anterior nutation then occurs on the opposite side, before the sacrum againreturns to neutral. This process is continually repeated. According to variousstudies, themotion of posterior nutation (counter-nutation) does not appear toextendpasttheneutralpositionduringthenormalwalking/gaitcycle.

5LegLengthDiscrepancyanditsRelationshiptotheKineticChainandthePelvis

Iwould personally say that themajority of patients and athleteswhovisitmyclinicinOxfordgenerallypresentwithpainsomewhereintheirbodies.Partofmyinitialscreeningistohavethepatientstandwiththeirbacktome;withtheminthisposition,Iplacebothmyhandsontopoftheiriliaccresttoseeifthereisanypelvicobliquity;inotherwords,Ilookforaloworahighside,asshowninFigure 5.1.Veryoften I do find that there is a discrepancy in the level of theheightof theiliaccrestbetweenthetwosides,whichcouldpossiblyindicatealeglengthdiscrepancy(LLD),or,asithasbeenalternativelytermed,ashort-legsyndromeoralong-legsyndrome.

LLD ispossibly themost significantposturalasymmetry thatpresents itself tothe physical therapist. The existence of a considerable difference between thetwosidescanbeverydetrimentaltohowwefunctiononaday-to-daybasis,notleastduring thewalking/gaitcycle: thediscrepancycansignificantlyaffectnotjustthepelvisandSIJbutalsoouroverallposture.

Figure5.1.Observationofmeasurementofleglengthbypalpationoftheiliaccrest.

Definition:Leglengthdiscrepancy(LLD)isaconditionwhereonelegisshorterthantheother.

One has to decide if there is an “actual” (or “true”) anatomical LLD or an“apparent”LLD,astheconditionhasbeenimplicatedinallsortsofdeficienciesrelatedtoourgaitpatternandrunningmechanics.LLDhasalsobeenlinkedtoposturaldysfunctions,aswellastoincreasedincidenceofscoliosis,lowerbackpain,SIJdysfunction,andosteoarthritisofthespine,hip,andknee.Evenstressfracturesofthehip,spine,andlowerextremityhavebeenrelatedtochangesinleglength.

Figure5.2.Trueleglengthmeasurement,takenfromtheASIStothemedialmalleolus.

The actual (true) leg length measurement is the length that is typicallydeterminedbytheuseofatapemeasurefromapointonthepelvis—theASIS—to the medial malleolus (distal part of the tibia), as shown in Figure 5.2; theASISisnormallyusedasthelandmark,sinceitisimpossibletotrulypalpatethefemurbelow the iliac crest.Before taking thismeasurement, it isbeneficial tomeasurethedistancefromtheASISontheleftandrightsidestotheumbilicus,as shown in Figure 5.3, to ascertain if any pelvic rotation is present. If adifference in the two measurements is found, the pelvic rotations need to becorrectedbeforeareassessmentisdone(Chapter13).

Figure5.3.MeasurementtakenfromtheASIStotheumbilicus.

IfthemeasurementstakenfromtheASIStothemedialmalleolusonbothsidesare the same, it can then be assumed that the lengths of the two limbs areeffectivelyequal;ontheotherhand,ifthemeasurementsdiffer,onecanassumethatanactual(true)LLDispresent.

Theapparentleglengthmeasurementistakenfromtheumbilicustothemedialmalleolus,asshowninFigure5.4.Ifthemeasurementstakenonbothsidesaredifferent, one can assume that a dysfunction exists somewhere, which willrequirefurtherinvestigation.

Figure5.4.Apparentleglengthmeasurement,takenfromtheumbilicustothemedialmalleolus.

SupinetoLongSitting

ThesupinetolongsittingtestiscommonlyusedtoascertaintherelevanceoftheSIJ to an apparent or true LLD. With the patient in a supine position, thetherapist initiallycomparestherelativepositionsofthetwomedialmalleoli, toseeifadifferenceexistsbetweenthesetwobonylandmarks,asshowninFigure5.5(a).

Figure5.5.(a)Palpationforthepositionsofthemedialmalleoli(leglength)inthesupineposition.

Next the patient is asked to sit up, while keeping their legs extended. Thepositionsofthetwomedialmalleoliarecomparedonceagain,toseeifthereisanychange,asshowninFigure5.5(b–c).

Figure5.5.(b)Observationofthepositionsofthemedialmalleoli(leglength)afterthesupinetolongsittingtest.

Figure5.5.(c)Close-upviewofthepositionsofthemedialmalleoli(leglength)afterthesupineto

longsittingtest.Themalleoliappeartobelevelinthiscase.

If, for example, there is a posterior innominate present, the leg that appearedshorter in the supine positionwill now appear to lengthenwith the sitting-upmotion. If there is ananterior innominate present (very common on the rightside), the leg that appeared longer in the supine position will now appear toshortenwiththesitting-upmotion,asshowninFigure5.5(d).

Figure5.5(d).Close-upviewofthepositionsofthemedialmalleoli(leglength)afterthesupinetolongsittingtest.Therightlegappearsshorter,possiblyindicatingarightanteriorinnominaterotation.

Ifanactual(true)LLDispresent,thetruelonglegwillappeartobelongerinthesupinepositionaswellas in thesittingposition,sonoobviouschangewillbeobserved (this, along with further discussion on leg length changes, will bepresentedinmoredetailinChapter12).Fornow,itissufficienttosimplynotedownifthereareanychangesinthepositionofthemedialmalleoliinthesupineandlongsittingpositions.

Note:This testcanhelp indifferentiatingbetweena trueLLDanda

sacroiliacdysfunction.Pleasebecarefulwhenaskingyourpatientstoperform this test: the motion of the test (sitting up) can easilyexacerbate a patient’s symptoms because of the forces needed toperform the action. Assistance by the therapist might sometimes benecessary.

TypesofLLD

LLDcanbedividedintothreemaingroups:

1. Structural: This is an actual (or true) shortening of the skeletal system,typicallycausedbyoneoffourthings:

•Congenitaldefect,e.g.congenitaldysplasiaofthehipjoint

•Surgery,e.g.totalhipreplacement(THR)

•Trauma,e.g.fracturedfemurortibia

•Diseaseprocess,e.g.tumor,osteoarthritis,Osgood–Schlatterdisease,orLegg–Calvé–Perthesdisease

Fracturedbonesinchildrenhavebeenknowntogrowfasterformanyyearsafter the healing process: this can naturally result in the limb becominganatomicallylonger.

2.Functional:Thiscanbeadevelopment fromalteredbiomechanicsof thelower body, such as ankle and foot over-pronation or supination, pelvicobliquity,muscleimbalances(asaresultof,forinstance,aweakGmedandabdominals or tight adductors and hip flexors), hip or knee jointdysfunction,andevenpoorinnercorestabilization,tonamejustafew.

3. Idiopathic: If there are obvious findings during the history taking andassessmentprocess,thephysicaltherapistmayhaveanideaastothecauseofthepatient’sLLD.However,ifthetherapistcannotascertainareasonforthechangeinthepresentingleglength,theconditionwouldbeclassifiedasidiopathic,whichmeansthatitarisesindependently,notasaresultofsomeothercondition.

Kiapouretal.(2012)estimatethataLLDofaslittleas0.4”(1cm)increasestheloadacrosstheSIJfivefold.

Figure5.6.Leftlong-legsyndromeversusrightshort-legsyndrome.

Assessment

Thetherapisthastobeveryintuitiveduringtheinitialassessment.Whenplacingtheirhandsontopoftheiliaccrestofapatientinastandingpositioninordertoascertainpelvicobliquity, thetherapistneedstobeawareofa“pelvicshift”asthepatientstands.Letmegiveyouanexample:ifthepatienthasaweakGmed

muscle on the left side, the pelvismight appear to drop to the right side anddeviateorlaterallyshifttotheleft;thiswillhavetheeffectoftheleftiliaccrestappearing elevated on that side (left), thus giving the natural appearance of alongerleftleg.

When thepatientpresents to theclinic,onecanassume that thepainhasbeenpresentforawhile;sincethepainhaspersistedforanextendedperiodof timewe can safely say that the presenting condition is now in the chronic stage.Because of the natural overcompensatorymechanisms that occur through softtissue chronicity, the postural muscles are probably held in a shortened andsubsequentlytightposition;oneparticularlumbarspinemusclethathasanaturaltendencytoshortenasaresultofLLDistheQL.Aperceivedproblemcanarisewhenthepatientliesontheirback(supineposition),sothatyoucanobservethepositionsof theleftandrightmedialmalleoliwhenlookingforanyLLD.Youmay notice that the leftmedialmalleolus appears nearer to the patient’s head(cephalic) than the one on the right, giving the appearance of a short left leg.ThisapparentshortnessofthelegispossiblyaresultofatightleftQLmuscle.Whenthepatientwasstanding,however,youmayhaveconvincedyourselfthatthepatient’sleftlegactuallylookedlonger!

Thismightseeminitiallyconfusing,butjustthinkaboutitforamoment.Coulditnot simplymean (this isonlyoneexamplebecause therearemanypotentialcausesofahigheriliaccrest)thatwhenthepatientadoptsastandingpositiontheGmedontheleftsideisweak,causingthepelvistoshifttothesideofweakness,nowgivingtheappearanceofalongerleftleg?Conversely,isitnotpossiblethatwhen the patient is in a supine position, the left QL is held in a shortenedposition, which is responsible for hitching up the pelvis, having the effect ofpullingthelegclosertotheheadandthusmakingtheleftlegappearshorter?

Thefollowingphrasemighthelpyourememberthisprocess:

“When you are standing, the weak muscles show themselves; when you arelying,theshortmusclesshowthemselves.”

FootandAnklePosition

Oneofthemostneglectedaspectsofthebody,especiallywhenpatientspresentto the clinic, is the position of the lower limb. Every single day osteopaths,

chiropractors, and physical therapists see lots of patientswho initially presentwithlowerback,pelvis,andsacroiliacpain.Thesespecialisttherapistsnaturallyspend a lot of time observing and assessing the pelvis and lumbar spine toascertainwhichtissuetheypersonallyconsider toberesponsibleforgivingthepersonthepain.Thispresentingpainmay,however,justbeasymptom,andthecauseofthepaincouldbesomewhereelse,awayfromtheactualsiteofthepain.

Dr.IdaRolf,whoinventedtheRolfingsofttissuetechnique,states:“Whereyouthinkthepainis,theproblemisnot.”OneofmypopularsayingsthatIimpresson my students (which I consider to relate to what Dr. Rolf states) is thefollowing:

“Theonlypersoninterestedinthepainisyourpatient;youthetherapistshouldtrytofindtheactualcauseofthepainandnotsimplytreatwhereithurts.”

It is very important thatwhen assessingyourpatients, you shouldobserve theposition of the lower limb and in particular the foot and ankle complex, as afaultyfootandanklestructurecanprofoundlyaffect leg lengthand thenaturalpositionofthepelvis.Themostcommonasymmetricalfootpositionthatpatientspresentwithhas tobewhat is commonlycalled anover-pronated foot (orpesplanus),asshowninFigure5.7.

Ithasbeenwidely thought thatwhenweactuallypresentwitha trueLLD, thebodywilltrytocompensateforthelongerlegthroughloweringthemedialarchofthefootbypronatingattheSTJ.Theactionofpronationiscalledtri-planarmotionandconsistsofthreemovements:dorsiflexionoftheankle,eversion,andabduction of the foot complex. The position of this increased pronation isbasicallythebody’snaturalcompensatorymechanismtotryto“shorten”thelegbecauseitisanatomicallylonger.

Figure5.7.Over-pronationsyndrome.

The plantar surface of our feet has thousands of sensory receptors that areresponsible for the position of the foot; the smallest shift in weight will beenough to signal the brain to induce a compensatory reaction. On thecontralateral side (shorter leg), the compensatory mechanism will cause themedial arch toadopta supinatedposition (tri-planarmotionofplantar flexion,inversion,andadduction).Thecompensatorymechanismchangesthepositionofthe arch in an attempt to lengthen the apparent shorter leg. When physicaltherapists assess their patients they will need to check for this compensatorypattern, because, if left unchecked, excessive foot pronation caused by ananatomically longer leg (subsequent supination of the contralateral foot as

compensation)willinturncauseaninternalrotationofthelowerextremityandan external rotation of the contralateral lower limb. This compensatorymechanismwillthenhavetheeffectofalteringthewholekineticchainfromthefootallthewayuptotheocciput.

TrueLLDandtheRelationshiptothePelvis

Let’s continuewith a “thoughtprocess” just for amoment.Nowconsider thatyourpatienthasanactuallongerlegontheleftside,whichyouhaveascertainedbecauseof thehigherpositionof the iliaccrestand thepossiblecompensatorypronationoftheSTJonthesameside,aswellastheleglengthappearinglonger(through observation of the medial malleoli) in the supine and long sittingposition. Before I continue with the discussion, just have a think to yourselfabout what position the innominate bone might be in if the left leg, say, isanatomicallylonger.

TheinnominaterotationwillnaturallybecoupledwithaLLDasaresultofthecompensatorymechanisms: if you look at Figure 5.8(a), youwill see that thefemoral head on the long-leg side forces the innominate into a superior andposteriorlyrotatedposition.Conversely,theinnominateonthelowfemoralheadsidedropsdownandanteriorlyrotates,asshowninFigure5.8(b).Whatwehavenow,therefore,istheleftinnominatebeingforcedintoaposteriorrotationandtherightinnominateintoananteriorrotation.

Figure5.8.(a)Long-leginnominatecompensation.

Figure5.8.(b)Short-leginnominatecompensation.

Thinkaboutwhatliesbetweenthetwoinnominatebones—yes,thesacrum.Asaresultofthecompensatoryrotationofbothoftheinnominatebones(becauseoftheanatomicalLLD)inoppositedirectionstoeachother,amotionofthesacrumoccurs—left-on-left (L-on-L)sacral torsion (Figure5.9),whichwascovered inChapter2.Recall,aL-on-Lsacraltorsionmeansthatthesacrumhasrotatedtothe lefton the leftobliqueaxisandhassidebent to the right,as it is ruledbyType I spinal mechanics (rotation and side bending are coupled to oppositesides,asestablishedbyFryette (1918)and the lawofspinalmechanics,whichwillbediscussedinChapter6).Thiscomplexityoftheinnominaterotationsthatarecoupledwithasacraltorsionisusuallydepictedasapelvictorsion,orevena

pelvicobliquity,andwillrequireagoodunderstandingbeforeatreatmentplanisintroduced.

Figure5.9.L-on-Lsacraltorsion.

TrueLLDandtheRelationshipBetweentheTrunkandtheHead

Youwill notice in Figure 5.10(a)& (b) that on the left side there is a lowershoulderpositionon thehigh innominateside: this isacommonfinding in thecase of a compensatory functional scoliosis. Some authors, however, haveconsidered this to occur as a result of a “handedness pattern”: for example, ifyouare lefthanded, the left shouldermightappear tobe lower,and ifyouare

righthanded,therightshouldermightappeartobelower.Iagreethatthepatternofhandedness is probably true, but only if the iliac crests are level; otherwisesome form of scoliosis has to exist, especially if the iliac crest and shoulderpositionsareasymmetric.

Figure5.10.(a)Functionalscoliosiscompensation.

WhatelsedoyouobserveinFigure5.10(b)?Ifyoulookatwhatishappeningtothe left QL, you might assume that this muscle is being held in a shortenedpositionbecauseofthehigherleftinnominate.Thisassumptioniscorrect,asyoucan also see that the lumbar spine is side bending toward the longer left leg(concavity)androtatingtowardtheshorterrightleg(convexity).

Figure5.10.(b)Functionalscoliosiscompensation.Quadratuslumborumonleftisshort/tight.

As a result of the ascending functional scoliosis, the right shoulder is higher.Youmightalsonoticeashort“C”curveinthecervicalspine;thiswillprobablycausethescalenes,sternocleidomastoid(SCM),uppertrapezius,andpossiblythelevatorscapulaemusclesontherightsidetoadoptashortenedandsubsequentlytightposition.Thistypicaladaptationofmuscularimbalancewillhelpmaintainanerectheadpositionwiththeeyeslevel.Thebodywillalwayswanttobelevelnomatterwhatandwilldoalmostanythingtoaccomplishthis,throughnaturallyadapting the position of the occipitoatlantal joint (OAJ), and in so doing cansuffer enduring pain tomaintain equilibrium.Common painful conditions thatpatients might present with are headaches, active trigger points, tinnitus,temporomandibularjoint(TMJ)dysfunction,andeveneyeandfacialpain.

LLDandtheGaitCycle

Aswewalk,ifourgaitcyclepatternhasbeenalteredbecauseofanactualoranapparentLLD,theshorterlegwillfeellikeitissteppingdown,andthelonglegwillcompensatebyasortof“vaulting”motion.Itisalmostlikesteppingintoasmall pothole with every step you take; imagine repeating this at least ten tofifteen thousand times a day—it will easily cause potential pain patterns ofdysfunction! Common compensations are sometimes seen when patients areaskedtowalk:ontheshort-legside,thepatientmighthaveatendencytowalkontheirtoes,andonthelong-legside,thepatientmayhaveatendencytoflextheirknee,butthiswilldependonthediscrepancy.

For thebodytobeaneffective locomotorduring thegaitcycle,awell-alignedandsymmetricalbodyisessential.Whenthepositionsoftheinnominatebonesofthepelvisarealteredbyactualorapparentleglengthdiscrepancies,itiseasytoseehowpatientscanpresentwithpain,notonlyattheSIJandlumbarspinebut also everywhere else in their body that is going through a compensationpattern.

Imentionedearlier that therecouldbeaweaknessoftheGmedononesideofthe body; this weakness could lead to a potential compensatory pattern forsubsequentshortness issueswith the tensorfasciae latae(TFL)andITBontheother side. If there is weakness of the Gmed, the patient can have either aTrendelenburgpatternofgaitoracompensatoryTrendelenburgpatternofgait(see“StandingBalanceTest,”laterinthischapter).Whicheverwayyoulookatthis, thepatient isgoing tohaveanantalgic typeofgait,which simplymeansthat theywillwalkwithsomeformof limp; thiscompensationcanonlycauseonethingovertimeandthatwillsimplybepain.

SummaryofLLDCompensationstotheSacrum

•Thesacrumtypicallyrotatestowardthelonglegandsidebendstowardtheshortleg.

•Aposteriorsacrum(counter-nutation)hasbeenfoundtobeassociatedwithsame-sidepiriformisspasm.

•Ananteriorsacrum(nutation)hasbeenfoundtobeassociatedwithsame-

sideGmedspasm.

SummaryofLLDCompensationstotheLumbarSpine

• The lumbar spine typically rotates toward the side of the low sacralbase/shortlegandsidebendstowardthelongleg.

• Facet pain due to compression is common on the concavity side (side-bendingside)ofthelumbarspine.

•Theiliolumbarligamentcancausepainasitisstretchedontheconvexsideofthelumbarspineandhasbeenarguedtoreferpaintothegroin,testicle,andmedialthighonthesamesideasthestretchedligament.

SummaryofLLDCompensationstotheIliopsoasMuscle

•Theiliopsoasmuscleisgenerallyconsideredtobetightonthesideof theshort leg.Note that a left iliopsoasmuscle spasmcan cause apelvic sideshifttotheright,mimickingashorterleftleg.

•Theiliopsoasmuscle(iliacus inparticular)cancausetheinnominateboneto compensate by rotating anteriorly on the side of the short leg,functionallycausingalengtheningofthatleg,whiletheinnominateboneonthelongsidemaydotheopposite(posteriorinnominaterotation).

• Unilateral spasm (contraction) of the iliopsoas can create a lumbarconcavityonthesameside(becauseofsidebending),withrotationto theopposite side, and potentially sets up a positive side shift on the sideopposite to the spasm. It is important that the physical therapist alwaysassessesforandtreatsiliopsoasspasminthecaseofasuspectedshortlegorapositivepelviclateralsideshift.

•Iliopsoasspasmpainisgenerallyworseonstandingfromaseatedposition,andlesspainisperceivedastheiliopsoasstretchesout.

Insummary,whenlookingattheleveloftheiliaccrest,onehastodetermineifthereisaLLD.Ifthereis,onethenhastoascertainifthedysfunctionisatruediscrepancyorafunctionaldiscrepancy,asthecompensationpatterncanchange

dependingonthediagnosis.Forexample,ifyoufindatrueanatomicalLLD,theinnominateboneon the longer legwillnormally try tocompensatebyrotatingposteriorly,asseeninFigure5.7andexplainedearlier.Moreover,thefemurandlowerlimbontheanatomicallylongerlegwillfollowthecompensatorymodelbyrotatingmedially,asseeninFigure5.5,andthefootwilltrytopronateattheSTJ, since the longer legwill attempt to shorten itself.At the same time, theactual shorter leg will compensate by supinating at the ankle mortise; this ineffectcancausethetibiaandfemurtorotateexternallyandtheinnominatebonetorotateanteriorlyasthelegtriestomakeitselfappearlonger.

Over-PronationSyndrome

Let’s lookatanothercompensationmodel forapatientwhoappears tohaveaLLD. In this case it is a functional LLD, and the apparent shorter leg of thepatient exhibits an over-pronation of the STJ, rather than the true longer legcompensating by pronating to shorten itself. As a result, the body will try tocompensatebycausingan internal rotationof the tibiaandfemur,asshowninFigure 5.11(a); this will have the effect of the innominate bone rotatinganteriorly (posteriorly in a true LLD, as explained earlier), which in turn cancauseanincreasedlumbarlordosiswithsubsequentlowerbackpain.

Figure5.11.(a)Afootinover-pronationwithinternaltibialrotation.

According to podiatrists, over-pronation syndrome is a very common patternfound in themajorityofpeople to someextentor another. It is best identifiedwiththepatientstandingbarefoot.Thebigclueisthatonearchislowerorflatterthantheother:thelowerarchsideisover-pronating.Sometimes,bothsidesmaybeover-pronating,butonesideisgenerallyover-pronatingmorethantheother,oronesidemightbenormalandtheothersidelower.

It is easy to confirm the condition by simply placing one finger under thepatient’sarch,notinghowmuchofyourfingergoesunderneath,andcomparingthe result with the other side. Are they the same or different? If one side is

noticeablylowerthantheother,youhavefoundapatientwithanover-pronationsyndrome. Another test to confirm over-pronation is to observe the Achillestendonfromtheposterioraspect:youwilltypicallynoticeabowingonthesidewiththelowerarch.

It shouldbenoted thatover-pronationsyndromecouldoriginatenotonly fromthefootandanklebutalsofromtheinnominateboneofthatside.Whenthefootand ankle complex over-pronates, the innominate bone will normally rotateanteriorly.However,ifwelookatittheotherwayaround,ananteriorrotationoftheinnominate(commonontherightside)canforcethemedialarchofthefootintoanover-pronatedposition.Thisbecomesachickenandtheeggsituation,butthatisirrelevant,astheonlyconsiderationiswhateverpresentsitselfnow.Inmyexperience, you might need to correct the innominate rotation and the over-pronationtohelpreducethepatient’spresentingsymptoms.

Ifyoufeelthepronationisattributedtothemostcommonpresentationofarightanterior innominate rotation with a compensatory left posterior innominaterotation,thenyoumightalsonoticetherightfootappearstobeinapositionofrelativeexternalrotationorabduction,eventhoughthetibiaisstillinapositionofinternalrotationbecauseofthepronationoftheSTJ.Thisispossiblycausedby the anticlockwise (left) rotation of the pelvis (comparedwith the left foot,whichappearstobeinsupinationandrelativeinternalrotationoradduction).Asmentionedearlier,eventhoughthefootappearstobeexternallyrotated,thetibiaisstillinanoverallpositionofinternalrotation,asshowninFigure5.11(b).

Figure5.11.(b)Externalrotation/abductionofthefootandanklewithSTJpronation,commonlyfoundwitharightanteriorinnominaterotation.

On the side that appears to be pronated with a relative external rotation orabductionofthefoot(mostcommonontherightside;thetibiaisstillmaintainedinaninternallyrotatedposition),thefollowingmusculoskeletalpresentationsarecommon:

•Medialcollateralligamentandmedialplica

•Groinand/ormedialthighpain

•Medialtibialstresssyndrome(shinsplints)

•Medialankleligamentssprain

•Posteriortarsaltunnelsyndrome/posteriortibialnerve

•Compressionofthesuralnerveatthelateralankle

•IncreasedQangle(valgus)andstresstothelateralcompartmentoftheknee

•Lateraltrackingofthepatella

•Plantarfasciitis

•Sesamoiditis

•Achillestendinopathy

Figure5.11.(c)Internaltibialrotationandankle/footwithSTJpronation,commonlyfoundwitharightanteriorinnominaterotation.

On the side that appears to be supinated with a relative internal rotation oradductionofthefootascomparedtotheotherside(commonontheleftside;thetibia is still maintained in an externally rotated position), the followingmusculoskeletalpresentationsarecommon:

•Straintothehipabductors

•Greatertrochantericbursitis

•Lateralshinpain

•Lateralankleligamentssprain

• Nerve traction injury to the lateral femoral cutaneous and superficialperonealnerves

• Increased pressure to themedial knee compartment due to varus positionanddecreasedQangle

•Tractionofthelateralcollateralligament

•Tibialandmetatarsalstressfractures

•Plantarfasciitis

•Morton’sneuroma

•Achillestendinopathy

Figure5.11.(d)Externaltibialrotationandankle/footwithSTJsupination,commonlyfoundwithaposteriorinnominaterotation.

You can see already that both compensatory mechanisms I have mentionedthroughoutthischapterhaveapronationissueattheSTJ;however,thetrueleglength compensation of the longer leg forced the innominate bone to rotateposteriorly,whereasthefunctionalLLDoftheover-pronationsyndromecausedtheinnominatebonetorotateanteriorly.

Youcanprobablygatherfromall theinformationabovethat therecanbealotgoingonatthesametimethroughoutthekineticchain;everythingthathasbeenmentionedcanaffectthelengthoftheleg.Itiscorrecttoassumethatthisareaof

discussionissomewhatcomplex,anditmightbedifficulttoknowwheretostartintheassessmentoreveninthetreatmentprogram.

Inallthathasbeendiscussedabove,thereliesapotentialsolutiontothejigsawpuzzleofpatients’symptomsanddysfunctions.ThereexistswhatIcallakeytounlocking the problem; the difficulty in physical therapy, however, is findingwheretostartand“insertthekey”(excusetheexpression).Icanguaranteethat,over theyears, inexperienced therapistswillhave timeand timeagain insertedthekeyintothewrongplace,i.e.wherethepatientfeelsthepainandnotwheretheproblemlies.RecallthewisewordsofDr.IdaRolf!

Duringthepracticalcomponentsofmylecturestophysicaltherapistsattendingmycourses,Isometimeshearmyselfsayingthefollowing:

“Treatanydysfunctions thatyou findat the timeduring the treatment session,andthebodywillhopefullyguideyouontothecorrectpathway.”

AfterthatstatementInormallysaythis:

“If, however, after three or even five physical therapy sessions, the patient’ssymptomsarenotreducing,thenyouthetherapistwillneedtoalteryourthoughtprocessandreassessandpotentially treatotherareasof thepatient’sbody thatyouinitiallyfeltmightnotberelatedtothecauseoftheirpresentingsymptoms.”

LLDandtheRelationshiptotheGlutealMuscles

Sohowdoesallthisaffecttheglutes?Whenyouhaveacompensationpattern,the femurnotonly rotates to compensate in the transverseplane (as explainedearlier), but also experiences a compensatory mechanism of adduction andabductioninthefrontalplane.Thus, insimpleterms, ifyouhavea lowerlimbthat is held in an adducted position, then the abductor muscle group can beforced into a lengthened and subsequently weakened position, while theadductorswillbeheldinashortenedandsubsequentlytightposition.Foralegthatisheldinabduction,thesituationisreversed.

If you look back at Figure 5.6 you will see that the left leg appears longerbecauseofthehigherleftiliaccrest,theinnominatehasrotatedposteriorly,thefemurhasinternallyrotated,andthefoothaspronated.Inthiscompensationthe

left legwill be in a position of adduction (Figure 5.12), and consequently therightlegwillbeheldinapositionofabduction(Figure5.13).Thiswillhaveaneffectonthemusculatureoftheassociatedareas:someofthesemuscleswillbeheldinashortenedpositionandsomeinalengthenedposition.

Figure5.12.Leftlegcompensations—adductorsandQLshortandtight,withGmedandTFLlongandweak.

Figure5.13.Rightlegcompensations—adductorsandQLlongandweak,withGmedandTFLshortandtight.

StandingBalanceTest

Whenapatient is asked to standonone leg and lift theoppositeknee towardtheirwaist, thephysical therapistneeds toobserve the levelof thePSISas thepatienttransferstheirweighttooneleg.Thepatientshouldbeabletoshifttheirweight onto the stance leg (the right leg in Figure 5.14) with goodmuscularcontrolof theGmedof that leg.If thePSISdipsdownonthelegthat isbeinglifted (the left leg inFigure 5.15) rather than remaining level (Figure 5.14), itmightbeassumed that theGmedon theopposite side (right side) isunable to

control the movement; the patient might then have an altered pattern of gaitwhentheygothroughthegaitcycle,asshowninFigure5.16.ThisalteredgaitpatterniscalledaTrendelenburggaitandisillustratedforaweakleftGmedinFigure 5.16. If this dysfunctional gait is present over a prolonged period, acompensatory Trendelenburg might develop, as shown in Figure 5.17. Thereasonsforthisalteredgaitcanbenumeroustosaytheleast,butonecausecouldbethatoneofthelegsisheldinanadductedpositionbecauseoftheshorteningoftheadductors(asmentionedabove).Thisalteredpatternwillinturnresultinareciprocal inhibition (RI) to the antagonistic muscles: the abductors—inparticular theGmed—will nowbe held in a lengthened position that can thenpredisposetheGmedtobecomingweak.

Figure5.14.Standingbalancetest—normal.

Figure5.15.PositivetestforweaknessoftherightGmed—theleftPSISdipsdownontheleft.

Figure5.16.Trendelenburggait—weakleftGmed.

Figure5.17.CompensatoryTrendelenburggait—weakleftGmed.

WhenI teach thestandingbalance test (Figure5.14), Isay tomystudents thatyouneedtolookoutforthreethings:

1.PositionofthePSIS

The first, as Imentionedabove, is thepositionof thePSISas thepatienttransferstheirweightfromonelegtotheother.

2.Shiftofthepelvis

The second is howmuchmovement occurs as the patient shifts onto the

weight-bearing leg;youmaynoticeonesideshiftingmore than theother,indicatingapossibleGmedweakness.

3.Stabilityononeleg

Finally, the third is how stable the patient iswhen they stand on one legcomparedwith theother.Youwillbeamazedhowmanyvery fit athletesstruggle to stand on one leg unaided and maintain good control. Thisinstability could be a result of a weak Gmed, but remember also that achange in a patient’s ability to stabilize might be due to a previousinjury/trauma to the ankle complex, thus affecting the neurologicalproprioceptorsincontrollingthespecificposition.

Friel et al. (2006) conducted a study about ipsilateral hip abductor weaknessafter an inversion ankle sprain; their results showed that hip abduction andplantarflexionweresignificantlyweakerontheinvolvedside.Theyconcludedthatunilateralanklesprainsledtoweakerhipabduction(Gmed),andsuggestedexercises to strengthen the hip abductors when developing rehabilitationprotocolsforankleinversionsprains.

Schmitz et al. (2002) demonstrated through an EMG study that there was anincrease in Gmed activity during sudden ankle inversion motion in healthysubjectsaswellasinthosewithfunctionallyunstableankles.

Hopefully,afterreadingthischapter,youwillhavesomeunderstandingofwhatishappeningwhenapatientpresentswithmusculoskeletaldysfunctions,suchasLLD, over-pronation syndrome, andmuscle imbalances. In the next chapter Iwill continue with the journey on this theme by looking at the specificmovementmechanicsofthespine.

6TheLawsofSpinalMechanics

SpinalMechanics:FactorFiction?

AmedicaldoctorbythenameofRobertLovettwasthefirstperson(Ibelieve)toconfirm coupled spinal motions, other than the standard primary motion offlexionandextension(Lovett1903).Hebelievedthatsidebendingandrotationofthespinearepartsofonecompoundmovementandcannotbedissociated:hefound that a flexible rod bent in one plane could not bend in another planewithouttwisting.InallhisexperimentsLovettprovedthatifthespinewasinapositionoflordosis,itrotatedintheoppositedirectiontothatofthesidebendingmotion;moreover, if the spinewas in a position of kyphosis, it rotated in thesamedirectionasthatofthesidebendingmotion.

He considered that only three spinal movements were possible within thevertebralcolumn:(1)flexion;(2)extension;and(3)sidebendingwithrotation.Healsoconcludedthatsidebending,or lateralflexion,mustaccompanyspinalrotation(i.e.themotionsarecoupled).

Lovettproposedthatcoupledmotionoccursinasecondplaneofmotionwithinajointsystem,andispartandparceloftheprimarymotion.Twoormoremotionsareconsidered“coupled”whenitisnotpossibletoproduceonemotionwithoutinducing the secondone; spinal couplingoccurs becauseof themorphologicalshape of the facet joint surfaces and the connecting ligaments and spinalcurvatures.

In the early 1900s the osteopath Harrison M. Fryette contributed somepioneeringworkonthemechanicsofspinalmotion.Hespentmanyyearsofhislife researching this topic and eventually presented a paper in 1918 on theprinciples of spinal motion, which was sent to the American OsteopathicAssociation(Fryette1918).

Initially, Fryette’s paperwas poorly received and he did not gain acceptance.

Many years passed before he eventually received formal recognition for hisideas. In the late1940sFryettewas invited to theUKbyEdwardHall todoapresentation on his work. Fryette spoke about what he called “The TotalOsteopathic Lesion,” and he had such a profound effect on Hall that hisbiomechanicalviewofspinalmotionwasrelabeledto“Fryette’sLawsofSpinalMechanics,”whichupuntil thenhadbeen referred toonlyasprinciples. (Hallwrote the first articleon that subject in the1956yearbookofTheOsteopathicInstituteofAppliedTechnique.)

AquotefromFryette:

“Nointelligentscientificspinaltechniccanbedevelopedthatisnotbasedonanaccurateunderstandingofthephysiologicalmovementsofthespine.”

Regarding themotionof the spine,Stoddard (1962) states the following inhismanualonosteopathictechnique:

“Rotationofthespineisalwaysaccompaniedbysomedegreeoflateralflexion.Likewise, lateral flexion of the spine is accompanied by some degree ofvertebralrotation.”

HowAllThisCameAbout

Fryette utilized and established correlations with a lot of the earlier workconductedbyLovettin1903.Theresearchmethodologyconsistedofcadavericstudyandinvivoresearchviatheapplicationofgummedpaperstickers.Thesebitsofstickypaperwereattachedtothespinousprocessesofthevertebraeofasmall number of individuals; the results were then obtained by observing therelativespinalmotionofthesegummedpaperstickers.

It is hard to appreciate how much the research into spinal mechanics hasprogressedoverthelast50–100years,fromthesimpleobservatorytechniquesofFryette employing sticky paper to the use of advanced technology such ascomputersimulation,computerizedtomography(CTscan),magneticresonanceimaging (MRI scan), and cineradiology (viewing an organ in motion with aspecialmovie camera).We can evendetectmotionof the spine andpelvis byimplantinggalliumballsandSteinmanpins.

Ifwewereabletojumpaheadintothefutureby,say,100years,itwouldbeveryinterestingtoseewhatactuallychangesintermsofresearchandtechnology.Itgoes without saying, especially as time passes, that the more we are able tovisualizeandresearchlivingspinalmotion,themorecomplexandunpredictablethe precise combination of individual spinal joint motion becomes for eachparticularareaandsegmentofthevertebralcolumn.

Ihavereadnumerousarticlesandmanybooksbyvariousauthorsoverthelastfew years while researching the subject of spinal motion, before eventuallydecidingtowritethisparticularbookonthepelvisandSIJ.Thosepractitionersin question,who I consider to be experts in their field ofmanual therapy, allseem tohave a slightlydifferent opinionon spinalmechanics/motion,which Ithinkisfine,aseveryoneisentitledtohaveanopinion.Someoftheinformationthat Ihave read,however, actuallycomesacrossas ratherconflicting,becausetherecurrentlydoesnotappear tobeanystandardization in this fieldofstudy.Ratherthanhavingwhatwecalldefinitive“lawsofspinalmotion”or“principlesofspinalmotion,”therearesubstantialindividualandregionalvariations,and,asyet,notrueaccuratemodelforpredictingthebehaviorofthevertebralcolumnasregardsspecificmotion.

Koushikphysio(2011)saysinhiswebsiteblog:

“The work of Fryette must be applauded for its longevity and insight, andcelebratedaspartofourosteopathicheritageandhistory,butthe“laws”cannolonger be viewed as such, nor do they serve as a viable explanation ofphysiologicalmotionbehavior.Withallthisuncertaintywhydosomeofusstillpersistinpromotingamodelforphysiologicalmotionbasedonworkconductedover100yearsago?”

InonewayItotallyagreewithwhatthisauthorsays.Yes,IambasicallyofthesamemindthatperhapstheworkofFryettemightbeoutdated;however,anotherpart of me totally disagrees with what is being said. Why, I hear you ask?BecauseIspendalotofmytimetravelingtheworld,aswellastheUK,teachingavarietyofphysicaltherapycourses;whenthesecoursesrelateinparticulartothemotionofthespine,itamazesmethatthemajorityoftherapistswhoIcomeintocontactwithhavenotbeentaughtanythingaboutthespecificmotionofthevertebralcolumnandthebiomechanicsofthepelvicgirdle/SIJduringtheirownstudies…andthistrulydisappointsme.Thisistrueeveninthecaseofqualifiedandexperiencedosteopaths,chiropractors,andphysiotherapists.

These days, if I am honest, I have no idea of the current criteria for what isactuallycoveredintermsofspinalmotioninspecificdegreecoursesrunintheUK.OnethingIknowforsure,however,isthattherecannotbemuchtimespentlearning about this fascinating area during these undergraduate and evenpostgraduatecourses,asotherwisemyownphysicaltherapycourseswouldnotbeasbusyastheyare.

Ithereforenowhaveadilemma:Imustatleastteachaconceptofspinalmotiontomystudents,sothequestionis,doIteachaconceptfromFryettethathasbeenaround for over 100 years and is considered by some to be outdated—eventhoughsomeexpertssayFryette’sviewsshouldnotbeusedanymore?OrdoIteachwhat is believed tobe themost recent findings, as contradictory as theymightbe?

TheansweristhatIofcourseteachFryette’sLaw,asmyownpersonalapproachtothisisthefollowing.Iteachmystudentsoneway,onemethod,andasIhavealready said, I use the conceptofFryette’swayof thinkingabout theway thespinemoves.At least then, I honestlybelieve, after completingmycourse thestudents(includingthemoreexperiencedtherapists)willactuallybeabletogettogripswith, andhopefullyhavea farbetterunderstandingof, the conceptofFryette’slawsandtheunderpinningprinciplesandconceptsofspinalmechanics.

UltimatelyIammorethanhappythatthosetherapistswhohavechosentoattendmycourseswillhaveagood initialgrounding inapplying the lawsofFryette,hopefullywith specific relevance and application to their own private patientsand athletes presenting with back or pelvic pain. Naturally, over time, thingsprogress,especiallyinrelationtocurrentresearchmethodologyandtechnology.Therapistscan themselvesgraduallyevolve their techniques inpracticeas theybecomemoreexperiencedandknowledgeable, so theyshouldbeable toadaptverywelltothoseongoingchanges.

Gracovetsky’s“SpinalEngineTheory”

Serge Gracovetsky (1988) elaborated on a particular idea of spinal motion,whichhediscussedinhisbookTheSpinalEngine.Heconsideredthespinetobethe“primaryengine”intheroleoflocomotionandproposedthatthelegswerenot responsible for gait, but were merely “instruments of expression” andextensionsof the spinalengine.Heargued that the spinewasnota rigid lever

duringthegaitcycleandthatitsabilitytoproduceaxialcompressionandtorsionwasafundamentaldrivingforceduringlocomotion.

InhisdiscussionsGracovetskysaysthatduringheel-strike,kineticenergyisnotdisplacedintotheearthasinthepedestrianmodel,butefficientlytransmittedupthroughthemyofascialsystem,causingthespinetoresonateinthegravitationalfield.Hedidnotviewthespineasacompressive loadingsystem,wherebytheintervertebral discs act as shock absorbers; he regarded the outer annulus discfibers and their accompanying facet joints as dynamic antigravity torsionalspringsthatstoreandunloadtensionalforcestoliftandpropelthebodyinspace.Healsoconsideredthatthenaturalprocessofinterlockingofthefacetjointsandintervertebral discs transmitted virtually all of the available counter-rotationalpelvic torque that is needed to aid the inner and outer core muscles forlocomotion.

AquotefromGracovetsky:

“Thespineisanenginedrivingthepelvis.Humananatomyisaconsequenceoffunction. The knee cannot be tested in isolation, as it is part of the overallfunctionandpurposeofthemusculoskeletalsystem.Thelegtransferstheheel-strikeenergytothespine.Itisamechanicalfilter.Thekneeisacriticalpartofthat filter and improper energy transfer will affect spinal motion. Functionalassessmentofthespineoughttobepartoftheassessmentofkneesurgery.”

Let’s think back to the earlier concept of Lovett: it is this lumbar lateralflexion/rotation coupling that serves as the Gracovetsky spinal engine“drivetrain.”Forexample,leftlaterallumbarflexionwilldriverightrotationofthelumbarspine,andsubsequentlytheSIJandpelvis.

What I would like to do now is return to the discussion of Chapter 4 and inparticularofthegaitcycle,andlookatthisconceptinaslightlydifferentway.Someauthorshaveconsidered that thebicepsfemorismuscleof thehamstringgroup,alongwithitsconnectiontotheposterior(deep)longitudinalsling(Figure6.1),effectivelystartsthespinalengine.Thebicepsfemorishasbeenlikenedtothe pull cord of the spinal engine in view of its action of inducing a “forceclosure”mechanism in theSIJ.This closureof theSIJwillnaturally lead toasubsequenttransmissionofforceupintotheosteo-articular-ligamentoustissuesofthelumbosacralspine;thisforcewilleventuallycontinueintothemusclesofthelumbarerectorspinae.

Figure6.1.Posterior(deep)longitudinalsling.

EMGstudies have demonstrated that the biceps femorismuscle is particularlyactive at the end of the swing phase of gait, through the early loading of thestancephase.Duringthetransitionfromswingtostance,theheelcontactphaseofthegaitcycleeffectivelyclosesthekineticchain,andthebicepsfemoriscannow perform its work in a manner that is commonly called a closed kineticchain.Within the closed chain, the biceps femoris acts on its more proximalattachment within the chain, namely the pelvis. The biceps femoris attachesdirectlytotheischialtuberosityandalsotothesacrotuberousligament,sacrum,iliaccrests, andup through themultifidi and lumbarerector spinae (see figure6.1).

Atheel contact the ipsilateral (same side)hip and contralateral (opposite side)shoulder are in a position of flexion, which effectively preloads the posteriorobliquesling(Figure6.2(a)),specificallytheipsilateralGmaxandcontralaterallatissimus dorsi. This allows extra-spinal propulsion in a “sling-like”manner,with the superficial lamina of the thoracolumbar fascia serving as anintermediary between these kinetically linked muscles as shown by a personrunningbyfigure6.2(b).

Figure6.2.(a)Posteriorobliquesling.

Theforcetransmittedthroughtheosteo-articular-ligamentousstructuresinduces“form closure” of the spinal facet joints and rotation in the lumbar spine;

coupledwithalateralflexionmoment,thespinalengineinitiatesandselectsthegears to drive the pelvis into a forward rotation. The induced lumbar rotationeffectivelystoreselasticenergyinthespinalligamentsandtheannulusfibrosesoftheintervertebraldiscs,anditisthisreturnofenergythatdrivesgait.

In order to return the energy, the spinemust be stabilized from above: this isaccomplished via contralateral arm swing and trunk rotation produced by thecontralateralGmaxand latissimusdorsi involvement.Thecouplingpatternsofthespinehaveevolvedtofacilitatethereturnofthisforce.Thecounter-rotationisconsideredtoberecruiteddirectlyfromthespineandnotfromthelegs.

Figure6.2.(b)Posteriorobliqueslingutilizedwhilstrunning.

SpinalMechanicsExplained

Eachandeverypatient,especiallyfromaspinalmechanicspointofview,shouldbe assessed on the basis that they are unique, especially since some peoplepresent with vertebral anomalies, which may cause abnormal physiologicalmovement.Thefollowinginformationrelatingtospinalphysiologicalmovementisbasedonempiricalexperienceratherthanonscientifictheory;however,it isdependableandusefulinhelpingthebuddingtherapisttounderstandwhattheyshouldexpecttopalpateinthemajorityofpeople.

Bydevelopinggoodhand–eyecoordinationandtactiletissuetensionsense,itiscertainly possible to detect spinal lesions or, inmodern terms, somatic spinaldysfunctions. These dysfunctions can be palpated as abnormal vertebralpositioning; they function either statically or dynamically, while surroundingabnormal soft tissue texture is a common feature. Once the somatic spinaldysfunctions have been identified and appropriately treated, the offendingvertebralsegment(s)canthenbere-evaluatedtodeterminewhetherthetreatmentapproach has been successful. This whole process can be demonstratedclinically, provided that the underpinning knowledge of basic spinalphysiological movement has been studied and put into practice by thepractitioner.

Fryette’sLawsbasically consist of three laws (originallyknownasprinciples)pertainingtospinalpositioning.ThefirsttwolawsweredevelopedbyFryettein1918,andthethirdlawbyC.R.Nelsonin1948.Thelawsaredefinedasasetofguiding principles that can be used by appropriately trained practitioners todiscriminatebetweendysfunctionsthatarepresentwithintheaxialskeleton.

The first two laws only relate to the thoracic and lumbar vertebrae, and themotion available is only considered to be governed by the patterns of forcegeneratedbytheintervertebraldiscs,ligaments,andassociatedmusculature.Onthe other hand, cervical spinemotion,which is not classified as amotion thatfollowsFryettemechanics, ismainlydeterminedbytheorientationofthefacetjoints. We can, however, describe the cervical spine motion as Fryette-likemechanicsbecauseofthesimilarity.

Law1:NeutralMechanics—TypeI

Neutral mechanics relates to standing or sitting in a relaxed upright position,withnormalneutralspinalcurves.Butwhatisneutral?Neutral intheworldofspinalmechanicsisnotdefinedasasinglepoint,butratherasarangeinwhichtheweightofthetrunkisborneonthevertebralbodiesandintervertebraldiscs,andthefacetjointsareinanidlestate.

Fryettewrote:“Neutralisdefinedtomeanthepositionofanyareaofthespineinwhich thefacetsare idling, in thepositionbetweenthebeginningofflexionandthebeginningofextension.”

This basically means that in neutral, the facet joints are neither in a state ofextension (closed) nor in a state of flexion (open)—they are simply idling orrestingbetweenthesetwopositions.

AccordingtoFryette,whenthespineisinaneutralposition,sidebendingtooneside will be accompanied by horizontal rotation to the opposite side: this isreferredtoasTypeIspinalmechanics(Figure6.3).ThisfirstlawisobservedinwhatisknownasaTypeIspinaldysfunction,wheremorethanonevertebraisoutofalignmentandcannotbereturnedtoneutralbyflexionorextensionofthevertebrae. The group of vertebrae in question demonstrates a coupledrelationship: when side bending forces are induced in a group of typicalvertebrae tooneside, theentiregroupwill rotate to theopposite side, inotherwords obeying Type I or Law 1 spinal mechanics. This spinal motion willproduceaconvexitysimilartoaspinalcurvatureknownasascoliosis.

Figure6.3.TypeIspinalmechanics—sidebendingleft,rotationright.

TypeI(neutral)dysfunctionsgenerallyoccuringroupsofvertebrae,forexampleT1–7,andaretypicallyseeninspinalconditionssuchasscoliosis.ThevertebraeofaTypeIdysfunctiontendtocompensateforasingleTypeIIdysfunction,andareusually at thebeginningor the endof thegroupdysfunction, although thedysfunctioncansometimesbelocatedattheapexofthecurvature.

AnotherwayoflookingatTypeIspinalmechanicsisasfollows.Intheneutralpositionforthethoracicandlumbarspines,sidebendingwillcreateaconcavityto the same side as the side bend and a convexity to the side of the rotation(oppositeside).Forexample,sidebendingtotheleftwillcreateaconcavecurve

ontheleftsideofthebodyandaconvexcurveontherightside.

Note:NeutralspinalmechanicsisanaturallyoccuringmotionofthethespinethatisrequiredtopromoteGracovetsky’s spinal engine, due to the side bending and rotation to the opposite side. Any spinaldysfunctionthatarepresentwillreducetheoveralleffciencyofthe‘engine’(spinal).

Law2:Non-NeutralMechanics—TypeII

Fryette states that when the spine is in a position of flexion or extension, byeither standing or sitting while in a forward-or backward-bent position (alsoknownasnon-neutral),sidebendingtoonesidewillbeaccompaniedbyrotationtothesameside:thisisreferredtoasTypeIImechanics(Figure6.4).

Figure6.4.TypeIIspinalmechanics—sidebendingleft,rotationleft.

This second law is observed in Type II spinal dysfunctions, where only onevertebralsegmentisrestrictedinmotion,andbecomesmuchworseinapositionof flexion or extension. As mentioned above, there will be a coupled spinalmotion, with side bending and rotation in the same direction when thisdysfunctionispresent.

Let’slookatthisfromanotherangle.Putsimply,ifthethoracicorlumbarspineis sufficiently forward or backwardbent, the coupledmotions of side bendingandrotationofasinglevertebralunitwilloccurinthesamedirection(i.e.tothesameside).

Type II (non-neutral) spinal dysfunctions are generally thought to occur in asinglevertebralsegment.However,twoTypeIIdysfunctionscanappearnexttoeachotheratthesametime,buttheoccurrenceofmorethantwoisrare.

Law3

AccordingtoNelson(1948),whenmotionisintroducedinoneplane,themotionin theother twoplanes ismodified(reduced).The third lawbasicallysumsupthefirst twolaws: itsimplystatesthatdysfunctioninoneplaneofmotionwillreducethemotioninallotherplanes.Forexample,ifrotationisrestricted,thensidebendingandflexion/extensionwillalsoberestricted.

ViewingPerspective

Whenassessingforspinalmovement,thespineisusuallyviewedfrombehind.Generally speaking, a spinal dysfunction exists when we try to place thepatient’sspineinaneutralposition,butthispositionofsymmetrycannottobeachieved;thelikelyreasonforthisisadysfunctionofeitheragroupofvertebraeorasinglespinalsegment.

It is possible to detect an abnormalROMof the spinewhen patients performflexion,extension,sidebending,androtationinthecardinalplanes;oneshouldbeabletoseeifthereisarestrictedROM.

Thefollowingsectionsdetailthespecificspinalmechanicmotionforeachoftheareasofthevertebralcolumn.Ihavealreadyexplainedthetermneutral(i.e.thefacetjointsareidlingbetweenflexionandextension),sothispositionistermed

neutralmechanics.Bycontrast,thetermnon-neutralmechanicsgenerallyrefersto either a spinal position of forward bending (flexion) or a spinal position ofbackwardbending(extension).

1.LumbarSpine

NeutralMechanics:TypeI

Whensidebendingtooneside,thevertebralbodiesrotatetotheoppositeside.

Non-NeutralMechanics:TypeII

Whensidebendingtooneside,thevertebralbodiesrotatetothesameside.

ExceptionstotheRule:5thLumbarVertebra(L5)

In neutral mechanics, during side bending to one side the 5th lumbar vertebra(L5)mayrotatetoeithertheoppositesideorthesameside(obeyingnon-neutralmechanics, even though the spine is in a relatively neutral position)wheneverthereissomeasymmetry/dysfunctionofthesacralbaseoriftherearefacetjointanomaliespresent.

2.ThoracicSpine

NeutralMechanics—TypeI

Whensidebendingtooneside,thevertebralbodiesrotatetotheoppositeside.

Non-NeutralMechanics—TypeII

Whensidebendingtooneside,thevertebralbodiesrotatetothesameside.

3.CervicalSpine

Asmentionedearlier, spinalmotion in thecervical spine ismainlydeterminedby the orientation of the facet joints and does not come within the realm ofFryette’s laws; however,we can say thesemechanics areFryette-like, becausethemotionissimilar.

OccipitoatlantalJoint

The occipitoatlantal joint (OAJ) connects the occipital bone to the atlas andalwaysfollowsTypeI(like)mechanics:insidebendingtooneside,theocciputrotatestotheoppositeside,independentofwhethertheocciputisinaneutraloranon-neutralposition(flexionorextension).

AtlantoaxialJointC1/C2

Theatlantoaxialjoint(AAJ),whichliesbetweentheatlasandtheaxis,ismainlyconsidered to only rotate. There has been some discussion suggesting that, ineither neutral or non-neutral mechanics, during side bending movements theatlas (C1) is capableof rotating toeither side.Dysfunctions typically foundatthislevelarethoughttoconsistmainlyofarotationalcomponent.

ThelevelofC2–C6inthecervicalspineisbelievedtoonlyfollowTypeII(like)mechanics,inthatsidebendingandtherotationarealwayscoupledtothesameside, regardlessofwhether thecervical spine is inaneutralpositionoranon-neutralposition(flexionorextension).

C2–C6:NeutralMechanics

Whensidebendingtooneside,thevertebralbodiesrotatetothesameside,i.e.TypeII-likemechanics.

C2–C6:Non-NeutralMechanics

Whensidebendingtooneside,thevertebralbodiesrotatetothesameside,i.e.TypeII-likemechanics.

C7hasfacetjointsthatareorientatedinasimilarwaytothethoracicspine,sothisspinallevelwillfollowtheclassiclawofFryette.

SpinalMechanics:Definitions

Thespecificpositionofavertebracanbereferredtointwodifferentways:

1.Thepositionofthevertebra,relativetothevertebrabelow.

2. The direction of the motion restriction of the vertebra, relative to thevertebrabelow.

Inotherwords,thesamevertebralsegmentcanbedescribedfromtwodifferentpointsofview.

For example, let’s say T4 (4th vertebra of the thoracic spine) is fixed in anextended,side-bentright,androtated-rightposition.ThissimplymeansthattheT4 is fixed in a position of extension, side bend, and rotation, all to the rightside,ontopofthevertebraimmediatelybelow,i.e.T5.ThisisbecausetherightT4 inferior facet is fixed inaclosedpositionon thesuperior facetonT5.Themotionrestrictionhastobeinforwardflexionaswellasinleftsidebendingandleftrotation(oppositetothefixedposition).ThistypeofdysfunctionobeysTypeIImechanics,asalreadyexplainedearlier;however,takingitastagefurther,wewouldnowclassifythespinaldysfunctionasaT4extension,rotation,sidebendright,orT4ERS(R),whichwillbediscussedshortly.

In terms of diagnosing somatic spinal dysfunction, the positional diagnosis isdetermined and named according to the direction of the vertebra that has theeasiestmotion.Let’stakealookatwhatImeanbythatinmoredetail.

Spinal dysfunction is typically described as either extended or flexed, with arotation and a side bending component to the same side, or possibly to theoppositeside,asyouwillreadlater.

Before we define the terminology for spinal dysfunctions, we first need toconfirmthepresenceofaspinaldysfunctionbyascertainingthespecificpositionandmotion of the vertebra being tested.We can establish this by asking ourpatient to adopt three different positions of the vertebral column: neutral,extension,andflexion.Thevertebralpositionthroughpalpationsimplybecomeseither symmetrical (level) or asymmetrical (not level) in these three positions,dependingonthetypeofspinaldysfunction/facetrestrictionpresentatthetime.

Iftherearenofacetrestrictionspresent,whenyouforwardbendyourspine,theleft and right facet joints (top vertebra in relation to the bottomvertebra)willslideforwardinasuperiorandanteriordirectiontoopen;conversely,whenyoubackwardbendyourspine,theleftandrightfacetjointswillslidebackwardinan inferiorandposteriordirection toclose.However, if the facet jointsare for

somereasonrestrictedineitheraflexionoranextensionposition,therestrictedjointwillnowactasapivotpoint,especiallywhenperformingthespinalmotionofforwardandbackwardbending.

Toillustratethis,askyourpatienttoadoptaneutralposition(normallyasittingposition,forthethoracicspine)andlightlyplaceyourleftandrightthumbsontheT4/5transverseprocess(TP).Lightlypalpateforafewsecondsandcomparethe left and right TPs to see if there is any asymmetry; if so, you have nowidentifiedthepresenceofaspinaldysfunction—inaverysimpleway,youhavelocatedafacetrestriction.Forinstance, if theleft thumb,whileincontactwiththeleftTP,appearedtopalpateshallow(i.e.theTPfeelsclosertothesurfaceoftheskin),whereastherightthumb(ontherightTP)palpateddeep(i.e.thethumbtraveled further to reach the right TP), this would be indicative of the T4vertebra (superior) having rotated to the left side on theT5 vertebra (inferior)below,asshowninFigure6.5(c).

Whatthisdoesnottellyou,however,iswhethertheleftfacetjointisfixedinaclosedpositionorwhethertherightfacetjointisfixedinanopenposition.Thatis why it is necessary to palpate the TPs in the position of spinal extension(backwardbending)andspinalflexion(forwardbending)inordertoconfirmordiscountthepresenceofafixedclosedfacetjointorafixedopenfacetjoint.

Let’strytolookatthisconceptinarelativelysimpleway(Ihope)byusingthethoracicT4/5asanexample.Asalreadydiscussedabove,weshouldnowknowthatwhenthepatientis inaneutralposition, theT4vertebrahasrotatedtotheleftside,becausetheleftTPpalpatedasshallow(moreprominent)andtherightTPpalpatedasdeep(lessprominent).Fromtheneutralposition,wenowaskourpatienttoforwardbend,whilethethumbsarestillincontactwiththeTPs;younotice the left and right TPs in the forward-bent position become moreasymmetrical(theTPononesidebecomesmoreprominent,andtheTPontheotherlessprominent).

Imagine just for a moment that you consider the left thumb to feel moreprominent (think of it as a bump) and now the right thumb feels even deeper(less prominent); this must mean that the left facet joint is fixed in a closedposition on the left side, as shown in Figure 6.5(i). Why? When the patientforwardbends,therightfacetjointisfreetoglideanteriorlyasnormal,buttheleft facet joint is now fixed posteriorly; because the left facet cannot opennormally during forward bending, the left facet joint that is fixed in a closed

position becomes a pivot point. Because of this pivot, one could say that therightfacetbasicallyhastoopenevenmoreduringforwardbending,butendsuprotatingaroundtheleftfixedfacetjointthatcannotopen;thisiswhytheleftandright thumbs appear even more asymmetric. In this case the left thumb hasbecome more prominent (the bump increases because the left TP is fixedposteriorly)intheforward-bentposition.

Whenyouaskthepatienttoadoptapositionofextension,thethumbswillnowpalpatelevel(symmetric),becausetheleftfacetjointisalreadyfixedposteriorlyinaclosedposition,andtherightfacetjointsimplycontinuesitsnaturalmotionof closing. The left and right thumb positions on the TPs therefore becomesymmetric(level)inextension(thebumpontheleftTPdisappears),asshowninFigure6.5(f).

Considernowanothertypeofdysfunction—thecasewheretherightfacetjointis fixed inanopenposition.Whenwepalpate theT4/5TP inneutral,wewillstill notice the left thumb is shallow (bump) and the right thumb is deeper,indicatingaleftrotation,asshowninFigure6.9(c).However,whenthepatientforwardbends their spine, the thumbsnowbecomesymmetric (i.e. the thumbsarenowlevelandthebumpdisappears),asshowninFigure6.9(i).Bycontrast,whenthepatientbackwardbendstheirspine,younoticethatthethumbsbecomeasymmetric(i.e.symmetryislostinextension—thebumpfeltbytheleftthumbontheTPincreases),asshowninFigure6.9(f).Thistimetheleftthumbactuallyappearsmoreprominent (bumppresent), and the right thumbappears to traveldeeperinthebackward-bentposition.Why?Inaforward-bentposition,bothofthefacetjointsareabletoopenasnormal,hencethethumbsbecominglevelinthis position; however, in a backward-bent position of extension, because theright facet is fixed in an open position (even though it has rotated to the leftside), the facet joint cannot close on the right side, but the fixed pivot pointcreated by the right open facets keeps the right TP fixed anteriorly. Since thebackwardbendingmotioncausestheleftsidetomovemoreposteriorly,theleftTP appears to move further into left rotation. The thumbs therefore appearasymmetricandnow, in thebackward-bentposition, the left thumbon the leftTPbecomesmoreprominent(bumpappears)thantherightthumb.

Note: The above dysfunction relates to the right facet joint fixed in an open position. This is called anFRS(L)asyouwillreadshortly.

Onewayofrememberingthesetwoprocesses,asitwillhelpyouwithyourownpatients,istounderstandthefollowingtworules:

Rule1:Inforwardbending,iftheprominentTPbecomesevenmoreprominent(bumpappears),thenthatsideisfixedclosed.

Rule 2: In backward bending, if the prominent TP becomes more prominent(bumpappears),thentheoppositesideisfixedopen.

Maitland (2001) offers another explanation, which might help you betterunderstandwhat I am trying to say. First, you determine rotation in a neutralposition.Then,keepingyourthumbsontheTPsoftherotatedvertebra,forwardand backward bend your client, and feel andwatchwhat happens under yourthumbs. Look for the position where the bump (the posterior or prominentvertebraTPof the rotatedvertebra)disappears.Maitlandsays that thepositionwhere the bump disappears (or vertebral derotation appears to occur) is thepositioninwhichthefacetsarerestricted:

“Ifthebumpdisappearsinforwardbending,thefacetsarefixedintheforward-bentposition,whichmeansthefacetsarefixedopen(flexionfixed).”

“If thebumpdisappears inbackbending, the facets are fixed in thebackbentposition,whichmeansthefacetsarefixedclosed(extensionfixed).”

Wewill now look at someof the typical terminology that practitioners use intheirclinics,alongwithafewcommonexamplesofspinaldysfunctionalpatternsthat patientsmight presentwith in your own clinic.Hopefully, onceyouhaveread all the information in this chapter, and practiced all the necessary spinalpositionsinordertoconfirmordiscountthepresenceofeitherafixedfacetoranopen facet,we can look at some formof treatment strategy, especially for thelumbar spine (discussed inChapter 13). Specific treatment for the area of thethoracic spine, however, is not covered in this text, even though I have givensomeexamplesof theassessmentprocess.Nevertheless,oneshouldbeable tomodifythetreatmenttechniquesshownforthelumbarspineinChapter13andadapt/applythemtodysfunctionsinthethoracicspine.

Definition: An extension, rotation, side bending (ERS) dysfunctioninvolvesafacetjoint(inferiorandsuperiorcomponent)whichisfixedin a closedposition. It is classified as anon-neutral (Type II) spinalmechanicsdysfunction.

Extension,Rotation,SideBendingLeft—ERS(L)

Extension,Rotation,SideBendingLeft—ERS(L)

Thisisasituationinwhichtheleftfacetjointisfixedinaclosedposition.

ERS(L) refers to the orientation of an uppermost vertebra that is fixed in anextended, side-bent, and rotated position to the left side, as shown in Figure6.5(a).

Figure6.5.(a)Extension,rotation,sidebendingleft—ERS(L).

Two exampleswill be considered: in the first, the 4th thoracic vertebra (T4) isassumed to be fixed in a closed position on the left side on the 5th thoracicvertebra(T5);inthesecond,the5thlumbarvertebra(L5)isassumedtobefixedinaclosedpositionontheleftsideonthe1stsacralvertebra(S1).Wewillnowtest the levelsofT4/5andL5/S1 in the threepositionsofneutral, flexion,andextension.

NeutralPosition

With the patient in a neutral position, place your thumbs approximately 1”(2.5cm) lateral to the T4 andT5 spinous processes, so that the thumbs are ingentlecontactwiththeleftandrightTPs(repeatthesameprocesswhenyouarereadytodotheL5/S1vertebrae).IfthereisanERS(L)present,youwillnoticethattheleftthumbappearstobemoreprominent(shallow)andtherightthumbappearstobedeeperintheneutralposition(seeFigure6.5(b–d)),indicatingthatthevertebrahasrotatedtotheleftside.

Figure6.5.(b)Neutralposition—theleftthumbappearsshallowandtherightthumbappearsdeeper,indicatingaleftrotationofthevertebra.(c)ThoracicspineT4/5.(d)LumbarspineL5/S1.

ExtensionPosition

Asthepatientbackwardbends,observetherelativelevelsofyourthumbs.Youwillnoticethattheleftandrightthumbsarelevel,asshowninFigure6.5(e–g).

Figure6.5.(e)Extensionposition—theleftandrightthumbsnowappeartobecomelevel.(f)ThoracicspineT4/5.(g)LumbarspineL5/S1.

FlexionPosition

Nextlookattherelativepositionsofyourthumbsasthepatientforwardbends.Thistimeyouwillnoticethattheleftthumbappearstobecomemoreprominent(bumpappears)and that the right thumbappears to traveldeeper,as shown inFigure 6.5(h–j). This asymmetric positioning of the thumbs indicates a fixedclosedfacetjointontheleftside.

Figure6.5.(h)Flexionposition—theleftthumbappearsmoreprominentandtherightthumbappearsdeep,indicatingafixedclosedvertebraontheleftside.(i)ThoracicspineT4/5.(j)LumbarspineL5/S1.

Figure6.6.ThumbpositionsforERS(L).

Extension,Rotation,SideBendingRight—ERS(R)

Thisisasituationinwhichtherightfacetjointisfixedinaclosedposition.

ERS(R) refers to the orientation of an uppermost vertebra that is fixed in anextended, side-bent, and rotated position to the right side, as shown in Figure6.7(a).

Figure6.7.(a)Extension,rotation,sidebendingright—ERS(R).

Two exampleswill be considered: in the first,T4 is assumed to be fixed in aclosedpositionontherightsideonT5;inthesecond,L5isassumedtobefixedinaclosedpositionontherightsideonS1.WewillnowtestthelevelsofT4/5andL5/S1inthethreepositionsofneutral,flexion,andextension.

NeutralPosition

With the patient in a neutral position, place your thumbs approximately 1”(2.5cm) lateral to the T4 andT5 spinous processes, so that the thumbs are ingentlecontactwiththeleftandrightTPs(repeatthesameprocesswhenyouareready todo theL5/S1vertebra). If there isanERS(R)present,youwillnoticethat the right thumb appears to be shallow and the left thumb appears to bedeeperintheneutralposition(seeFigure6.7(b–d)),indicatingarightrotationofthevertebra.

Figure6.7.(b)Neutralposition—therightthumbappearsmoreprominentandtheleftthumbappearsdeeper,indicatingarightrotationofthevertebra.(c)ThoracicspineT4/5.(d)LumbarspineL5/S1.

ExtensionPosition

Asthepatientbackwardbends,observetherelativelevelsofyourthumbs.Youwillnoticethattheleftandrightthumbsarelevel,asshowninFigure6.7(e–g).

Figure6.7.(e)Extensionposition—theleftandrightthumbsnowappeartobecomelevel.(f)ThoracicspineT4/5.(g)LumbarspineL5/S1.

FlexionPosition

Nextlookattherelativelevelofyourthumbsasthepatientforwardbends.Youwill notice that the right thumb appears to become more prominent (bumpappears)andtheleftthumbappearstotraveldeeper,asshowninFigure6.7(h–j).Thisasymmetricpositioningofthethumbsindicatesafixedclosedfacetjointontherightside.

Figure6.7.(h)Flexionposition—therightthumbappearsmoreprominentandtheleftthumbappearsdeeper,indicatingafixedclosedvertebraontherightside.(i)ThoracicspineT4/5.(j)LumbarspineL5/S1.

Figure6.8.ThumbpositionsforERS(R).

Definition: A flexion, rotation, side bending (FRS) dysfunctioninvolvesafacetjointwhichisfixedinanopenposition.Itisclassifiedasanon-neutral(TypeII)spinalmechanicsdysfunction.

Flexion,Rotation,SideBendingLeft—FRS(L)

Thisisasituationinwhichtherightfacetjointisfixedinanopenposition.

Note that, although the dysfunction is to the right facet,FRS(L) refers to theorientation of an uppermost vertebra that is fixed in a flexed, side-bent, androtated position to the left side. It is the right facet, however, that isdysfunctional,becauseitisfixedinanopenposition,asshowninFigure6.9(a).

Figure6.9.(a)Flexion,rotation,sidebendingleft—FRS(L).

WewillnowtestthelevelsofT4/5andL5/S1inthethreepositionsofneutral,flexion,andextension.

NeutralPosition

With the patient in a neutral position, place your thumbs approximately 1”(2.5cm) lateral to the T4 andT5 spinous processes, so that the thumbs are ingentlecontactwiththeleftandrightTPs(repeatthesameprocesswhenyouareready todo theL5/S1vertebra). If there isanFRS(L)present,youwillnoticethattheleftthumbappearstobemoreprominentandtherightthumbappearstobe deeper in the neutral position (see Figure 6.9(b–d)), indicating that thevertebrahasrotatedtotheleftside.

Figure6.9.(b)Neutralposition—theleftthumbappearsshallowandtherightthumbappearsdeeper,indicatingaleftrotationofthevertebra.(c)ThoracicspineT4/5.(d)LumbarspineL5/S1.

ExtensionPosition

As the patient backward bends, observe the relative position of your thumbs.Youwill notice that the left thumbappears tobecomemoreprominent (bumpappears)andtherightthumbappearstotraveldeeper,asshowninFigure6.9(e–g).Thisasymmetricpositioningofthethumbsindicatesafixedopenfacetjointontherightside(sideoppositetorotation).

Figure6.9.(e)Extensionposition—theleftthumbappearsmoreprominentandtherightthumbappearsdeeper,indicatingafixedopenfacetjointontherightside.(f)ThoracicspineT4/5.(g)LumbarspineL5/S1.

FlexionPosition

Next lookat therelativepositionofyour thumbsas thepatientforwardbends.Youwillnoticethattheleftandrightthumbsarenowlevel,asshowninFigure6.9(h–j).

Figure6.9.(h)Flexionposition—theleftandrightthumbsnowappeartobecomelevel.(i)ThoracicspineT4/5.(j)LumbarspineL5/S1.

Figure6.10.ThumbpositionsforFRS(L).

Flexion,Rotation,SideBendingRight—FRS(R)

Thisisasituationinwhichtheleftfacetjointisfixedinanopenposition.

Note that, although the dysfunction is to the left facet, FRS(R) refers to theorientation of an uppermost vertebra that is fixed in a flexed, side-bent, androtated position to the right side. It is the left facet, however, that isdysfunctional,becauseitisfixedinanopenposition,asshowninFigure6.11(a).

Figure6.11.(a)Flexion,rotation,sidebendingright—FRS(R).

WewillnowtestthelevelsofT4/5andL5/S1inthethreepositionsofneutral,flexion,andextension.

NeutralPosition

With the patient in a neutral position, place your thumbs approximately 1”(2.5cm) lateral to the T4 andT5 spinous processes, so that the thumbs are ingentlecontactwiththeleftandrightTPs(repeatthesameprocesswhenyouareready todo theL5/S1vertebra). If there isanFRS(R)present,youwillnoticethat the left thumb appears to be shallow and the right thumb appears to bedeeperintheneutralposition(seeFigure6.11(b–d)),indicatingthatthevertebrahasrotatedtotheleftside.

Figure6.11.(b)Neutralposition—therightthumbappearsshallowandtheleftthumbappearsdeeper,indicatingarightrotationofthevertebra.(c)ThoracicspineT4/5.(d)LumbarspineL5/S1.

ExtensionPosition

As the patient backward bends, observe the relative position of your thumbs.Youwillnoticethattherightthumbappearstobecomemoreprominent(bumpappears)andtheleftthumbappearstotraveldeeper,asshowninFigure6.11(e–g).Thisasymmetricpositioningofthethumbsindicatesafixedopenfacetjointontheleftside(sideoppositetorotation).

Figure6.11.(e)Extensionposition—therightthumbappearsmoreprominentandtheleftthumbappearsdeeper,indicatingafixedopenfacetjointontheleftside.(f)ThoracicspineT4/5.(g)LumbarspineL5/S1.

FlexionPosition

Next lookat therelativepositionofyour thumbsas thepatientforwardbends.Youwillnoticethattheleftandrightthumbsarenowlevel,asshowninFigure6.11(h–j).

Figure6.11.(h)Flexionposition—theleftandrightthumbsnowappeartobecomelevel.(i)ThoracicspineT4/5.(j)LumbarspineL5/S1.

Figure6.12.ThumbpositionsforFRS(R).

Definition: A neutral mechanics (Type I) dysfunction of a group ofvertebrae(NR) typicallyinvolvesagroupofthreeormorevertebrae,andthesidebendingisconsideredtobetheprimarymotionrestriction,with a secondary rotational component. As explained earlier, thisdysfunctionproducesaconcavityonthesamesideasthesidebending,andaconvexityonthesideoftherotation.Thistypeofdysfunctionisconsidered to be a compensatory group dysfunction as a result of aprimarydysfunction; theprimarydysfunctionsareusuallyanFRSorERS.Thevertebraeinquestionsidebendtoonesideandrotatetotheoppositeside.

GroupNeutralDysfunction,RotationLeft—NR(L)

This isasituation involvingat least threevertebrae,whicharesidebent to therightandrotatedtotheleft.

Therotationtotheleftismaintainedthroughouttherangeofbackwardbending,neutral,andforwardbending,asshowninFigure6.13.TheamountofrotationmayvaryalittlethroughoutthisROM,andwillmostlikelybemaximalintheneutralposition.

Figure6.13.Neutraldysfunction—sidebendingright,rotationleft—NR(L).

GroupNeutralDysfunction,RotationRight—NR(R)

GroupNeutralDysfunction,RotationRight—NR(R)

This isasituation involvingat least threevertebrae,whicharesidebent to theleftandrotatedtotheright.

The rotation to the right is maintained throughout the range of backwardbending,neutral,andforwardbending,asshowninFigure6.14.TheamountofrotationmayvaryalittlethroughoutthisROM,andwillmostlikelybemaximalintheneutralposition.

Figure6.14.Neutraldysfunction—sidebendingleft,rotationright—NRR

7MuscleEnergyTechniquesandTheirRelationshiptothePelvis

In later chapters youwill read and learn about specific techniques that canbeincorporated into a treatment plan to help correct pelvic and lumbar spinedysfunctions.IconsiderthetechniquesIwillbedemonstratinginthischaptertobe someof thebest soft tissue techniques that one canuse to correct any softtissueorspinaljointanomalies.Youmighthavealreadyguessedwhattheseare—muscleenergytechniques(METs).

Since I discuss in this bookhow to treat specificdysfunctions associatedwiththeSIJ,pelvis,andlumbarspine,IneedtoexplaintheroleofMETs,sothatyouhaveabetterunderstandingofwhenandwhytoemploythistypeofsofttissuetreatment.PhysicaltherapistshavewhatIcallatoolboxofvarioustechniquesattheir disposal, to help release and relax muscles, which will then assist thepatient’s body to promote the healing mechanisms. METs, first described byFredMitchell in 1948, are one such tool, which if used correctly can have amajor influence on a patient’s well-being. (The reader is referred to Gibbons(2011)forafulleraccountofMETs.)

Definition: Muscle energy techniques (METs) are a form ofosteopathic manipulative diagnosis and treatment in which thepatient’s muscles are actively used on request, from a preciselycontrolled position, in a specific direction, and against a distantlyappliedcounterforce.

METsareuniqueintheirapplication,inthatthepatientprovidestheinitialeffortand the practitioner just facilitates the process.The primary force comes fromthecontractionof thepatient’s soft tissues (muscles),which is thenutilized toassist and correct the presenting musculoskeletal dysfunction. This treatmentmethod is generally classified as a direct form of technique as opposed toindirect, since the use of muscular effort is from a controlled position, in a

specific direction, and against a distant counterforce that is usually applied bythepractitioner.

SomeoftheBenefitsofMETs

When teaching the concept of METs to my students, one of the benefits Iemphasize is their use in normalizing joint range, rather than in improvingflexibility. This might sound counterintuitive; what I am saying is if, forexample,yourpatientcannotrotatetheirneck(cervicalspine)totherightasfaras they can to the left, they have a restriction of the cervical spine in rightrotation.Thenormalrotationalrangeofthecervicalspineis80degrees,butlet’ssaythepatientcanonlyrotate70degreestotheright.ThisiswhereMETscomein.AfteranMEThasbeenemployedonthetightrestrictivemuscles,hopefullythecervicalspinewillthenbecapableofrotatingto80degrees—thepatienthasmadealltheeffortandyou,thepractitioner,haveencouragedthecervicalspineintofurtherrightrotation.Youhavenowimprovedthejointrangeto“normal.”This isnot stretching in the strictest sense—even though theoverall flexibilityhasbeenimproved,itisonlytothepointofachievingwhatisconsideredtobeanormaljointrange.

DependingonthecontextandthetypeofMETemployed,theobjectivesofthistreatmentcaninclude:

•Restoringnormaltoneinhypertonicmuscles

•Strengtheningweakmuscles

•Preparingmusclesforsubsequentstretching

•Increasingjointmobility

RestoringNormalToneinHypertonicMuscles

ThroughthesimpleprocessofMETs,weasphysicaltherapiststrytoachievearelaxation in thehypertonic shortenedmuscles. Ifwe thinkof a joint asbeinglimited in its ROM, then through the initial identification of the hypertonicstructures, we can employ the techniques to help achieve normality in thetissues.Certaintypesofmassagetherapycanalsohelpusachievethisrelaxation

effect,andgenerallyanMETisappliedinconjunctionwithmassagetherapy.Ipersonally feel that massage with motion is one of the best tools a physicaltherapistcanuse.

StrengtheningWeakMuscles

METscanbeusedinthestrengtheningofweakorevenflaccidmuscles,asthepatient is asked to contract themuscles prior to the lengthening process. ThetherapistshouldbeabletomodifytheMETbyaskingthepatienttocontractthemuscle that has been classified as weak, against a resistance applied by thetherapist (isometric contraction), the timing of which can be varied. Forexample, thepatient canbeasked to resist themovementusingapproximately20–30%oftheirmaximumcapabilityfor5–15seconds.Theyarethenaskedtorepeat the process five to eight times, resting for 10–15 seconds betweenrepetitions.Thepatient’sperformancecanbenotedandimprovedovertime.

PreparingMusclesforSubsequentStretching

In certain circumstances, what sport your patient participates in will bedeterminedbywhatROMtheyhaveattheirjoints.Everybodycanimprovetheirflexibility, and METs can be used to help achieve this goal. Remember, thefocusofMETsistotrytoimprovethenormalROMofajoint.

Ifyouwanttoimprovethepatient’sflexibilitypastthepointofnormal,amoreaggressive MET approach might be necessary. This could be in the form ofasking the patient to contract a bit harder than the standard 10–20% of themuscle’scapability.Forexample,wecanaskthepatienttocontractusing,say,40–70% of the muscle’s capability. This increased contraction will helpstimulatemoremotorunitstofire,inturncausinganincreasedstimulationoftheGolgitendonorgan(GTO).Thiswillthenhavetheeffectofrelaxingmoreofthemuscle,allowingittobelengthenedevenfurther.Eitherway,onceanMEThasbeenincorporatedintothetreatmentplan,aflexibilityprogramcanfollow.

IncreasingJointMobility

OneofmyfavoritesayingswhenIteachmuscle-testingcoursesis:

“Astiffjointcancauseatightmuscle,andatightmusclecancauseastiffjoint.”

Doesthisnotmakeperfectsense?WhenyouuseanMETcorrectly,itisoneofthebestwaystoimprovethemobilityofthejoint,eventhoughyouareinitiallyrelaxingthemuscles.ThisisespeciallythecasewiththeuseofMETstocorrectanydysfunctionsthatyoufindinthepelvis,whichiscoveredinChapter13.ThefocusoftheMETistogetthepatienttocontractthemuscles;thissubsequentlycausesa relaxationperiod,allowingagreaterROMtobeachievedwithin thatspecificjoint.

PhysiologicalEffectsofMETs

TherearetwomaineffectsofMETsandtheseareexplainedonthebasisoftwodistinctphysiologicalprocesses:

•Post-isometricrelaxation(PIR)

•Reciprocalinhibition(RI)

WhenweuseMETs, certain neurological influences occur.Beforewe discussthe main process of PIR/RI, we need to consider the two types of receptorinvolvedinthestretchreflex:

•Musclespindles,whicharesensitivetochange,aswellasspeedofchange,inlengthofmusclefibers

•GTOs,whichdetectprolongedchangeintension

Stretching themuscle causes an increase in the impulses transmitted from themusclespindle to theposteriorhorncell (PHC)of thespinalcord. In turn, theanteriorhorncell(AHC)transmitsanincreaseinmotorimpulsestothemusclefibers, creating a protective tension to resist the stretch. However, increasedtensionafterafewsecondsissensedwithintheGTOs,whichtransmitimpulsesto the PHC. These impulses have an inhibitory effect on the increasedmotorstimulusattheAHC;thisinhibitoryeffectcausesareductioninmotorimpulsesandconsequentrelaxation.Thisimpliesthattheprolongedstretchofthemuscleswill increase the stretching capability, because the protective relaxation of theGTOs overrides the protective contraction due to the muscle spindles. A faststretch of the muscle spindles, however, will cause immediate muscle

contraction, and since it is not sustained, there will be no inhibitory action(Figure7.1).Thisisknownasthebasicreflexarc.

Figure7.1.Thestretchreflexarc.Aquick“stretchbyhand”toactivatethemusclespindles.

PIRresultsfromaneurologicalfeedbackthroughthespinalcordtothemuscleitselfwhenanisometriccontractionissustained,causingareductionintoneofthemusclewhichhasbeencontracted(Figure7.2).Thisreductionintonelastsfor approximately 20–25 seconds, so you now have a perfect window ofopportunitytoimprovetheROM,asduringthisrelaxationperiodthetissuescanbemoreeasilymovedtoanewrestinglength.

When RI is employed, the reduction in tone relies on the physiologicalinhibitingeffectofantagonistsonthecontractionofamuscle(Figure7.2).Whenthemotorneuronsofthecontractingagonistmusclereceiveexcitatoryimpulsesfromtheafferentpathway,themotorneuronsoftheopposingantagonistmusclereceive inhibitory impulses at the same time, which prevent it contracting. Itfollows that contraction or extended stretch of the agonist muscle must elicitrelaxation or inhibit the antagonist; however, a fast stretch of the agonistwillfacilitateacontractionoftheagonist.

Figure7.2.Post-isometricrelaxation(PIR)andreciprocalinhibition(RI).

Inmost applications ofMETs, the point of bind, or just short of the point of

bind,isthepreferredpositioninwhichtoperformanMET.Clearly,anMETisafairly mild form of stretching compared with other techniques, so one canassume its use is therefore more appropriate in the rehabilitation process. Itshouldbeborneinmindthatmostproblemswithmuscleshorteningwilloccurinposturalmuscles.Sincethesemusclesarecomposedpredominantlyofslow-twitchfibers,amilderformofstretchingisperhapsmoreappropriate.

METProcedure

•Thepatient’slimbistakentothepointwhereresistanceisfelt,i.e.thepointofbind.Itcanbemorecomfortableforthepatientifyoueaseofftoapointslightlyshortofthepointofbindintheaffectedareathatyouaregoingtotreat,especiallyifthesetissuesareinthechronicstage.

•Thepatientisaskedtoisometricallycontractthemuscletobetreated(PIR)or the antagonist (RI), using approximately 10–20% of the muscle’sstrengthcapabilityagainstaresistancethatisappliedbythetherapist.Thepatient shouldbeusing theagonist if themethodofapproach isPIR; thiswill release the tight, shortened structures directly. (See the PIR examplebelow.)

• If the RI method of MET is used, the patient is asked to contract theantagonistisometrically;thiswillinducearelaxationeffectintheoppositemuscle group (agonist), which would still be classified as the tight andshortenedstructures.(SeetheRIexamplebelow.)

• The patient is asked to slowly introduce an isometric contraction, lastingbetween10and12seconds,avoidinganyjerkingof thetreatedarea.Thiscontraction, as explained above, is the time necessary to load theGTOs,whichallows them tobecomeactiveand to influence the intrafusal fibersfrom themuscle spindles. This has the effect of overriding the influencefrom themuscle spindles, which inhibitsmuscle tone. The therapist thenhastheopportunitytotaketheaffectedareatoanewpositionwithminimaleffort.

• The contraction by the patient should cause no discomfort or strain. Thepatientistoldtorelaxfullybytakingadeepbreathin,andastheybreatheout, the therapist passively takes the specific joint that lengthens the

hypertonic muscle to a new position, which therefore normalizes jointrange.

•After an isometric contraction,which induces aPIR, there is a relaxationperiodof15–30seconds; thisperiodcanbetheperfect timetostretchthetissuestotheirnewrestinglength.

•Repeatthisprocessuntilnofurtherprogressismade(normallythreetofourtimes)andholdthefinalrestingpositionforapproximately25–30seconds.

• A period of 25–30 seconds is considered to be enough time for theneurologicalsystemtolockontothisnewrestingposition.

•Thistypeoftechniqueisexcellentforrelaxingandreleasingtoneintight,shortenedsofttissues.

A refractoryperiod (thebriefperiodneeded to restore the restingpotential)ofabout 20 seconds occurswith RI; however, RI is thought to be less powerfulthanPIR.Therapistsneedtobeabletousebothapproaches,becausetheuseoftheagonistmaysometimesbe inappropriateowing topainor injury.Since theamount of force used with an MET is minimal, the risk of injury or tissuedamagewillbereduced.

METMethodofApplication

“PointofBind”(or“RestrictionBarrier”)

Inthischaptertheword“bind”ismentionedmanytimes.Thepointofbind,orrestriction barrier, occurs when resistance is first felt by the palpatinghand/fingers of the therapist. Through experience and continual practice, thetherapistwill be able to palpate a resistance of the soft tissues as the affectedarea is gently taken into the position of bind. This position of bind isnot theposition of stretch—it is the position just before the point of stretch. Thetherapistshouldbeabletofeelthedifferenceandnotwaitforthepatienttosaywhentheyfeelastretchhasoccurred.

AcuteandChronicConditions

ThesofttissueconditionsthataretreatedusingMETsaregenerallyclassifiedaseitheracute or chronic, and this tends to relate to tissues that have had someform of strain or trauma. METs can be used for both acute and chronicconditions. Acute involves anything that is obviously acute in terms ofsymptoms, pain, or spasm, as well as anything that has emerged during thepreviousthreetofourweeks.AnythingolderandofalessobviouslyacutenatureisregardedaschronicindeterminingwhichvariationofMETissuitable.

Ifyoufeelthepresentingconditionisrelativelyacute(occurringwithinthelastthreeweeks), the isometric contraction can be performed at the point of bind.After thepatienthascontracted themuscle isometricallyfor thedurationof10seconds,thetherapistthentakestheaffectedareatothenewpointofbind.

In chronic conditions (persisting for more than three weeks), the isometriccontractionstartsfromapositionjustbeforethepointofbind.Afterthepatienthas contracted themuscle for 10 seconds, the therapist then goes through thepointofbindandencouragesthespecificareaintothenewposition.

PIRversusRI

Howmuchpainthepatientispresentingwithisgenerallythedecidingfactorindetermining which method to initially apply. The PIR method is usually thetechniqueofchoiceformusclesthatareclassifiedasshortandtight,asitisthesemusclesthatareinitiallycontractedintheprocessofreleasingandrelaxing.

Onoccasion, however, a patientmay experience discomfortwhen the agonist,i.e. the shortened structure, is contracted; in this case it would seem moreappropriate to contract the opposite muscle group (antagonist), as this wouldreducethepatient’sperceptionofpain,butstillinducearelaxationinthepainfultissues. Hence, the use of the RI method, using the antagonists, which areusuallypainfree,willgenerallybethefirstchoiceifthereisincreasedsensitivityintheprimaryshortenedtissues.

When the patient’s initial pain has been reduced by the appropriate treatment,PIRtechniquescanbeincorporated(asexplainedearlier,PIRusesanisometriccontractionofthetightshortenedstructures,incontrasttotheantagonistsbeingused in theRImethod). To some extent, themain factor in deciding the bestapproach iswhether the sensitive tissue is in the acute stage or in the chronicstage.

After having used PIR and RI on a regular basis, I have found that the bestresultsforlengtheningthehypertonicstructuresareachievedwithPIR(providedthepatienthasnopainduringthistechnique).However,onceIhaveperformedthePIRmethod, if I feelmoreROM is needed in the shortened tight tissue, IbringintoplaytheantagonistsusingtheRImethodforapproximatelytwomorerepetitions, as explained in theRI example below.This personal approach formypatientshashadthedesiredeffectofimprovingtheoverallROM.

PIRExample

ToillustratethePIRmethodofMETtreatment,wearenowgoingtoapplytheprocedure to the adductor pollicis muscle (pollicis relates to the thumb, orpollex).YoumightconsideritmoreappropriatetodemonstratehowMETsworkbymeansofanexamplerelatedtothepelvis;however,Iwantedthetherapisttobe able to practice the technique on themselves first, so that they can betterunderstand the MET concept. Once the technique has been understood andsubsequently practiced using this simple example, the therapist will then bereadytotacklemorecomplexMETswiththeaimofhelpingtorestorefunctiontothepelvis.

Placeyour left (or right) handonto a blankpieceof paper and,with thehandopenasmuchaspossible,drawaroundthefingersandthethumb(Figure7.3).

Figure7.3.Thedistancebetweenthethumbandfingerismeasured.

Removethepaperandactivelyabductthethumbasfarasyoucan,untilapointofbindisfelt.Next,placethefingersofyourrighthandontopoftheleftthumband, using an isometric contraction,adduct your thumb against the downwardpressureofthefingers,sothatanisometriccontractionisachieved(Figure7.4).After applying this pressure for 10 seconds, breathe in, and on the exhalationpassively take the thumb into furtherabduction (but do not force the thumb).Repeat this sequence twomore times and on the last repetition, maintain thefinalrestingpositionforatleast20–25seconds.

Figure7.4.Adductingthethumbagainstaresistanceappliedbytheoppositehand(PIRmethod).

Now place your hand back on the piece of paper and draw around it again(Figure 7.5); hopefully youwill see that the thumb has abducted further thanbefore.

Figure7.5.ThehandredrawnaftertheMETtreatmentusingPIRandRI.

RIExample

ToapplytheRImethod,followthesameprocedureasforthePIRmethod,i.e.gotothepointofbindbystillabductingthethumb.Fromthispositionofbind,insteadofadductingthethumb(PIR)againstaresistance,performtheoppositemovement and abduct your thumb (using the abductor pollicis brevis/longusmuscle) against a resistance (Figure 7.6). After applying this pressure for 10seconds,breathein,andontheexhalationpassivelytakethethumbintofurtherabduction(again,donotforcethethumb).Repeatthissequenceoneortwomoretimes and on the last repetition,maintain the final resting position for at least

20–25seconds.

Figure7.6.Abductingthethumbagainstaresistanceappliedbytheoppositehand(RImethod).

Asbefore,placeyourhandbackonthepieceofpaperanddrawarounditagain(Figure 7.5); hopefully youwill see that the thumb has abducted further thanpreviously.

METsandtheMusclesofthePelvis

ThemusclesthatIconsidertobespecificallyrelatedtothepositionofthepelvisandlumbarspineare:

•Iliopsoas

•Rectusfemoris

•Adductors

•Hamstrings

•Tensorfasciaelatae(TFL)andiliotibialband(ITB)

•Piriformis

•Quadratuslumborum(QL)

Iamgoingtoshowyouhowtoassessforeachofthesemuscles,whichhaveanatural tendency to shorten and subsequently become tight. After the testingprocedure has been explained, Iwill demonstrate specificMETs to encouragethese short/tight muscles to lengthen, so that we can assist and hopefullynormalizethedysfunctionalposition.

Iliopsoas

Figure7.7.(a)Origin,insertion,action,andnerveinnervationoftheiliopsoas.

Origin

Psoas major: TPs of all the lumbar vertebrae (L1–L5). Bodies of the 12th

thoracic and all lumbar vertebrae (T12–L5). Intervertebral discs above eachlumbarvertebra.

Iliacus: Superior two-thirds of the iliac fossa. Anterior ligaments of thelumbosacralandSIJs.

Insertion

Lessertrochanterofthefemur.

Action

Mainflexorofthehipjoint.Assistsinlateralrotationofthehip.Actingfromitsinsertion,itflexesthetrunk,asinsittingupfromthesupineposition.

Nerve

Psoasmajor:Ventralramioflumbarnerves(L1–L4).

Iliacus:Femoralnerve(L2–L4).

AssessmentoftheIliopsoas

Figure7.7.(b)Thepsoasmajorandiliacussuperimposedontheabdomen.

It is important thatwe are able to assess for relative shortnesswithin the hipflexor group, as Grieve (1983) says that an increased tension in the iliopsoasmuscleisfelttobeoneofthemainreasonsfortherecurrenceofmalalignmentsyndrome,evenafterthealignmentofthepelvishasbeencorrected.

Schamberger(2013)pointsoutthatitiscommontofindmoretension/tendernessintheleftiliopsoasthanintherightside.Onereasonforthismightbethattheleft SIJ may actually become hypermobile as a result of the increased stressimposed if the right SIJ becomes “locked” (as a result of a right anteriorinnominatewith a compensatory left rotatedposterior innominate) or becomeshypomobileforotherreasons.TheleftiliopsoaswouldcontractinanattempttostabilizethenowhypermobileleftSIJ.

ModifiedThomasTest

Totesttherighthip,thepatientisaskedtoliebackontheedgeofacouchwhileholding onto their left knee.As they roll backward, the patient pulls their leftkneeas far as theycan toward their chest, as shown inFigure7.7(c).The fullflexionofthehipencouragesfullposteriorrotationoftheinnominateboneandhelpstoflattenthelordosis.Fromthisposition,thetherapistlooksatwherethepatient’srightkneelies,relativetotherighthip.Thepositionofthekneeshouldbejustbelowthelevelofthehip;Figure7.7(c)demonstratesanormallengthoftherightiliopsoas.

Figure7.7.(c)Therightkneeisbelowthelevelofthehip,indicatinganormallengthoftheiliopsoas.

InFigure7.8thetherapistdemonstrateswiththeirarmsthepositionoftherighthipcomparedwith the rightknee.Youcansee that thehip isheld ina flexedposition,whichconfirmsthetightnessoftherightiliopsoasinthiscase.

Figure7.8.Atightrightiliopsoasisconfirmed.Atightrectusfemoriscanalsobeseenhere.

WiththepatientinthemodifiedThomastestposition,thetherapistcanapplyanabductionof thehip(Figure7.9),andanadductionof thehip(Figure7.10).AROMof10–15degreesforeachoftheseiscommonlyacceptedtobenormal.

Ifthehipisrestrictedinabduction,i.e.abindoccursatanangleoflessthan10–15degrees,themusclesoftheadductorgroupareheldinashortenedposition;ifthe adduction movement is restricted, the TFL and the ITB are held in ashortenedposition.

Figure7.9.Restrictedhipabduction,indicatingtightadductors.

Figure7.10.Restrictedhipadduction,indicatingatightTFL/ITB.

METTreatmentoftheIliopsoas

To treat the right side, thepatient adopts the samepositionas in themodifiedThomastestabove.Thepatient’sleftfootisplacedintothetherapist’srightsideandpressureisappliedbythetherapisttoinducefullflexionofthepatient’slefthip. Stabilizing the patient’s right hipwith their right hand, the therapist putstheir left hand just above the patient’s right knee.The patient is asked to flextheir right hip against the therapist’s resistance for 10 seconds, as shown inFigure7.11;thisspecificcontractionoftheiliopsoasmusclewillinduceaPIR.

Figure7.11.Thepatientflexestheirrighthipagainstresistancefromthetherapist’slefthand,whilethehipisbeingstabilizedbythetherapist’srighthand.

Following the isometric contraction, and during the relaxation phase, thetherapist slowly applies a downward pressure. This will cause the hip topassivelygointoextensionandwillinducealengtheningoftherightiliopsoas,as shown in Figure 7.12. Gravity will also play a part in this technique, byassistinginthelengtheningoftheiliopsoas.

Figure7.12.Thetherapistpassivelyextendsthehiptolengthentheiliopsoas,withtheassistanceofgravity.

Alternatively,itispossibletocontracttheiliopsoasfromtheflexedposition,asshowninFigure7.13.Thisisnormallyusediftheoriginalmethodofactivatingtheiliopsoascausesdiscomforttothepatient.Allowingthehiptobeinamoreflexedpositionwillslackentheiliopsoas,whichwillassistinitscontractionandhelpreducethediscomfort.

Figure7.13.Thepatientresistshipflexionfromaflexedposition.

The patient is asked to flex their right hip against a resistance applied by thetherapist’slefthand(Figure7.13).Aftera10-secondcontraction,andduringtherelaxationphase, the therapist lengthens the iliopsoasby taking thehip intoanextendedposition,asdemonstratedinFigure7.14(a).

Figure7.14.(a)Lengtheningoftherightiliopsoas.

Tip:Thepsoasmajorisalsoknownasfiletmignon,whichisapieceof beef taken from the tenderloin.A bilateral shortness of the psoasmajorcancausethepelvistoanteriorlytilt,inturncausingthelumbarspinetoadoptapositionofhyperlordosisanddrawingthesacrumintoapositionofincreasednutation.Thiscanresultincompressionofthefacetjoints,leadingtolowerbackpain.

Note:Iffullsit-upsareperformedonaregularbasis(notrecommended),theiliopsoasispredominantlythemusclebeingused.Repeatedsit-upswillmaketheiliopsoasstrongerandtighter,andresultinweaknessoftheabdominals;thiscanmaintainapatient’slowerbackpain.

Toprovetheinvolvementoftheiliopsoas(duringthesit-upmotion),haveyourpatientlieontheirbackwiththeirkneesbent.Holdthepatient’sanklesandaskthemtodorsiflextheirankleswhileyouresistthemovement.Thiswillstimulatethe anterior chain musculature, including the iliopsoas, which is part of thischain.The patient then performs the full sit-upmovement as shown inFigure7.14(b)(mostfitindividualswillbeabletodomanysit-ups).

Figure7.14.(b)Dorsiflexionassiststheactivationforthecontractionoftheiliopsoas(switchon).

Todeactivateorswitchofftheiliopsoas,thepatientisaskedtoplantarflextheirankles(insteadofdorsiflexingthem),ortosqueezetheirglutes.Eitheroftheseactions stimulates the posterior chain musculature, causing the iliopsoas toswitch off, as activation of the gluteal muscles results in a relaxation of theiliopsoas throughRI.When thepatient isnowasked toperform thesit-up, themovementwillprovetobeimpossible,confirmingthattheiliopsoasisgenerallytheprimemoverinafullsit-up,asshowninFigure7.14(c).

Figure7.14.(c)Plantarflexionoractivatingtheglutesassiststhedeactivationforthecontractionoftheiliopsoas(switchoff).

RectusFemoris

Figure7.15.Origin,insertion,action,andnerveinnervationoftherectusfemoris.

Origin

Straighthead(anteriorhead):AIIS.

Reflectedhead(posteriorhead):Grooveabovetheacetabulum(ontheilium).

Insertion

Patella,thenviathepatellarligamenttothetuberosityofthetibia.

Action

Extends the knee joint and flexes the hip joint (particularly in combinationmovements,suchasinkickingaball).Assistsiliopsoasinflexingthetrunkonthe thigh. Prevents flexion at the knee joint as the heel strikes the groundduringwalking.

Nerve

Femoralnerve(L2–L4).

AssessmentoftheRectusFemoris

ModifiedThomasTest

This test is an excellent way of identifying shortness not only in the rectusfemoris but also in the iliopsoas as explained earlier. To test the right rectusfemoris,thepatientadoptsthepositioninFigure7.16,inwhichtheyareholdingontotheirleftleg.Thepatientisaskedtopulltheirleftkneetowardtheirchest,as thiswillposteriorlyrotate the innominateboneon thatside; thiswillbe thetest position. From this position, the therapist looks at the position of thepatient’srightkneeandrightankle.Theangularpositionofthekneetotheankleshouldbeabout90degrees;anormallengthoftherightrectusfemorisisshownbelow.

Figure7.16.Totesttherightrectusfemoris,thepatientliesonthecouchandholdsontotheirleftleg.Anormallengthoftherectusfemorisisshown.

InFigure7.17thetherapistdemonstratesthepositionoftherightkneecomparedwith the right ankle. Here, the lower leg is seen to be held in a position ofextension,whichconfirmsthetightnessoftherightrectusfemoris.Youwillalsonotice the position of the hip—it is held in a flexed position.This indicates atightnessoftheiliopsoasandwasdiscussedearlier.

Figure7.17.Thekneeisheldinextension,indicatingatightrectusfemoris.

METTreatmentoftheRectusFemoris

Thepatientisaskedtoadoptaproneposition,andthetherapistpassivelyflexesthe patient’s right knee until a bind is felt. At the same time, the therapiststabilizes the sacrumwith their righthand,whichwill prevent thepelvis fromrotatinganteriorlyandstressingthelowerlumbarspinefacetjoints.

Note:Ifyouconsiderthepatienttohaveanincreasedlumbarlordosis,apillowcanbeplacedundertheirstomach.Thiswillhelpflattenthelordosisandcanreduceanypotentialdiscomfort.

From the position of bind, the patient is asked to extend their knee against aresistanceappliedbythetherapist(Figure7.18),asthiscontractionwillinduceaPIRintherectusfemorismuscle.

Figure7.18.Thepatientextendstheirkneewhilethetherapistappliesresistance.

After a 10-second contraction, and during the relaxation phase, the therapistencouragesthekneeintofurtherflexion,whichwilllengthentherectusfemoris,asshowninFigure7.19.

Figure7.19.Thetherapistpassivelyflexesthepatient’skneetolengthentherectusfemoriswhilestabilizingthelumbarspine.

AlternativeMETTreatmentoftheRectusFemoris

Some patients may find that the previousMET for the rectus femoris puts astrainontheirlowerback.AnalternativeandpossiblyamoreeffectiveMETfortherectusfemorisisbasedonthemodifiedThomastestposition.

ThepatientadoptsthepositionofthemodifiedThomastestasdescribedearlier.The therapist controls the position of the patient’s right thigh, and slowly andpassively flexes the patient’s right knee toward their bottom. A bind will bereached very quickly in this position, so take extra carewhen performing thistechniqueforthefirsttime.

From the position of bind, the patient is asked to extend their knee against aresistance applied by the therapist (Figure 7.20). After the 10-secondcontraction, and during the relaxation phase, the therapist passively takes thekneeintofurtherflexion(Figure7.21).Thisisaveryeffectivewaytolengthenatightrectusfemoris.

Tip:Bilateralhypertonicityoftherectusfemoriswillcausethepelvisto adopt an anterior tilt, resulting in lower back pain due to the 5thlumbar vertebra facet joints being forced into a lordotic (extended)position.

If one side (typically the right side) of the rectus femorismuscle isheld in a shortened position, this will have the effect of pulling theinnominate bone into an anteriorly rotated position, with relativecounter-nutationofthesacrumtothesameside.

Figure7.20.Thetherapistpalpatestherectusfemoris,andthepatientextendstheirkneeagainstaresistance.

Figure7.21.Thetherapistpassivelyflexesthepatient’skneetolengthentherectusfemoris.

Adductors

Figure7.22.Origin,insertion,action,andnerveinnervationoftheadductors.

Origin

Anteriorpartof thepubicbone(ramus).Adductormagnusalsohasitsoriginontheischialtuberosity.

Insertion

Entirelengthofthemedialsideofthefemur,fromthehiptotheknee.

Action

Adduct,flex,andmediallyrotatethehipjoint.

Nerve

Magnus:Obturatornerve(L2–L4).Sciaticnerve(L4,L5,S1).

Brevis:Obturatornerve(L2–L4).

Longus:Obturatornerve(L2–L4).

AssessmentoftheAdductors

HipAbductionTest

To test the left side, the patient adopts a supine position on the couch. Thetherapisttakesholdofthepatient’sleftlegandpassivelyabductsthehipwhilepalpating the adductors with their right hand (Figure 7.23).When they feel abind, the position is noted. The normal ROM for passive abduction is 45degrees;iftherangeislessthanthis,atightleftadductorgroupisindicated.

Figure7.23.Thetherapistabductsandpalpatestheadductorsforbind.

However,thereisanexceptiontotherule.IftheROMislessthan45degrees,itcould be that the medial hamstrings are restricting the movement of passiveabduction. To differentiate between the short adductors and the medialhamstrings, the knee is flexed to 90 degrees (Figure 7.24); if the range nowincreases,thisindicatesshortnessinthemedialhamstrings.

Figure7.24.Thekneeisbenttoisolatetheshortadductors.

Insummary,toidentifyifthehamstringsaretherestrictivefactor,thetherapistpassively flexes thekneeand thencontinueswith thepassiveabduction. If theROM improves, the hamstrings are the restrictive tissues and not the shortadductors.

Note:Thetermshortadductorreferstoalloftheadductormusclesthatattachtothefemur,theexceptionbeing thegracilis.Thisparticularmuscleattaches toapointbelowtheknee,on thepesanserinus (goosefoot)areaofthemedialknee,andactsonthekneeaswellasonthehip.

METTreatmentoftheAdductors

Oneofthemosteffectivewaysoflengtheningtheadductors(short)istoutilizean MET from the position, shown in Figure 7.25(a–b). The patient adopts asupinepositionwiththeirkneesbentandheelstogether;thehipsareslowlyand

passively taken into abduction by the therapist until a bind is felt in theadductors.

From the position of bind, the patient is asked to adduct their hips against aresistanceappliedbythetherapist,tocontracttheshortadductors.

Figure7.25.(a)Thepatientadductstheirlegsagainstresistancefromthetherapist.

Figure7.25.(b)Alternativeposition—thetherapistkneelsonthecouchasthepatientadductstheirlegsagainstresistancefromthetherapist.

After a 10-second contraction, and during the relaxation phase, the hips arepassively taken into further abduction by the therapist, as shown in Figure7.26(a–b).

Figure7.26.(a)Thetherapistlengthenstheadductors.

Figure7.26.(b)Alternativeposition—thetherapistlengthenstheadductors.

Tip:Overactivityoftheadductorswillpotentiallyresultinaweaknessinhibition of the abductormuscles, in particular theGmed. This canresultinaTrendelenburgpatternofgait,asexplainedinChapter5.

Hamstrings

Origin

Ischialtuberosity(sittingbone).Bicepsfemorisalsooriginatesfromthebackofthefemur.

Insertion

Semimembranosus:Backofthemedialcondyleofthetibia(upperinsidepartoftibia).

Semitendinosus:Uppermedialsurfaceoftheshaftofthetibia.

Biceps femoris:Head (top) of the fibula.Lateral condyle of the tibia (upper

outsidepartoftibia).

Action

Flex the knee joint. Extend the hip joint. Semimembranosus andsemitendinosus alsomedially rotate (turn in) the lower legwhen theknee isflexed.Bicepsfemorislaterallyrotates(turnsout)thelowerlegwhenthekneeisflexed.

Nerve

Branchesofthesciaticnerve(L4,L5,S1,S2,S3).

Figure7.27.Origin,insertion,action,andnerveinnervationofthehamstrings.

GeneralAssessmentoftheHamstrings

HipFlexionTest

This test helps to provide the practitioner with an overall impression of thegeneral length of the hamstringmuscles. The patient lies in a supine positionwithbothlegsextended.Thetherapistpassivelyguidesthepatient’slefthipintoflexionuntilapointofbind is felt.ThenormalROMisanywherebetween80and90degrees;lessthan80degreesindicatesthatthehamstringsareheldinashortenedposition.However,“neuraltension”ofthesciaticnerveandaspecifichamstringinjurycanalsorestricttheROM(flexion)ofthehipjoint.

As you can see in Figure 7.28(a), the patient has a normal ROM in theirhamstrings.Anything less than80–90degreeswouldbe classified as short, asshowninFigure7.28(b).

Figure7.28.(a)Hipflexiontest.AROMof80–90degreesisnormal.

Figure7.28.(b)Hipflexiontest.AROMof45degreesisdemonstratedhere,indicatingshorthamstrings.

METTreatmentoftheHamstrings(Non-Specific)

Thefollowingtechniqueisverygoodforlengtheningthehamstringsasagroup;laterinthischapterwewillseehowtospecificallytargetthemedialandlateralhamstrings.

Thetherapistadoptsastandingpostureandpassivelycontrolsthepatient’srightlegintohipflexionuntilabindisfeltinthehamstrings.Fromthisposition,thepatient’slowerlegisplacedonthetherapist’srightshoulder,asshowninFigure7.29.

Figure7.29.Thepatientpushestheirrightlegdownagainstthetherapist’sshoulder.

The patient is asked to push down against the therapist’s shoulder for 10seconds.Afterthecontractionofthehamstrings,andduringtherelaxationphase,thetherapistpassivelytakestherightlegintofurtherflexion,asseeninFigure7.30.

Figure7.30.Thetherapistpassivelytakesthehipintofurtherflexion.

AlternativeMETfortheInsertionoftheHamstrings

This technique is very good for lengthening the insertion component of thehamstrings.Thepatient’ship isnowflexed to90degreesand the lower leg isplacedovertheshoulderofthetherapist,asshowninFigure7.31.

Figure7.31.Withthehipflexedto90degrees,thepatientplacestheirlowerlegoverthetherapist’sshoulder.

From this position, the patient is asked to pull their heel toward their glutealmuscles,asthiswillactivatethecontractionofthehamstrings.Aftera10-secondcontraction,andduringtherelaxationphase, thetherapistpassivelyencourageskneeextensionuntilanewpointofbindisfelt,asshowninFigure7.32.

Figure7.32.Thetherapistpassivelyencourageskneeextensiontolengthenthehamstrings.

RIMethod

Thepatientisaskedtocontactthehamstringsasdescribedabove;however,afterthe10-secondcontraction,andduringtherelaxationphase, thepatient isaskedtoslowlystraightentheirknee(whichwasflexedtostartwith)as the therapistpassively takes theknee into furtherextension.Thepatientwillbecontractingtheirquadricepsastheystraightenthekneeactively;thiswillinduceanRIeffectinthehamstrings,allowingamoreeffectiveandsafelengtheningtooccur.

AssessmentoftheMedialHamstrings(Semitendinosusand

AssessmentoftheMedialHamstrings(SemitendinosusandSemimembranosus)

Afterconductingageneralassessmentofthehamstrings,iftheROMislessthan80degrees,wecanconcludethatthereisasofttissuerestrictionpresentwithinthe hamstringmuscle group. However, the assessment does not tell us whichaspectofthehamstringsisthetighterstructure.

Withspecific testing it ispossible to identify the individualcomponentsof thehamstringmusclesthatareresponsible.Thefollowingtestscanbeincorporatedinto theassessment tohelpdifferentiatemuscle lengthanomalies in themedialhamstringsfromthoseinthelateralhamstrings.

In order to investigate whether the semitendinosus/semimembranosus is therestrictivetissue,themedialhamstringsareisolatedasfollows.Thepatient’slegis controlled by the therapist, who applies an external rotation and abduction,whileatthesametimethehipispassivelyflexed(Figure7.33(a–b)).Thepointof bind is noted; if the ROM is less than that in the original test, themedialhamstringscanbeassumedtobetheshortenedmuscles.

Figure7.33.(a)Tospecificallyidentifythemedialhamstringsastherestrictivetissue,thepatient’slegisexternallyrotatedandabductedwhilethehipispassivelyflexed.(b)Alternativeviewofthetestposition.

AssessmentoftheLateralHamstrings(BicepsFemoris)

Thisspecifictestwillisolatethebicepsfemoris.Thetherapistappliesaninternalrotation and adduction, while the patient’s leg is taken into passive flexion(Figure 7.34(a–b)). If the motion feels restrictive, the therapist needs todeterminewhethertheROMislessthanthatintheoriginalhipflexiontest;ifitis, the lateral hamstring of the biceps femoris can be identified as the shorttissue.

Tip:Remember,themedialandlateralhamstringsmightneedtreatingindividuallyratherthantogether.

Figure7.34.(a)Totestthebicepsfemoris,thetherapistappliesaninternalrotationandadductionwhilethelegistakenintopassiveflexion.(b)Alternativeviewofthetestposition.

TensorFasciaeLatae(TFL)andIliotibialBand(ITB)

Figure7.35:Origin,insertion,action,andnerveinnervationoftheTFL/ITB.

Origin

Outeredgeoftheiliaccrest,towardthefront.

Insertion

Joinstheiliotibialtract(longfascialatatendon)justbelowthehip,whichrunstotheupperlateralsideofthetibia(Gerdy’stubercle).

Action

Flexes,abducts,andmediallyrotatesthehipjoint.Tensesthefascialata,thusstabilizingtheknee.

Nerve

Superiorglutealnerve(L4,L5,S1).

AssessmentoftheTFLandITB

Ober’sTest

AnorthopedicsurgeonbythenameofFrankOberwroteanarticlecalled“Backstrain and sciatica” (Ober 1935a) and first described this test in 1937. HediscussedtherelationshipofacontractedTFLmuscleandtheITBtolowerbackpainandsciatica.

The patient is asked to adopt a side-lying position, and the therapist (with theassistance of the patient) places the patient’s shoulder, hip, and knee inalignmentasshowninFigure7.36(a).

When the therapist feels that the patient has sufficiently relaxed, they slowlybend their own knees (as in a half squat) while maintaining control of thepatient’sleftkneeasitisloweredtothecouch.Ifthekneeisseentodropbelowthe level of parallel, the TFL/ITB is classified asnormal, as shown in Figure7.36(b);ifthethighremains(ordropsonlyslightlybelow)parallel,theTFL/ITBisclassifiedasshort,asshowninFigure7.36(c).

Figure7.36.Ober’stest:(a)Thetherapistcontrolsthepatient’sleftkneeandasksthepatienttorelaxfullybeforethekneeisloweredtowardthecouch;(b)anormallengthoftheTFL/ITB,indicatedbythekneedroppingdown;(c)atightTFL/ITB,indicatedbythekneeremainingwhereitis;(d)allowingthehipto“fall”intohipflexionandinternalrotationcanleadtotheincorrectconclusionofanormalITB/TFL.

Note:IfthereisperceivedshortnesswithintheTFLandITB,thelegwillremainrelativelyabducted,butthehipwillnaturallywantto“fall”intohipflexionwithinternalrotationasthetherapistlowerstheleg(seeFigure 7.36(d)). If this is allowed to happen as the leg approximates the couch, one could mistakenlyassume the length of the TFL and ITB to be normal, but a tight TFL/ITB will take the hip into thisdysfunctionalposition.Itisthereforeimportanttobeverydiligentwhencontrollingthepatient’slegduringthetestandnotallowthehiptoflexandinternallyrotate.

Please bear inmind the following: whenOber’s test is positive, we naturally

assume that the TFL and ITB are short and subsequently tight, and that thetreatmentprotocol is to“stretch”and/orperformmanual therapy techniques toencourage lengthening of the ITB. However, research has now shown thataltering the length of the ITB through manual therapy is next to impossible:accordingtoChaudhryetal.(2008),achangeinlengthoftheITBbyonly1%will require approximately 1 ton (925kg) of pressure. Hence, there is littlechanceofactuallycausinganysignificantdeformationtotheITBandmakingitlesstightthroughmanualtherapyandstretchingtechniques.

AstudybyTenneyetal. (2013),however,demonstrated that theactivationoftheabdominalsandhamstringmusclesinsubjectswhoexperiencelumbopelvicpain (withapositiveOber’s test) led toan improvement in thepositionof thepelvis,andsubsequentlytoanoverallimprovementintheresultsofOber’stest.

METTreatmentoftheTFLandITB

IconsiderthefollowingMETanappropriateproceduretobeincludedwithinatreatmentplan,asIfeelthatitwillassistinsomewaytoalterthe“tone”oftheTFLmuscle,ratherthanalteringthelengthoftheconnectivetissuecomponent,i.e.theITB.ItmakesalotmoresensetometousethePIReffectofMETsontheTFLmuscle,asIpersonallybelievethatthistechniquehelpsrelaxtheTFLand hopefully will induce some reduction in tone in the ITB. This is mypreferredwayof treating these structures, rather than spending a great deal oftimeperformingdeepmassage techniques (generallycalledstripping the ITB),oradvocatingtheuseofafoamroller,tohelplengthentheITB.Techniquesofthis type (foam roller in particular)maynot actually be doingwhat theyhavesupposedlybeendesignedforinthepast,becausethesofttissuestructureoftheITB (as already discussed) has been shown through research not to change inlengthbyeven1%usingalmostonetonofpressure.

Let me give you an example to illustrate the above. When the weather isparticularlywarmatmyclinicinOxford,andespeciallywhenIamlecturing,Itendto lookoutof thewindowandacross therunningtrack toasmallareaofgrass.Almost every day (onlywhen theweather is good), I see a youngmanspendinganywherebetween twoand threehours rollinghis legsusinga foamroller.Hehasbeengiventhenickname“RollerDave”forobviousreasons,andIhaveevenquestionedhimonwhyhedoesthistohislegs.HesimplysaystomethathistherapistrecommendsdoingthateverydaytoreleasehisITBs…Iwillleave that thoughtprocesswithyou! Iamsuresomeof thestudentswhohave

attended my courses in Oxford will be smiling when they read about RollerDave,astheytoohaveundoubtedlyseenhimrollinghislegsmanytimes!

Anyway, back to the treatment protocol.The patient adopts a supine position,and the therapist crosses the patient’s flexed left leg over the right leg. Thetherapistcontrolsthepatient’sleftkneewiththeirrighthandandholdsontothepatient’s right anklewith their lefthand.Thepatient’s right leg is thenplacedinto an adducted position until a bind is felt. From the position of bind, thepatient is asked to abduct their right leg against a resistance applied by thetherapist,asshowninFigure7.37.

Figure7.37.Thepatientabductstheirrightlegagainstaresistance.

After a 10-second contraction, and during the relaxation phase, the therapistpassively takes the patient’s right leg into further adduction (Figure 7.38(a)).Thiswill encourage a lengtheningof the rightTFLandmaypossiblyhave aneffectontheITBaswell(albeitsmall).

Figure7.38.(a)Thepatient’sleftkneeisstabilized,whilethetherapistadductstherightleg,lengtheningtheTFLmuscle.

IfyoulookatFigure7.38(b),thepatienthasadoptedasidebentpositiontotheleft; this will encourage a lengthening of the right QL muscle as well as alengtheningoftheTFLandITB.

Figure7.38.(b)Thepatientsidebendstotheleft,whilethetherapistadductstherightleg,lengtheningtheQLandTFLmuscles.

Piriformis

Figure7.39.Origin,insertion,action,andnerveinnervationofthepiriformis.

Origin

Internal(front)surfaceofthesacrumS2–S4.

Insertion

Greatertrochanter(top)ofthefemur.

Action

Laterallyrotatesandextends thehip joint.Abducts the thighwhenthehip isflexed.Helpsholdtheheadofthefemurinitssocket.

Nerve

Ventralramiofthelumbarnerve(L5)andthesacralnerves(S1,S2).

ObservationAssessmentofthePositionoftheHip

The initial assessment for the relative length of the piriformis muscle is byobservation.Thepatientisaskedtoadoptthesupineposition,andthepatient’slower limbs are observed from the cephalic end of the couch. The focus ofattentionwillbeontherelativepositionofthefoot.

AsyoucanseeinFigure7.40,thepatient’sleftfootappearstobefurtherawayfrom themidline than the right foot.Theactualmovementhas come from thehip, which is in a position of external rotation. This possibly relates to ashortenedpiriformisontheleftside.

Thepiriformis isaveryimportantmuscleregardingsacral torsions,becauseofits attachment onto the anterior surface of the sacrum. Since its pull is in adiagonal direction, the muscle can rotate the sacral base posteriorly anddownward relative to the innominate bone. This motion can then cause awedgingagainst the innominate, resulting ina lossofmobilityof theSIJ, andconsequentlyhypomobilityofthejoint.

Figure7.40.Theleftlegisheldinanexternallyrotatedposition.

PassiveAssessmentofthePiriformis

Inordertolookatthepositionofthehiptohelpusdecidewhetherthepiriformisisheldinashortenedposition,weaskthepatienttoadoptaproneposition.Oneofthepatient’skneesisflexedto90degrees,andthehipispassivelycontrolledbythetherapistandallowedtointernallyrotate.Thisisrepeatedwiththeotherknee flexed to90degrees.The side that has the leastROMpossibly indicatesrelativeshortnessofthecorrespondingpiriformis(Figure7.41).

Figure7.41.Thelefthipispassivelytakenintointernalrotationtoassessforshortnessofthepiriformis.

Anotherwayofassessingtherelativelengthofthepiriformisisasfollows.Thepatientisaskedtoadoptapronepositionwithbothoftheirkneesbent,andthenlettheirlegs“flopout”;thiswillinduceinternalrotationofthehipjoints.

Fromthecephalicpositionof thepatient, the therapistobservesthepositionofthe lower limb. As you can see in Figure 7.42, the lower limb appears to beasymmetric on one side. One can assume that the patient’s left side is thedysfunctional side, as thehip is inapositionof external rotation. In this case,internalrotationofthehipisrestricted,whichmeansthatthepiriformisonthat

sideisheldinashortenedposition.

Figure7.42.AdecreasedROMofthelefthip,indicatingashortleftpiriformis.

METTreatmentofthePiriformis

Thepatientadoptsthepositionofthetestasdescribedabove,butwiththerightleg straight and the left knee bent. The therapist makes sure that thepelvis/sacrumisstabilizedwith their righthand,whilecontrolling thepatient’sleftlegwiththeirlefthand.Thepatient’sleftlegispassivelytakenintointernalrotationuntilthepositionofbindisfelt,andthepatientisaskedtocontractthepiriformis by pulling their leg against resistance applied by the therapist’s lefthand.Thiswillinduceanexternalrotationofthehipjoint(Figure7.43).

Figure7.43.Thepatientisaskedtopulltheirleftlegacrosstheirbodyagainstaresistance.Thetherapiststabilizesthelumbarspinewiththerighthand.

Aftera10-secondcontractionofthepiriformis,andduringtherelaxationphase,the therapist takes thepatient’s left hip into further internal rotation.Thiswilllengthenthepiriformis,asshowninFigure7.44.

Figure7.44.Thetherapistlengthensthepiriformiswhilestabilizingthelumbarspine.

AlternativeMETTechniqueforthePiriformis

Technique1

This time the patient is asked to adopt a supine position, and the therapistpassivelytakesthepatient’sleftlegandcrossesitovertherightleg.Controllingthemovementofthepatient’sleftinnominatewiththeirrighthand,thetherapistapplies pressure to the patient’s left knee, passively inducing adduction of thehiptothepointofbind.

Thepatientisaskedtoabducttheirleftleg(thepiriformisisanabductor),while

thetherapistresiststhemovement,asshowninFigure7.45.

Figure7.45.Technique1:fromthepointofbind,thepatientabductsagainstthepressureappliedbythetherapistinthedirectionofthearrow.

After a 10-second contraction, and during the relaxation phase, the therapistpassively takes thepatient’s left leg into furtheradduction,asshowninFigure7.46.

Figure7.46.Technique1:thetherapisttakesthepatient’sleftlegintofurtheradductionandstabilizestheinnominate/lumbarspinewiththerighthand.

Technique2

Thisismypreferredwayoflengtheningthepiriformismuscle.

Controlling thepatient’s left leg, the therapist tries toencourage flexionof thehip,whileatthesametimeexternallyrotatingthehipwithsomeadduction.Thistechniquewillplacethepiriformisintoapositionofrelativebind,butwillneedfine-tuningbythetherapistandfeedbackfromthepatienttofinallyachievetheoptimumposition.Fromthisfinelytunedpositionofbind,thepatientisaskedtopush their knee away, into the abdomen of the therapist. This will induce a

contractionofthepiriformis,asshowninFigure7.47.

Figure7.47.Technique2:thistechniquewillneedfine-tuningtogettotheoptimumposition.Fromthepositionofbindthepatientisaskedtopushtheirkneeaway.

After a 10-second contraction, and during the relaxation phase, the therapistpassivelyencouragesthehipintofurtherexternalrotationwhileapplyingsomehipflexion/adductionasshowninFigure7.48.

Figure7.48.Technique2:usingtheirchestandhand,thetherapistencouragesfurtherexternalrotationandadductionofthepatient’slefthip.

Tip:The sciaticnerveofone in fiveof thepopulation (20%)passesthroughthepiriformismuscle.Thiscanresultinbuttockandlegpain,but generally no back pain is present, so make sure you eliminatedisc/lumbarspinepathologyfromyourhypothesis.

Note:Itisconsideredthatafter60degreesofhipflexion,thepiriformischangesfromanexternalrotatortoaninternalrotator—thisisbecauseofitsanatomicalattachments.IfyoulookcloselyatFigure7.48,thisisthereasonwhythepatient’slefthipisplacedinanexternallyrotatedposition.Thiswillnowlengthenthepiriformis,asthelefthiphasexceeded60degreesofflexion.

QuadratusLumborum(QL)

Figure7.49.Origin,insertion,action,andnerveinnervationoftheQL.

Origin

Iliac crest. Iliolumbar ligament (the ligament from the 4th and 5th lumbarvertebraetotheilium).

Insertion

12thrib.TPsoftheupperfourlumbarvertebrae(L1–L4).

Action

Laterally flexes vertebral column. Fixes the 12th rib during deep respiration(e.g.helpsstabilizethediaphragmofsingersexercisingvoicecontrol).Helpsextendthelumbarspinecomponentofthevertebralcolumnandgivesitlateralstability.

Nerve

Ventral rami of the subcostal nerve and upper three or four lumbar nerves(T12,L1,L2,L3).

AssessmentoftheQL

InmyexperienceIfindthatthestandingsideflexiontestisrelativelygoodforindicatingtightnessoftheQL.

Thepatientstandsuprightandmaintainsaneutralpositionofthelumbarspine.Fromthestandingposition,thepatientisaskedtosidebendtotheleft,andatthesame time slide their left handdown the outside of their left leg, as shown inFigure7.50.When thepositionof bind is reached (this is felt by the therapistpalpating the right side of the QL as the patient side bends to the left), thepatient’sleftmiddlefingershouldbeincontactwiththeheadofthefibulaontheleftside.

Ifthemiddlefingeriscloseortouchesthefibulaheadontheleftside,theQLontheright(contralateral)sideisclassifiedasnormal; if there isarestriction, theQLontherightisclassifiedastight.

Note:ThistestisnotconclusivefordeterminingshortnessoftheQL,asmanyotherlumbarspinefactorswill affect the overall result. For example, any intervertebral lumbar disc pathology or facet jointrestriction/painwillbeaffectedduringthistestandwillgivethetherapistafalse-positiveresult.

Figure7.50.ThelefthandapproximatestheheadofthefibulaiftherightQLisofnormallength.

METTreatmentoftheQL

PIRMethod

Thepatientisaskedtoadopttheshapeofabananaonthecouch:thisisachievedbythepatientassumingaside-lyingsupineposition,withtheirrighthandplacedunderneaththeirhead,andtheirrightlegovertheirleftleg.Theleftlegoverliestheedgeofthecouch,asshowninFigure7.51.

Figure7.51.Thepatient’srightQListakentothepointofbindbyassumingthe“banana”position.

Once thepatienthasadopted thisposition, the therapistplaces their righthandunder theheadof thepatient and cradles the right axilla.The left handof thetherapiststabilizesthepatient’sleftpelvis.

From this position, the patient is asked to side bend to the right against theresistanceappliedtotheiraxillabythetherapist’srighthand(Figure7.52).ThiswillinduceaPIRmethodofcontractionintheirrightQL.

Figure7.52.Thepatientsidebendstotherightwhilethetherapist’slefthandstabilizesthepatient’sleftpelvis.

After a 10-second contraction, and during the relaxation phase, the therapist

inducesfurthersidebendingtotheleft,whichwilllengthentheQLontherightside.

ReciprocalInhibition(RI)Method

ThepositionofthepatientandtheprocedurearesimilartothoseexplainedforthePIRmethod,theonlydifferencebeingthatwhenthetherapistencouragesthenewpositionofbind,thepatientisaskedtoreachtheirlefthandtowardtheirleftleg (Figure 7.53). Thiswill induce a contraction of the leftQL and cause therightQLtorelaxthroughRI,allowingalengtheningtooccur.

Figure7.53.Thepatientisaskedtoslowlysidebendtotheleftasthetherapistguidesthemotion.ThisinducesanRIeffectintherightQL.

AlternativeMETfortheQL

ForanalternativeMETfortheQL,thepatientisplacedinaside-lyingposition,with their left leg off the side of the couch, as shown in Figure 7.54. Thetherapist stabilizes the lower ribs (attachmentof theQL)with their right handand controls the patient’s left legwith their left hand. The patient is asked toabduct their left leg against the resistance applied by the therapist’s left hand;thiswillinduceaPIRcontractionoftheleftQLmuscle.

Figure7.54.Thepatientabductstheirleftleg,whilethetherapist’srighthandstabilizesthelowerribs.

After a 10-second contraction, and during the relaxation phase, the therapistslowly and passively takes the patient’s left leg into further adduction whilestabilizingthepatient’slowerback(Figure7.55).ThiswilllengthentheQLontheleftside.

Figure7.55.Thetherapiststabilizesthelowerbackandgentlyappliescephalicpressuretothe12thribwiththeirrighthandwhileencouragingadductionoftheleftleg.

Tip:TheQLcanbecomeoveractive and subsequently shorten if thecontralateral (opposite) Gmed is weak. It can also be strained byoverreaching to one side, for example to the right; in this case, thestrainsustainedtotheleftsidewillresultinaprotectivespasmoftheleft QL. If the left QL becomes shortened, it will appear as if aniliosacralupslip (seeChapter12)hasoccurredon the left sideof theinnominatebone.

8TheHipJointandItsRelationshiptothePelvis

Almost every time I give a lecture on the areas of the pelvic girdle, hip, andgroin,orevenonthekneeandanklejointcomplex,Ialwayshearmyselfsayingthefollowingtomystudents:

“Ifonehasanunderlyingpathologywithinthecomplexityofthehipjoint,thenthiswill eventuallybecomeapotential site forpain anddysfunction indistantsitesof thebody, especially in certainareasof thepelvis and lowerback, andeveninthekneejointandlowerlimb.”

Aftersaying this I tend to remind thestudentsof the famouswordsofDr. IdaRolf:

“Wherethepainis,theproblemisnot.”

ThischapterwillhopefullyhighlightthosewisewordsofDr.Rolf,whichrelateto not focusing our treatment where the pain is (i.e. the patient’s presentingsymptoms).Weasphysicaltherapists(whoIcall“detectivesoftherapy”)shouldtry to isolate theunderlyingcauseofapatient’spresentingpainand trynot tosimply“rubwhereithurts.”

IhaveseenagreatmanypatientswhohavepresentedtotheclinicwithwhathasbeendefinedorclassifiedasthetypicalpresentationofSIJpain,mainlybecausethepresentingpainis locatedinthisparticularareaof thepelvis.Atmysportsinjury and back pain clinic at the University of Oxford, I must have seenthousandsofpatientspresentingwithongoingpain in the lumbarspine, lateralhip,groin,buttocks,adductormuscles,andhamstringmuscles,aswellasinthekneejointandlowerlimb;theunderlyingcauseoftheirpain,however,istobefoundinacompletelydifferentstructure/tissue/sourcethantheareaofthebodythatsuffersthepain.

Nowwhenyou read this, I don’twant you to jump to any conclusionson thebasis of what I have just said. I am not saying that every time your patient

presentswithpainsomewhereintheirbodytheprimarycauseoftheirsymptomsrelatestothisspecificchapteraboutthehipjoint.However,occasionallyitmaywellbethatsomeunderlyingpathologylocatedwithinthehipjointcomplexisactually the key to unlocking the patient’s presenting symptoms.The focus ofthischapterisnaturallybiasedtowardthehipjoint,sotheextraknowledgeyouwill gain from reading it will potentially provide some of the answers to thequestionsyoumighthavebeenaskingyourselfaboutyourownpatients,orevenaboutsomeoftheissuesregardingyourownpresentingsymptoms.

Thischapterinitselfwillhopefullyguideyoualongtherightpathway.Theextrainformation you will gain through reading it should at least assist you inprovidingthecorrectmanagementstrategyforyourpatients:thiscanbethrougheithertreatingusingmanualtherapytechniquesorpossiblyevengivingyoutheconfidencetoreferpatientstoaspecialistforasecondopinion.

The assessment processes that I will be demonstrating below will help youformulate an accurate hypothesis of what might be the underlying causativefactor responsible formaintainingyour patient’s presenting symptoms.That iswhyIalwaysliketo“screen”thehipjointsofalmosteverypatientwhowalksthrough the clinic door—I personally want to make sure that there are nounderlying pathological changes within this joint, especially when patientspresentwith pain located in the areas of the pelvic girdle, lumbar spine, kneejoint,andsoon.

HipJointAnatomy

As I am sure you are aware, the hip joint (iliofemoral joint) is classified as asynovial ball and socket joint. This joint consists of the head of the femurarticulatingwiththesocket(acetabulum)ofthepelvicgirdle,whichismadeupofthreebones—theilium,ischium,andpubis.Becauseofthemultiaxialmotionthatispossibleatthehipjoint,itwillnotcomeasasurprisethatitisoneofthemost mobile joints of the body. Given its inherent architecture of a deepacetabulum (socket), however, the jointhas agreatdealof stability aswell asmobility(Figure8.1).

Figure8.1.Anatomyofthehipjoint(iliofemoraljoint).

Themotionpossibleatthehipjointcanvarybetweenindividuals,butthenormalrangesare:

•flexion:0–130degrees

•extension:0–30degrees

•internalrotation:0–35degrees

•externalrotation:0–45degrees

•abduction:0–45degrees

•adduction:0–25degrees

Asalreadyexplainedinpreviouschapters,thepelvicgirdleiscapableofanteriorand posterior rotation/tilt, while at the same time the lumbar spine is eitherflexingorextending.Allpelvicgirdlerotations/tilts/motionsactuallyresultfrommotionatoneormorelocations—thelefthip,therighthip,orthelumbarspine.It is not essential formovement to occur in all three of these areas; however,motionmustexistinoneofthemforthepelvistorotate.

Table 8.1 highlights specific motion at the pelvic girdle and the associatedmotionsofthelumbarspineandhipjoints.

Pelvicmotion/rotation Lumbarspinemotion Righthipmotion Lefthipmotion

Anteriortilt Extension Flexion Flexion

Posteriortilt Flexion Extension Extension

Leftlateralshift Leftsidebending Abduction Adduction

Rightlateralshift Rightsidebending Adduction Abduction

Lefttransverserotation Righttransverserotation Externalrotation Internalrotation

Righttransverserotation Lefttransverserotation Internalrotation Externalrotation

Table8.1.Pelvic,hip,andlumbarmotionguidelines.

ScreeningtheHipJoint

Withregardtoscreening,orassessing,thehipjoint,Itendtohaveafewsimplediagnostic tests thatwill either confirm or discount the presence of associatedpathologywithinthejoint:

1.PassiveROMforexternalrotation

2.PassiveROMforinternalrotation

3.PassiveROMforflexion

4.Quadranttest

5.FABERtest

6.FAIRtest

7.ThomastestandmodifiedThomastest

These tests are simply used as guidelines in screening for any underlyingpathologythatmightbeassociatedwiththehipjoint.Remember,thisbookisallabout thepelvis,notabout thehip joint.Nevertheless,oneneeds tomakesurethat the hip joint in itself is not responsible, or even partly responsible, fordysfunctionandpaininthepelvicgirdleorlumbarspineregions.ThetestsIwillbedemonstratingforthehipjointaretakenfrommyownexperiencesoftreating

thousandsofpatients,somuchsothatIhaveincludedsomeofmyownthoughtson thewayonemight apply someof the tests.Therearenumerousother teststhatcanbeusedtoscreenthehipjoint,butthatwillbethechoiceofthetherapistatthattimeintheirownclinicwiththeirownpatients;asIhavesaidalready,thetests I am demonstrating here have been selected on the basis of my ownpersonalexperienceandpreferences.

ThespecificpassiveROMtestsgiveninthischapterforscreeningthehipjointsforpathologyareusedinparticularforidentifyingtheawarenessonewouldfeelthrough one’s hands at the end range of the joint that is being tested; thistechnique is called the joint end feel. The end feel of a joint is basically thequality ofmovement that is perceived by the therapist at the very end of theavailableROM.The joint end feel can reveal a great deal about the nature ofvariouspathologieslocatedwithinthejointthatisbeingtested.

There are four commonclassificationsofwhat is considered tobe a “normal”joint end feel (or joint end range) andwhich are typically presentwithin anysynovialjoint:

•Softendfeel,e.g.kneeflexion

•Hardendfeel,e.g.elbowextension

•Muscularendfeel,e.g.hipflexion(hamstrings)

•Capsularendfeel,e.g.externalrotationoftheshoulderjoint

When you are assessing your patients/athletes, and especially when you areperformingthepassiveROMtests,youmayexperience(throughyourhands)adifferenttypeofjointendfeeltowhathasalreadybeendescribedasa“normalendfeel.”Inthiscaseyoucanassumethatthereiswhatiscalledapathologicalendfeelpresentwithin thearchitectureof the joint; thispositive testshouldbenoted down, and further investigation, or even a referral to a specialist,mightsubsequentlybenecessary.

Please remember that patients have two legs and one should perform acomparisonbetweenthetwo,justtomakesurethatanactualpathologyisindeedpresent.Forexample,ifyoupassivelytakethepatient’slefthipintofullflexion,witharangeofatleast130degreesbeingachievedwithnopainorstiffness,andyour patient is comfortable at the end of the available range, then one can

assumethatthismovementisnormalandnopathologyispresent.Suppose,ontheotherhand,onlyaround110degreesofflexionorlesscanbeachievedwhenthesamemovement(flexion)isperformedontherighthip,andtheendrangeofthejointalsobecomesparticularlypainfuland/orfeelsrestrictivetoyourpatient(especially in the groin area); in addition, you perceive a “harder end feel”duringthemovement.Fromthesefindings,youcansafelysaythattheROMoftherighthipisnotnormal;moreover,becauseof therestrictive/painfulbarrier,theendfeelwouldbeclassifiedaspathological,meaningthatthetestispositiveandfurtherinvestigationisrequired.

Justawordofcaution:inthepastIhaveassessedrelativelyyoungpatientswhohave actually demonstrated restrictions in some of the passive ROM tests forbothoftheirhipjoints;however,becausethemotionandtheROMarethesameonbothsides,wewouldstillregardthismovementasbeingnormalintermsofROM.

Another thing to consider when a hip joint has restricted internal/externalrotation is the possibility that this is caused by a pelvic dysfunction. Forinstance, suppose a patient has a right anterior innominate rotation (the mostcommondysfunction):internalrotationoftherighthipwillusuallybelimited,comparedwiththeleftside,andexternalrotationofthelefthipwillbelimited,compared with the right side. If the patient has a suspected left anteriorinnominaterotation,theoppositewillbefound:aleftinternalrotationrestrictionandarightexternalrotationrestriction.

Rotational restrictions of the hip joint can occurwhen pelvic dysfunctions arepresent,eventhoughthetotalpassiveROMininternal/externalrotationforeachhip jointwill be very similar.What Imeanby that is the following.Take thecaseofapatientpresentingwiththemostcommonmalalignmentsyndromeofarightanteriorinnominaterotation,withacompensatoryleftposteriorinnominaterotation.Becauseof thepelvicmalalignment, therighthip is restricted to,say,only25degrees(35degrees isclassifiedasnormal)on testingpassive internalrotation,andithasanincreasedrangeof55degrees(45degreesisclassifiedasnormal) on testing passive external rotation; this gives a total ROM of 80degrees.The lefthip,however,demonstratesan increased rangeof55degreesforinternalrotation,butalimitedrangeofonly25degreesforexternalrotation,thusalsogivingatotalROMof80degrees.

The discrepancy between the two hip joints on passive testing arises mainly

because of the altered malalignment position of the right and left innominatebones,whichhasadirect relationship to thepositionof theadjacenthip joint.Becauseofthisrelationship,achangeinthepositionoftheinnominatebonewillhaveadirecteffectonthepositionofthecorrespondingacetabulum(hip).

Onrealignmentofthepelvis,oneusuallyfindsanimprovementinROMtotheextentthatthefindingsfortherotationalcomponentsforboththeleftandrighthipsarenormal/equal,evenifthetotalROMremainsthesame(i.e.80degreesin this case). Pelvic corrections can, however, be very effective in improvingoverallhipROM,providedtherearenounderlyingstructuralpathologiespresentwithin thehip joint (corrections forpelvicgirdledysfunctionsareexplained inChapter13).

1.PassiveROMforExternalRotation

Thetherapistpassivelyflexesthepatient’shipandkneeto90degrees(Icallitthe90/90position),asshowninFigure8.2(a);onehandisplacedoverthekneeandtheotherhandattheankle.Thehipjointisthenpassivelytakenintoexternalrotation. A normal joint end feel range of 45 degrees should be achieved, asshownoverleafinFigure8.2(b).

Figure8.2.PassiveROMtests:(a)Thelefthipandkneearepassivelytakeninto90degreesofflexion—the90/90position.

Figure8.2.(b)Thelefthipispassivelytakenintoexternalrotationthroughanormalrangeof45degrees.

2.PassiveROMforInternalRotation

The therapist passively flexes the patient’s hip and knee to 90 degrees (asabove),withonehandplacedoverthekneeandtheotherhandattheankle.Thehip joint is thenpassively taken into internal rotation.Anormal joint end feelrangeof35degreesshouldbeachieved,asshowninFigure8.2(c).

Figure8.2.(c)Thelefthipispassivelytakenintointernalrotationthroughanormalrangeof35degrees.

3.PassiveROMforFlexion

The hip joint is passively taken into full hip flexion. A normal joint end feelrangeof130degreesshouldbeachieved,asshowninFigure8.2(d).

Figure8.2.(d)Thelefthipispassivelytakenintoflexionthroughanormalrangeof130degrees.

Note:YoucanseefromFigure8.2(e)thattherightleghasliftedoffthecouchduringthemovement;thispotentiallyindicatesarelativeshortnessoftherightiliopsoasmuscle.ThistestisalsoknownastheThomastestandisutilizedtolookforafixedflexiondeformityofthehipjoint,normallycausedbyatightiliopsoas.

Figure8.2.(e)Therighthipisseentobeheldinflexion,indicatingashortiliopsoasmuscle(Thomastest).

4.QuadrantTest

Thequadranttestisdesignedtoassesstheinnerandouterquadrantsofthehipjoint.Thetherapistpassivelyflexesthepatient’shipto90degrees;onehandisplacedoverthekneeandtheotherhandattheankle.Next,thetherapistappliesaforce longitudinally through the long axis of the femur, as shown in Figure8.3(a).Thetherapistthenabducts(withcompression)thehipinordertoassessthe outer quadrant, as shown in Figure 8.3(b), and adducts the hip (withcompression)toassesstheinnerquadrant,asshowninFigure8.3(c).

If there were any underlying pathology located within the hip joint, this testwouldbepositive,asindicatedbythemotionbecomingresistant,aswellasthepatientperceivingsomeformofdiscomfortorevenpain.

Figure8.3.Quadranttest:(a)Thelefthipiscompressedinneutral(90degrees).

Figure8.3.(b)Theouterquadrantistestedthroughabductingandcompressing.

Figure8.3.(c)Theinnerquadrantistestedthroughadductingandcompressing.

5.FABERTest

TheFABERtest(orPatrick’s test,namedafterHughTalbotPatrick)relates tothespecificmotionofflexion,abduction,andexternalrotation.

The therapistplaces thepatient’ship intoapositionof flexion,abduction,andexternal rotation,as shown inFigure8.4.Thepresenceofa restrictionorpainmight indicate a pathological changewithin the hip joint or possibly a pelvic(SIJ)dysfunction,especiallyifthismotionisparticularlypainfultotheSIJ.Let’slookatanexample.Ifyounoticethattheleftsideisrestrictedorpainful(tothe

groinor lateralhip),while tryingtosimplyplaceyourpatient intotheFABERpositionofflexion,abduction,andexternalrotation,thenthiscouldbecausedbya pathological condition within the left hip joint. Alternatively, therestriction/paincouldactuallyberelatedtotheright-sideinnominatebeingheldinapositionofanteriorrotationandshowingapositiveFABERtestontheleftside; in thiscaseacorrectionof therightanterior innominate(seeChapter13)might improve the overall interpretation of the FABER test on the left side.However, if an innominate correction makes no difference whatsoever to theFABERposition,onecanassumethat there iseitheranactualmusculoskeletalissuepresentwithinthehipjoint,ortheSIJisimplicated(ifthereispaininthearea of the posterior part of the pelvis, near to the PSIS); both of thesepathologicalconditionswouldrequirefurtherinvestigation.

Figure8.4.FABERtest:testingthelefthip.

6.FAIRTest

The FAIR test stands for flexion, adduction, and internal rotation and iscommonlyused to identifypiriformis syndrome (this test is alsoknownas theFADIR test—flexion,adduction, internalrotation).For the particularmotion Iwill be demonstrating, however, I have modified the test to rule out anyunderlyingpathologywithinthehipjoint.

The patient adopts a supine position and the therapist places the patient’s hipintoastartingpositionofflexion,abduction,andexternalrotation,asshownin

Figure8.5(a); the therapist thencontinues themotion,with flexion, adduction,andinternalrotation,asshowninFigure8.5(b).If thereisarestrictionorpainpresent (normally feltwithin thegroin area) during this test, thenpathologicalchanges within the hip joint might be indicated. However, if the patientperceivespainonlytothecentralpartoftheirbuttocks,andnottotheareaofthegroin,thenthepiriformismusclewouldbeimplicated.

Figure8.5.FAIRtest:(a)Startingpositionfortestingthelefthip.

Figure8.5.(b)Finishingpositionfortestingthelefthip.

7.ThomasTestandModifiedThomasTest

ThomasTest

This test is used to look for a fixed flexion deformity of the hip joint and therelationshiptotheapparentshortnessof thehipflexorsandinparticularof theiliopsoasmuscle.

Thepatient is asked to lie on their backon the couch andholdonto their leftknee.As thepatient rollsbackward, theypull their leftkneeasfaras theycantowardtheirchest(thetherapistcanassistwiththismotionifneeded),asshown

inFigure8.6(a).Thefullflexionofthehipencouragesfullposteriorrotationoftheinnominateboneandhelpstoflattenthelumbarlordosis.Anormallengthofthe iliopsoas,andanegative test,willbe foundwhere the rightposterior thighstaysinactualcontactwiththecouch,asshowninFigure8.6(a).

Figure8.6.Thomastest:(a)Anormallengthoftherightiliopsoas,asindicatedbytheposteriorpartofthehipincontactwiththecouch.

Afixedflexiondeformity,potentiallycausedbyshortnessoftherightiliopsoas,is indicated if thepatient’s right hiphas liftedoff the couch, as shownby thearrowinFigure8.6(b).

Figure8.6.(b)Therighthipisoffthelevelofthecouch,indicatingashortnessoftheiliopsoas.

ModifiedThomasTest

YoumayrecallthatthistestwasdemonstratedinChapter7onMETs;however,itisimportanttomentionthetestagain,asIbelieveitisveryrelevant,especiallyasthespecificmusclestested(iliopsoas/rectusfemoris)willhaveadirecteffectonthehipjointaswellasonthepelvis.

ThemodifiedThomastestisusedtotestforrelativeshortnessoftheiliopsoas,rectusfemoris,adductors,andTFL/ITB.Ialwayspointouttomystudentsthatthe iliopsoasmuscle inparticular (outof all themusclesmentioned) is alwaysinvolvedinonewayoranotherinanypathologicalchangestothehipjoint,aswellasbeinganintegralpartofthefunctionalityofthepelvisandlumbarspine.

Totesttherighthip,thepatientisaskedtoliebackontheedgeofacouchwhileholding onto their left knee.As they roll backward, the patient pulls their leftkneeas far as theycan toward their chest, as shown inFigure8.7(a).The fullflexionofthehipencouragesfullposteriorrotationoftheinnominateboneandhelpstoflattenthelumbarlordosis.Inthisposition,thetherapistlooksatwherethe patient’s right knee lies, relative to the right hip.Theposition of the kneeshouldbe justbelow the levelof thehip;Figure8.7(a)demonstratesanormallengthoftherightiliopsoasandrectusfemoris.

Figure8.7.ModifiedThomastest:(a)Therightkneeisbelowthelevelofthehip,indicatinganormallengthoftheiliopsoasandrectusfemoris.

InFigure8.7(b)thetherapistisdemonstratingwiththeirarmsthepositionoftheright hip comparedwith the right knee.You can see that the hip is held in aflexedposition,whichconfirmsthetightnessoftherightiliopsoasinthiscase.Atight rectus femoris muscle can also be seen, because the knee is held inextension.

Figure8.7.(b)Atightrightiliopsoasisconfirmed.Becausethekneeisheldinextension,atightrectusfemorisisalsoevident.

WiththepatientinthemodifiedThomastestposition,thetherapistcanapplyanabduction of the hip (Figure 8.8), and an adduction of the hip (Figure 8.9).AROMof10–15degreesforeachoftheseiscommonlyacceptedtobenormal.

Ifthehipisrestrictedinabduction,i.e.abindoccursatanangleoflessthan10–15 degrees, the adductor muscles are held in a shortened position; if theadductionmovement is restricted, theITBand theTFLareheld inashortenedposition.

Figure8.8.Restrictedhipabduction,indicatingtightadductors.

Figure8.9.Restrictedhipadduction,indicatingatightITB/TFL.

HipJointPathology

Mitchelletal.(2003)carriedoutastudyentitled“Hipjointpathology:Clinicalpresentation and correlation between magnetic resonance arthrography,ultrasound,andarthroscopic findings in25consecutivecases.”Theydiscussedthatthehipjointisbecomingincreasinglyrecognizedasasourceofgroinpainaswellasbuttockandlowerbackpain.

In their study they found that all of the subjects’ hips had undergone anarthroscopy at some stage, and that they had some underlying pathology;

furthermore,72%ofthepatientsexaminedreportedpaininthelumbarspineandalsointhegroinarea.Someofthepatients,however,presentedwithpaininthebuttocks(36%), lateralsideofknee(20%), thigh(16%),hamstring(12%),andsciaticnerve(16%),andevenintheareaoftheabdomen(8%).

Those authors mentioned that, although back pain is a very commonmusculoskeletalsymptom,apossiblecauseofthebackpainseenwithhipjointpathologyisthecloseassociationofthepsoasmusclewiththeanteriorsurfaceofthehipjoint.

Theonlyconsistentlypositiveclinicaltestresultwasarestrictedandpainfulhipquadrantcomparedwiththecontralateralhip(thepaininthistestcouldbeinthegroin, lateralhip,buttock,or lowerback).Itshouldbenotedthatapainfulhipquadrantcanalsoarisefromsomeotherlocalpathology(suchasapsoasbursitisor tendinopathy), and that a tight hip quadrant can arise from tight glutealmuscles. A positive FABER test result was found in 88% of the subjectsexamined,withpainusually in the lateralhip,butoccasionally in thegroinorbuttock. The differential diagnosis of a positive FABER test result is SIJpathology,especiallyifitreferstothecontralateralbuttock.

Theconclusionwasthathippathology,particularlyacetabular labralpathology(68%diagnosedwithlabraltears),mightbemorecommonthanhadpreviouslybeen thought. In those patients with chronic groin and lower back pain,especiallywherethereisahistoryofanacuteinjury,ahighindexofsuspicionshouldbemaintained.Clinical signsofapainful, restrictedhipquadrantandapositive FABER test result should suggest magnetic resonance (MR)arthrography in the first instance, and the consideration of hip arthroscopy ifpositive.

AcetabularLabralTear

Theacetabularlabrumisaringoffibrocartilagethatconnectsaroundtherimofthe acetabulum; its main function is to help deepen the socket to assist inpreventing dislocations. It is similar to the glenoid labrum located within theshoulderjoint.

Some patients and athletes (mostly women) who I have seen have torn thelabrummainlythrougharotatorytypeofsportingmotion,e.g.aerobics,skiing,or hockey. However, I have also come across a lady who tore her right

acetabularlabrum(Figure8.10)byforcefullytryingtopullherwellingtonbootout of themudwhen it got stuck.There are other types of injurymechanism,suchasafall;asdiscussedinthecasestudylater,thistraumacausedthepersoninquestiontosustainatearofthelabrum.

Figure8.10.Acetabularlabraltear.

Patientsgenerallytendtohavesomediscomfortintheareaofthegroin.Thisisnotalwaystrue,however—somehavepaininallsortsofplaces(thinkbacktotheMitchellresearcharticle),andonewouldnotevenconsider thehipjoint tobetheresponsiblestructureinthosecases.

It has been said that patients who have an acetabular labral tear do not getdiagnosedforatleast18monthstotwoyears;Ibelievethelikelyreasonforthisisthatthemajorityofphysicaltherapistshavedifficultyinconfirmingthetear.Thismustalsobetrueofme,especiallyinmyclinicatOxford,asthemajorityofpatientswhoIconsider tobepresentingwithasuspect labral tearhavehadpain,aswellasarestrictedmotionofthehipjoint,forwelloverayear.WhatIhave also noticed in the past is that most of my patients diagnosed with anacetabularlabralteararefemale.

I remember once discussingwith a patient on the telephone the pain shewassufferingaroundthehipandgroinareas.Thenextbitmaysoundratherstrange,butwhile Iwaschatting toher Iaskedher to lieon the flooronherbackandbringherkneeall theway towardherchestonhernon-symptomaticside.Shereported back, saying that themovementwas no problem and that no pain orstiffness was felt. I then asked her to repeat the same movement on thesymptomaticside;thistimeshesaiditwasastruggletoperformthemovementwithoutpain,andhergroinareawasparticularlystiff.ItoldhertogoforanMRIscanofherhipjoint,asIsaiditwasprobablyalabraltear.Mytheoryofherhipproblemwascorrect,assheemailedmea fewweeks later to tellme thenewsand toalsosay that shewasbeingscheduled foranarthroscopy to resolve thetear.

A clicking sensation and even a locking type of feeling in the groin area aresomeofthesymptomsthatpatientshavementionedtome.Istronglybelievethatthe longer the labral tear is left (without treatment), themore thehip jointwillaccumulate deterioration and permanent damage, e.g. osteoarthritis, especiallylateroninlife.

CaseStudy

AnosteopathfriendofmineaskedmeifIcouldhavealookather,asshewassuffering from pain that she felt was located in the right lower part of herbuttock,neartotheareaoftheischialtuberosity.However,shealsomentionedthatsometimesshewouldfeelthepaininotherareasofherbody,forexampletotheupperpartofherrighthamstrings;atothertimes,shewouldfeelthepaininthecentralaspectofherrightbuttock.Weirdly,onyetanotherday,thepainwasfeltinthegreatertrochanterofherrighthip—veryconfusingorwhat?

Thehistorywasveryimportant,astheinitialinjurysustainedoccurredwellover

fourmonthspreviously.Ithappenedwhileshewasrunningandshefellonsomeice, landingheavilyon the right sideofherbody; she said itwasanasty fall,because at the time, she experienced a lot of pain, and there was substantialbruisingaroundtherighthipandthigh.

Sherestedforaweekorso,buteverytimeshewentforarunshefeltpaininoneof the four areas that I have already mentioned. She had consulted a fewpractitioners during that time and received various opinions on the diagnosis.Some said the pain originated from a disc prolapse, while others said it wascaused by a hamstring tendinopathy, piriformis syndrome, trochanteric andischialbursitis,asacrotuberousligamentsprain,andevenfacetjointsyndrome,to name but a few conditions. She had anMRI scan of her lumbar spine andpelvis,butnothingofrelevancewasfound.

Imust admit thatwhen I palpated the potential sites of pain, the areas of theischial tuberosity, sacrotuberous ligament, piriformis, and trochanteric bursawere particularly tender. One might suspect any of these structures to beresponsible for her pain; I even considered that the lumbar spine might beresponsible,asafterinitiallyscreeningherhipjoint,Ifoundnothingofconcernatthetimeoftheexamination.

Afewweekspassed,andafteralongrunofapproximately10miles(16km),thepatient felt pain in her groin and started to run with a limp because of thediscomfort.HerGPwasa littlefrustrated,as theMRIofher lumbarspineandpelvisconfirmednopathologywaspresent,soalocalcorticosteroidwasinjectedintothehipjoint,justtoseeifthesymptomswouldchange.Thepainseemedtoreduce almost immediately, especially over the following few days; she wasthereforescheduledforanMRarthrogramofherhipjoint,andaposteriorlabraltear of the acetabulum was eventually diagnosed. The labral tear was quitesubstantial, so an arthroscopy was performed and the labrum repaired. Thepatient isnowable torunwithnopain inanyof theareas initiallyreportedasproblematic.

ThiscasestudyhopefullyreinforcesDr.IdaRolf’swordsregardingnottreatingwhere the pain is. If the area of the above patient’s presenting pain had beentreated,thenwithoutadoubtshewouldnothavegottenanybetterunlessshehadsimplyrestedcompletelyfromrunning,whichinthiscaseshedefinitelydidnotwanttodo.

FemoroacetabularImpingement

Another pathological problem associated with the hip joint that I have comeacross many times in my patients is a condition called femoroacetabularimpingement(FAI).Thisconditioncanalsoberesponsibleforcausingareferredtypeofpaintovarioussitesofthebody,similarlytothepresentingsymptomsofanacetabularlabraltear.

The words “femoroacetabular impingement” relate to an area of entrapmentbetweenthefemur(thighbone)andtheacetabulum(socket).Thisisaconditionwhereby some of the soft tissues around the hip joint are being compressed(impinged), and this pathology is generally considered to be caused byabnormally shapedbonesat this joint.Becauseof thealtered shape, the femurandtheacetabulumdonotfittogetherperfectly,hencethereasonwhytheystarttorubagainsteachotherandcausedamageinthejoint.

With femoroacetabular impingement, bone spurs tend to develop around thefemoralhead (ball) and/or along the acetabulum (socket) of thehipbone.Theextraboneovergrowthcausesthesebonestorubagainsteachother,ratherthanglidingsmoothly.Overtime,thiscanresultinthetearingofthelabrumandthebreakdown of articular cartilage, which can eventually cause degenerativechangesthatcanlaterleadtoosteoarthritis.

TypesofFAI

TherearethreemaintypesofFAI:cam,pincer,andcombinedcamandpincer.

1.Cam-TypeFAI

Cam-type FAI is generally more frequent in men than in women. With thisconditionthefemoralheadisnotasroundasitnaturallyshouldbeandcannotrotatesmoothlyinsidetheacetabulum.Abumpformsontheedgeofthefemoralheadthatcanhavetheappearanceofa“pistolgrip”(Figure8.11).Asaresultofthisextragrowthofbonespur,increasedshearing-typeforcesareplacedonthearticularcartilageandalsoontheacetabularlabrum.

Figure8.11.Cam-typeimpingement.

2.Pincer-TypeFAI

Apincer-type impingement occursmore often inwomen than inmen. In thiscase an extra bonegrowth extendsout over thenormal rimof the acetabulum(Figure 8.12).As a result of this pincer-type impingement, the labrum can beforcefully compressed and subsequently torn under the prominent rim of theacetabulum.

Figure8.12.Pincer-typeimpingement.

3.CombinedCam-TypeandPincer-TypeFAI

Combined impingement justmeans thatboth thepincer and thecam types arepresentsimultaneously(Figure8.13).

Figure8.13.Combinedcam-typeandpincer-typeimpingement.

Withfemoroacetabularimpingement,patientstendtohavepaininitiallyintheirgroin; this is normally associated with symptoms of clicking, locking, orcatching, especially when chronic impingement has resulted in an acetabularlabral tear. When a labral tear and FAI both exist at the same time, thepresenting symptoms tend to get worse, usually with prolonged periods ofstanding, sitting, or walking, but particularly with pivotal movements on theaffected leg. Because of the chronicity of the condition, secondary problemsnaturallytendtobepresent:forexample,somepatientsmaylimpbecauseofthepainandstiffness,andsomemaypresentaTrendelenburgsign.Otherpatientscanexperienceongoingpainintheirbuttocks,lowerback,andSIJs,aswellasin

theirthighsandknees.

9TheGlutealMusclesandTheirRelationshiptothePelvis

This book is obviously focused on the pelvic girdle and the sacroiliac joint;however, I think Iought tomention the roleof theglutes in this text,as thesespecificmusclesareacorecomponentoftheoverallfunctionandstabilityofthepelvicgirdle.

The objectives of this chapter are to look at the specific relationship of theglutealmusclestotheareaofthepelvis,andhowanydysfunctionthatmightbepresent within the pelvic girdle can cause a misfiring or potential weaknessinhibitionoftheactivationoftheglutealmusculature.

For this chapter I will concentrate on the anatomy, function, assessment, andrelationship to the pelvis of only the gluteus medius (Gmed) and gluteusmaximus(Gmax)muscles.

GluteusMedius(Gmed)

Figure9.1.Origin,insertion,action,andnerveinnervationoftheGmed.

Origin

Outer surface of the ilium, inferior to the iliac crest, between the posteriorgluteallineandtheanteriorglutealline.

Insertion

Obliqueridgeonthelateralsurfaceofthegreatertrochanterofthefemur.

Action

Upperfibers:Laterallyrotateandmayassistinabductionofthehipjoint.

Anteriorfibers:Mediallyrotateandmayassistinflexionofthehipjoint.

Posteriorfibers:Laterallyrotateandextendthehipjoint.

Nerve

Superiorglutealnerve(L4,L5,S1).

FunctionoftheGmed

IfyouthinkbacktoChapter4justforamoment,youmayrecallthatwhenweinitiatestandingononeleg,weactivatewhatiscalledthelateralslingsystem;asalready explained, this system consists of the Gmed, Gmin, adductors on theipsilateralside(sameside),andtheQLonthecontralateralside(oppositeside),asshowninFigure9.2.

Potential weakness in the Gmed probably results from the overactivation ofothermuscles, because of the compensation process (whichwill be discussedbelow). Patientswhopresentwithweakness in theirGmed, particularly in theposteriorfibers, tendtohaveoveractiveadductormusclesandITBthroughtheconnectionwith theTFL; thepiriformiscanalsoplayanoveractive role if theGmedposteriorfibersareshowntobeweak.

TheGmedisthoughtofasthemusclethatiskeytodynamicpelvicstability.Forexample, in my experience, patients who like to run for pleasure, or evencompetitively,andwhohavepoordynamicpelvicstabilitybecauseofapossibleweaknessoftheGmed,willtendtoshortentheirstridelength;theywilladoptamoreshufflingtypeofpattern,therebyreducingthegroundreactionforceatheelcontact and decreasing the amount ofmuscle control required formaintainingpelvicposture.

Fig9.2.(a)Lateralslingsystem.(b)Lateralslingmusclesactivatedduringthegait/walkingcycle.

AssessmentoftheGmed

Whenever I look at patients who present with knee, lower lumbar spine, orpelvicpain,partofmyassessmentprocessincludescheckingthestrengthoftheglutealmusclesandinparticulartheGmed.Inthischapter,aswellasdiscussingthe functional rolesof thismuscleand theGmaxand their relationships to thepelvis,Iwillalsoincludethehipabductionandhipextensionfiringpatterntests,which are used for determining the correctmuscle firing sequences of the hipabductors/extensors(includingtheGmed/Gmaxmuscles).

In my opinion, the Gmed (and also the Gmax) should be assessed for everysinglepatientandathletewhopresentswithpainintheareasofthelumbarspineandpelvis,andeveninthelowerandupperlimbs.Manyathletespresenttomyclinicwithrunning-relatedoverusetypesofinjurytothelowerlimbaswellastothetrunk,andthemajorityofthemalsopresentwithwhatIconsidertobepoorGmed or Gmax (or both) function. I have come to the conclusion that thestrength and control of these muscles is probably the most important overallcomponentinachievingabiomechanicallyefficientpattern,especiallyinsportslikerunning.Thisisnotsosurprisingwhenyouconsiderthatduringrunningyouarealwayseithercompletelyintheairordynamicallybalancedononeleg.All

physicaltherapistpractitionersshouldbeabletoassessandrestorethefunctionofboththeGmedandtheGmax.

Let’stakeacloserlookattheanatomyoftheGmed:themuscleattachestotheentire length of the iliac crest, to the external iliumbetween the posterior andanteriorgluteallines,totheglutealfascia,totheposteriorborderoftheTFL,andtotheoverlyingITB.TheGmedisdividedintothreedistinctportions—anterior,middle, and posterior—which collectively form a broad conjoined tendon thatwraps around, and inserts onto, the greater trochanter of the femur. Themorevertical anterior and middle portions of the Gmed appear to be in a betterpositionforabductingthehipthanthemorehorizontalposteriorportions.

As mentioned above, the Gmed contains a posterior fiber component in itsstructureaswell asananteriorcomponent; it is theposterior fibers thatweastherapists are concernedwith. TheGmed posterior fiberswork in conjunctionwith theGmax,and these twomuscles inparticularcontrol thepositionof thehipintoanexternalrotation,whichhelpstoalignthehip,knee,andlowerlimbasthegaitcycleisinitiated.

As an example, consider a patient who is asked to walk while the therapistobservestheprocess.Whenthepatientputstheirweightontheir left legat theinitial contact phase of the gait cycle, theGmed is responsible in part for thestabilitymechanismactingonthelowerlimb;thiswillalsoassistintheoverallalignmentofthelowerlimb.Thepatientcontinueswiththegaitcycleandnowenters the stancephase.Contractionof the leftGmed in this phase of the gaitcycleisresponsibleinpartforallowingabduction;thinkofitasahitchingtypeofmotion to therighthip,even though the leftGmed iscontracting.Therightsideofthehipisthenseentostarttoliftslightlyhigherthantheleftside.Thisprocessisveryimportant,asitallowstherightlegtoliftasmalldistanceoffthefloorandwillnaturallyallowtheswingmotionoftherightlegduringtheswingphaseofthegaitcycle.

If thereisanyweaknessinthe leftGmed,thebodywillrespondinoneof twowaysduring thegait cycle: either thepelviswill tipdownon the contralateralside to the stance leg (right in this case), giving the appearance of aTrendelenburgpatternofgait(Figure9.3(a));oracompensatoryTrendelenburgpatternwillbeadopted,inwhichthepatientwillbeobservedtoshifttheirwholetrunkexcessivelytotheweakerhip(Figure9.3(b)).

Figure9.3.(a)Trendelenburggait.(b)CompensatoryTrendelenburggait.

Gmedweaknesswillnotonlyhave implications for theoverall stabilityof thepelvic girdle and lumbar spine, but also have an effect all the way down thekinetic chain, from heel contact to the mid-stance phase. A weakness of theGmedcancause:

•TrendelenburgorcompensatoryTrendelenburgpatternofgait

•Lumbarspinepathologyandsacraltorsions

•Hypertonicityinthecontralateral(oppositeside)QL

•Hypertonicityintheipsilateral(sameside)piriformisandTFLmusclesandtheITB

•Excessiveadductionandinternalrotationofthefemur

• Drifting of the knee into a valgus or possibly varus position, causing apatellamal-trackingsyndrome

•Internalrotationofthelowerlimb(tibia),relativetothepositionofthefoot

•Increasedweighttransfertothemedialaspectofthefoot

•Excessivepronationofthesubtalarjoint(STJ)

As you can see from the above list of consequences of a weakness in thefunctionoftheGmed,anathlete/patientisatcontinualriskofanysports-relatedinjury condition that is somehowcaused by increased side bending/rotation ofthelumbarspine(potentiallybecauseofTrendelenburggaitpatterns),aswellasbyotherbiomechanicaleffectstothekineticchain.Anincreasedlumbarmotionof side bending, coupled with rotation (normally to the opposite side), willsubsequentlycausethesacrumtorotateandsidebendindirectionsoppositetothemotionofthelumbarspine;asaresult,aforwardsacraltorsionmightnowexist,forexampleaL-on-LoraR-on-R,asexplainedinChapter2.

TheweaknessoftheGmedcanalsocauseprolongedover-pronationoftheSTJ,resultinginconditionssuchaspatellofemoralpainsyndrome,medialtibialstresssyndrome(shinsplints),plantarfasciitis,orAchillestendinopathy.

HipAbductionFiringPatternTest

To check the firing sequence on the left side, the patient adopts a side-lyingposturewithbothlegstogetherandtheirleftlegontop.Inthissequence,threemuscles will be tested: Gmed, TFL, and QL. The therapist palpates the QLmuscle by placing their right hand lightly on themuscle.Next, to palpate theGmedandTFL,thetherapistplacestheirfingerontheTFLandtheirthumbontheGmed,asshowninFigures9.4(a)and(b).

Figure9.4.(a)PalpationoftheQL,Gmed,andTFL.(b)Close-upofthehandposition.

Thepatientisaskedtolifttheirleftlegintoabduction,afewinchesfromtheirright leg, while the therapist notes the firing sequence (Figure 9.5). It isimportant to check for any compensatory or cheating recruitment.The idea ofthistestisthatthepatientmustbeabletoabducttheirhipwithout:(1)hitchingtheleftsideoftheirpelvis(hiphitchingwouldmeantheywereactivatingtheleftQLmuscle);(2)fallingintoananteriorpelvictilt;or(3)allowingtheirpelvistotipbackward.

Figure9.5.Asthepatientabductstheirlefthip,thetherapistnotesthefiringsequence.

ThecorrectfiringsequenceshouldbeGmed,followedbyTFL,andfinallyQLataround 25 degrees of pelvis elevation. If the QL or the TFL fires first, thisindicates a misfiring sequence, potentially resulting in adaptive shortness ofthesemuscles.

Once we have ascertained the firing sequence for hip abduction, we have todecideonthenextstep.MostpatientsfeelthattheyneedtostrengthentheweakGmedmusclebygoingtothegym,especiallyiftheyhavebeentoldthismuscleis weak, and they do lots of side-lying abduction exercises. The difficulty instrengthening the apparent weak Gmed muscle is that this particular exercisewillnot,Irepeatnot,strengthentheGmed,especiallyiftheTFLandQLarethedominant abductors. The piriformis will also get involved, as it is a weakabductor,whichcancauseapelvic/sacroiliacdysfunction, furthercomplicatingtheunderlyingissue.

Sotheanswer is to initiallypostponethestrengtheningof theGmedandfocuson the shortened/tight tissues of the adductors, TFL, and QL. In theory, by

lengthening the tight tissues through METs as explained in Chapter 7, thelengthenedandweakenedtissuewillbecomeshorterandautomaticallyregainitsstrength. If, after a period of time (two weeks has been recommended), theGmedhasnotregaineditsstrength,specificandfunctionalstrengthexercisesforthismusclecanbeadded.

Gmed“AnteriorFibers”StrengthTest

To test the anterior fibers of the left Gmed, the patient adopts a side-lyingposturewiththeirleftleguppermost.Thetherapistpalpatesthepatient’sGmedwith their right hand, and the patient is asked to raise their left leg intoabduction, a few inches away from the right leg, and hold this positionisometrically to start with. Placing their left hand near the patient’s knee, thetherapistappliesadownwardpressure to the leg.Thepatient isasked to resistthe pressure (Figure 9.6); if they are able to do so, the anterior fibers of theGmedareclassifiedasnormal.

Figure9.6.Thepatientabductstheirlefthipagainstresistancefromthetherapist.

Gmed“PosteriorFibers”StrengthTest

Intestingtheleftside,toputmoreemphasisontheposteriorfibersoftheGmed,the therapist controls the patient’s left hip into slight extension and externalrotation,asshowninFigure9.7.The therapistappliesadownwardpressureasbefore(Figure9.8); if thepatient isabletoresist thisexternalforce, theGmedposterior fibers are classified as normal. If you want to assess muscularenduranceasopposed tostrength,ask thepatient tohold theabducted legandmaintainthepositionforatleast30seconds.

Figure9.7.Externalrotationandslightextensionofthehip,whichemphasizestheposteriorfibersoftheGmed.

Figure9.8.Thetherapistappliesadownwardpressuretothepatient’sabductedhip.

Recall,fromtheearlierdiscussionoftheroleoftheGmedduringthegaitcycle,that a weakness of the Gmed can cause either a Trendelenburg or acompensatoryTrendelenburgpatternofgait.Thinkabout this,andthepossibleconsequencesofthisweakness,forasecond!Asyoustepontoyourleftleg,thelateralslinghastocomeintoplay:theleftGmedisthemainmuscleresponsibleforthecontroloftheheightoftherightsideofthepelvisasyoutrytostabilizeontheleftleg.IftheGmedmuscleontheleftisweak,thepelviswilldip(totheright) as you bear weight. The dipping actionwill typically cause the lumbarspinetosidebend(totheleft)androtatetotheright(TypeIspinalmechanics)and the facet joints on the left side, aswell as the intervertebral disc and theexitingnerve root, to compress, resulting inpain.This sidebendingmotion totheleftcanalsocausetheiliolumbarligamentontherightsideofthespine,aswellasotherstructuressuchasthejointcapsuleofthefacetjoints,tobeplacedinastretchedposition,whichcanalsobeasourceofpain(localorreferred).

I alsomentioned sacral torsion earlier—if the leftGmedmuscle isweak, thenbecauseof the sidebendingof the lumbar spine to the left and rotation to theright, the effect will be to cause an opposite motion to the sacrum; thus, the

sacrumwill side bend to the right and rotate to the left, as in aL-on-L sacraltorsion.

Let’slookatanotherexample.IftheleftGmedisweak,theopposite(right)sideQLwillcompensateandworkharderasit triestotakeontheroleoftheweakmuscle.This increased compensatory patternwill over time cause an adaptiveshorteningof the rightQL,which can result in the formationof triggerpointsandsubsequentlyleadtopain.

CaseStudy

Considerthefollowingscenario:apatientpresentstotheclinicwithpainlocatedintheright lowersideof their lumbarspine/superior ilium(QLarea),whichisexacerbated especially by walking/running for a certain length of time. Afterpalpating the right side of the patient’s lower back/QL area, the physicaltherapistsaysthemuscleis tightandproceedstoreleasethetriggerpoints thatmight have developed within. A contract/relax type of technique, such as anMET,might thenbeusedtoencouragenormalityof the lengthof theQL.Thepatientandtherapistareveryhappywiththetreatment,asmostofthepresentingsymptoms have now subsided. However, as the patient walks the 10-minutejourneybacktotheircartheQLpainresumes—why?BecauseaweakleftGmedisforcingtherightQLtoworkalotharderthanithasbeendesignedtodo,andthe therapist has only treated the presenting symptoms and not the underlyingcause! Remember the wise old words of Dr. Rolf—where the pain is, theproblemisnot!

Please note that any pelvic dysfunction found in your patient or athlete (asoutlinedinChapter12)canalsobeoneofthemainunderlyingcausativefactorsfor the presentation of a weakness/inhibition of the gluteal musculature. Themalalignment position of the pelvis can be the key to the problem, as thisdysfunction can naturally induce an overcompensatory mechanism in othermusclesofthebody.Thisisbecausethealteredpelvicpositioncannowcauseamisfiringsequence in thespecificactivationof theglutealmuscles, rather thanthese muscles simply being weak and misfiring because of the antagonisticmusclesbeingheldinashortenedandtightenedposition.

Intermsoftreatment,thissuggeststhattheglutealmuscleswillnotresumetheirnormalfiringsequencecapability,orevendeveloptheirinherentstrength,until

the pelvis has been realigned.Onemight find that the glutealmuscles resumetheirnormal firing sequenceand regain their strength simplyby realigning theposition of the pelvis. After the correction of the pelvic girdle, it isrecommendedtolengthentheantagonisticmuscles(butonlyifyoufeelitisstillappropriate),beforepromotingstrength-basedexercisesforthesemuscles.

Let’s quickly recap the above. The first thing I suggest is to correct anypresenting pelvic dysfunctions (Chapter 13). Next, if you still find shortantagonisticmuscles,IwouldsuggestlengtheningthesethroughMETs(Chapter7). Finally, I recommend simple strength-based outer core exercises, toencourageandmaintaintherealignedpositionofthepelvis(Chapter3).

GluteusMaximus(Gmax)

Figure9.9.Origin,insertion,action,andnerveinnervationoftheGmax.

Origin

Outersurfaceoftheiliumbehindtheposteriorgluteallineandaportionofthebonesuperiorandposteriortoit.Adjacentposteriorsurfaceofthesacrumandcoccyx.Sacrotuberousligament.Aponeurosisoftheerectorspinae.

Insertion

Deepfibersofthedistalportion:Glutealtuberosityofthefemur.

Remainingfibers:Iliotibialtractofthefasciaelatae.

Action

Assists in adduction of the hip joint. Through its insertion into the iliotibialtract,helpstostabilizethekneeinextension.

Upperfibers:Laterallyrotateandmayassistinabductionofthehipjoint.

Lowerfibers:Extendandlaterallyrotatethehipjoint(forcefulextension,asinrunningorstandingupfromsitting).Extendthetrunk.

Nerve

Inferiorglutealnerve(L5,S1,S2).

FunctionoftheGmax

From a functional perspective, the Gmax performs several key roles incontrollingtherelationshipbetweenthepelvis,trunk,andfemur.Thismuscleiscapable of abducting and laterally rotating the hip,which helps to control thealignmentof thekneewith the lower limb.Forexample, in stairclimbing, theGmaxwilllaterallyrotateandabductthehiptokeepthelowerlimbinoptimalalignment,whileatthesametimethehipextendstocarrythebodyupwardontothe next step.When theGmax is weak ormisfiring, the knee can be seen todeviatemediallyandthepelviscanalsobeobservedtotiplaterally.

TheGmaxalsohasaroleinstabilizingtheSIJsandhasbeendescribedasoneofthe force closure muscles. Some of the Gmax fibers directly attach to thesacrotuberous ligament and the thoracolumbar fascia, which is a very strong,non-contractile connective tissue that is tensionedby theactivationofmusclesconnectingtoit.Oneoftheconnectionstothisfasciaisthelatissimusdorsi,andtheGmaxformsapartnershipwith thecontralateral (opposite) latissimusdorsivia the thoracolumbar fascia—this partnership connection is known as theposteriorobliquesling(seeFigure9.10),whichwasdiscussedinChapter3.Thissling increases the compression force to the SIJ during the weight-bearingsingle-legstanceinthegait/walkingcycle.

Figure9.10.Posteriorobliqueslingandtheconnectionwiththelatissimusdorsi.

Misfiring or weakness in the Gmax reduces the effectiveness of the posteriorobliquesling; thiswillpredispose theSIJs tosubsequent injury.Thebodywillthen try to compensate for this weakness by increasing tension via thethoracolumbar fascia by in turn increasing the activation of the contralaterallatissimus dorsi. As with any compensatory mechanism, “structure affectsfunction” and “function affects structure.” This means that other areas of thebody are affected: for example, the shoulder mechanics are altered, since thelatissimusdorsi has attachments on the humerus and scapula. If the latissimusdorsiisparticularlyactivebecauseofthecompensation,thiscanbeobservedasoneshoulderappearinglowerthantheotherduringastep-uporalungetypeof

motion.

Asexplained inChapter4, theGmaxplaysasignificant role in thegaitcycle,working in conjunction with the hamstrings. Just before heel-strike, thehamstrings will activate, which will increase the tension to the SIJs via theattachment on the sacrotuberous ligament. This connection assists in the self-lockingmechanismoftheSIJsfortheweight-bearingcycle.Theintervalofthegaitcyclefromheel-striketomid-stanceiswherethetensioninthehamstringsshoulddecreasethroughthenaturalanteriorrotationoftheinnominate,aswellas through the slackeningof the sacrotuberous ligament.The activation of theGmaxnowincreaseswhile thatof thehamstringsdecreases inorder to initiatetheactionofhipextension.TheGmaxsignificantlyincreasesthestabilizationoftheSIJsduringtheearlyandmid-stancephases throughtheattachmentsof theposteriorobliquesling.

Weaknessormisfiring in theGmaxwillcause thehamstrings to remainactiveduringthegaitcycleinordertomaintainstabilityoftheSIJsandthepositionofthe pelvis. The resultant overactivation of the hamstringswill subject them tocontinualandabnormalstrain.

AsImentionedearlier,thefocusofthischapteristolookatwhathappenstothefunctionofthepelviswhentheglutesbecomeweakenedthroughinhibition;welookedattheGminearlier,sointhissectionwewillconcentrateontheGmax.Thisphasicmusclehasatendencytofollowatraitofbecomingweakenediftheantagonisticmuscleshavebecomeshortandtightorifthereareanyunderlyingpelvic malalignments. However, the Gmax can also test weak if there is aneurologicaldisorder,suchasaherniateddisc(Chapter10),affectingtheL5andS1 nerve root (which innervates the Gmax muscle). Any type of hip jointpathology—forexampleanacetabularlabraltear(Chapter8)orjointcapsulitis—canalsocauseaninhibitionweaknessintheGmax.

ThemainmusclesthatcanpotentiallycauseaweaknessinhibitionintheGmaxaretheiliopsoas,rectusfemoris,andadductors,astheyallareclassifiedashipflexors, which are the antagonistic muscles to the hip extension action of theGmax.

The assessment of the iliopsoas and other associated shortened antagonisticmusclesusingthemodifiedThomastesthasalreadybeendiscussedinChapter7.Once thatassessmenthasbeenfullyunderstood,youwillneed tonormalize

the tight and shortened antagonistic muscles by the use of METs. Aftermasteringandapplyingtheseadvancedtechniques,thephysicaltherapistwillbeable to incorporate them into their own treatment modality, with the aim ofencouragingthelengtheningofthetighttissues.Thiswillthenpromoteanormalneutralpositionof thepelvisand lumbar spine,and in turnhopefullyhave theeffectof“switching”theweakenedGmaxbackon.

AssessmentoftheGmax

InthissectionIwilldiscussthehipextensionfiringpatterntest,whichisusedfordeterminingthecorrectfiringorderofthehipextensors(includingtheGmaxmuscle).Theaimofthetestistoascertaintheactualfiringsequenceofagroupofmuscles, to ensure that all are firing correctly, just like the cylinders of anengine.Amisfiringpatternwillcommonlybefoundinathletesandpatients.

Figure9.11shows thecorrect firingpattern inhip jointextension.Thenormalmuscleactivationsequenceis:

•Gmax

•Hamstrings

•Contralaterallumbarextensors

•Ipsilaterallumbarextensors

•Contralateralthoracolumbarextensors

•Ipsilateralthoracolumbarextensors

The hip extension firing pattern test is unique in its application. Think ofyourself asacarwith sixcylinders inyourengine:basically that iswhatyourbody is—an engine. The engine has a certainway of firing and so does yourbody.Forexample,theengineinacarwillnotfireitsindividualcylindersinthenumericalorder1–2–3–4–5–6;itwillfireinapredefinedoptimumsequence,say1–3–5–6–4–2.Ifwehaveourcarservicedandthemechanicmistakestwoofthesparkplug leadsandputs themback incorrectly, theenginewill stillworkbutnotveryefficiently;moreover,itwilleventuallybreakdown.Ourbodiesarenodifferent: in our case, if we are particularly active but have a misfiring

dysfunction,ourbodieswillalsobreakdown,ultimatelycausinguspain.

HipExtensionFiringPatternTest

Figure9.11.Correctfiringpatterninhipjointextension.

Sequence1

The therapistplaces their fingertips lightlyon thepatient’s lefthamstringsandleftGmax(Figures9.12(a)and(b)),andthepatientisaskedtolifttheirleftleg2” (5cm) off the couch (Figure 9.12(c)). The therapist tries to identify whichmuscle fires first and notes the result of this first sequence (Table A1.1 in

Appendix1canbeusedforthis).

Figure9.12.Hipextensionfiringpattern—sequence1:(a)Thetherapistlightlypalpatesthepatient’slefthamstringsandGmax;(b)Close-upviewofthetherapist’shandposition;(c)Thepatientliftstheirleftlegoffthecouch.

Sequence2

Thetherapistplacestheirthumbslightlyonthepatient’serectorspinae,andthepatientisaskedtolifttheirleftleg2”offthecouch(Figure9.13(a)and(b)).Thetherapist identifies and notes (in Table A1.1 in Appendix 1) which erectormusclefiresfirst.

Figure9.13.Hipextensionfiringpattern—sequence2:(a)Thetherapistlightlypalpatesthepatient’serectorspinae;(b)Thepatientliftstheirleftlegoffthecouch.

Sequences1and2arethenrepeatedwiththerightleg,andtheresultsrecorded(in TableA1.2 inAppendix 1).Having done this, the therapist can determinewhetherornotthemusclesarefiringcorrectly.Thefiringpatternshouldbe:(1)Gmax,(2)hamstrings,(3)contralateralerectorspinae,and(4)ipsilateralerectorspinae.

If,whenpalpatinginsequence1,theGmaxisfoundtofirefirst,youcansafelysay that this is correct. The same applies in sequence 2: if the contralateralerectorspinaecontractsfirst,thisisalsothecorrectsequence.

1st 2nd 3rd 4th

Gluteusmaximus○ ○ ○ ○

Hamstrings○ ○ ○ ○

Contralateralerectorspinae○ ○ ○ ○

Ipsilateralerectorspinae○ ○ ○ ○

Table9.1:Hipextensionfiringpattern—leftside.

1st 2nd 3rd 4th

Gluteusmaximus○ ○ ○ ○

Hamstrings○ ○ ○ ○

Contralateralerectorspinae○ ○ ○ ○

Ipsilateralerectorspinae○ ○ ○ ○

Table9.2:Hipextensionfiringpattern—rightside.

However, ifyoufeel that thehamstringsarenumber1 in thesequence,or thatthe ipsilateral erector spinae isnumber1 and theGmax isnot felt to contract,youcandeducethatthisisamisfiringpattern.Ifthemisfiringdysfunctionisnotcorrected,thebody(liketheengine)willstarttobreakdownandacompensatorypatternofdysfunctionwillbecreated.

Inmyexperience,Ihavefoundthatinalotofpatients, thehamstringsandtheipsilateralerectorspinaearetypicallyfirsttocontractandtheGmaxisfourthinthesequence.In thesecases theerectorspinaeandthehamstringswillbecomethedominantmuscles inassisting thehip inanextensionmovement.This cancause excessive anterior tilting of the pelvis, with a resultant hyperlordosis,whichcanleadtoinflammationofthelowerlumbarfacetjoints.

Note:Thefiringpatternsofmuscles5and6havenotbeendiscussedinthischapter,becauseweneedtomakesurethatthecorrectfiringorderofmuscles1–4isestablished.Ialsofindthatwhenthemuscle1–4firing sequencehasbeencorrected, the firingpatternofmuscles5 and6 isgenerally self-correcting andtendstofollowthenormalfiringpatternsequence.

Anotherfactorthatcanaffectfiringorderisapreviousinjury.Bullock-Saxtonetal.(1994)investigatedthetimingoftheposteriortrunkandlegmusclesduringhipextension firing, and the influenceof apreviousankle sprainon the firingorder.ThoseauthorsfoundasignificantdifferenceintheonsetofGmaxactivity(delayedonset)inthegroupwithanklesprainhistorycomparedwiththecontrolgroup.

GaitCycleContinued

AweakormisfiringGmaxmight lead to thecreationofseveralcompensatorypatterns. First of all, let’s look at the casewhere a patient has aweakGmax,potentially caused by weakness inhibition, commonly known as reciprocalinhibition (RI), through the antagonistic tightness of the iliopsoas, rectusfemoris, and adductors. This soft tissue tightness of the anterior muscles willlimit the amount of extension of the hip joint during the gait cycle. Ascompensatory reactions the innominatebonewillbe forced to rotatemore intoan anterior position, and the contralateral innominate will be forced to rotatefurther into a posterior position. The hamstrings, and in particular the bicepsfemoris, will be part of the compensation pattern by assisting the increased

anterior rotation of the innominate as a result of the weakness of the Gmax.Sahrman (2002) suggested that if the hamstrings are dominant because ofinhibition of the Gmax, an anterior shear of the trochanter could be palpatedduringthepronelegextension.

This now gets a little complex (but has already been explained in previouschapters),as thebit inbetweenthetwoinnominatebones, i.e. thesacrum,willnow have to rotate and side bend a bit more than normal because of theincreased innominate rotation. The sacrum will now have to compensate byincreasingitstorsion(rotateonewayandsidebendtheother)inonedirection;thiswillbeeitheraL-on-Lsacraltorsion(leftrotationontheleftobliqueaxis),asshowninFigure9.14(a),oraR-on-Rsacraltorsion(rightrotationontherightoblique axis), as shown in Figure 9.14(b).The lumbar spinewill also have tocompensatebypotentiallycounter-rotatingabitmoreintheoppositedirectiontothesacrum,asshowninthetwoFigures.

Figure9.14.Sacraltorsion:(a)L-on-L;(b)R-on-R.

Thereisanaturalrotationofthesacralandlumbarspinesduringthegaitcycle;

however,becauseof the increased innominate rotation, thesacrumand lumbarspineshavenochoicebut tocompensateaswell. Inbetween the lumbarspineand the sacrum (L5 and S1) there lies an intervertebral disc (Chapter 10);imagine now this disc being “torqued”between the two spinal segments.Thisactionwillhaveanegativeeffectonthedisc—itislikesqueezingwateroutofasponge,anddiscsdonotlikethattypeofincreasedmotion!

Onewayofpotentiallycorrectingthemisfiringsequenceisasfollows.Throughmusclelengthtesting(modifiedThomastest),weneedtofirstdeterminewhichmusclesareactuallyheldinashortenedposition;METs(Chapter7)andspecificmyofascialreleasetechniques(seeGibbons(2014)fordemonstrationsofthese)canthenbeusedtotreatandnormalizetheseshortenedandtighttissues.

RememberwhatItalkedaboutearlier:anyunderlyingmalalignmentpositionofthepelvicgirdlecanbeanothercausativefactorintheweaknessinhibitionoftheGmax. Bear that in mind, especially when trying to correct the misfiringsequence.

ThoracolumbarFasciaandItsRelationshiptotheGmaxandPelvis

The thoracolumbar fascia is a thick, strong sheet of a ligamentous type ofconnective tissue, which connects with, and covers, themuscles of the trunk,hips,andshoulders.ThenormalfunctionoftheGmaxwillbetoexertapullingactiononthefascia,therebytensingitslowerend,asshowninFigure9.15;youcanseefromthediagramthat thereisaconnectionbetweentheGmaxandthecontralateral latissimus dorsi muscle by means of the posterior layer of thethoracolumbar fascia.Both of thesemuscles conduct the forces contralaterally(i.e.totheoppositeside)duringthegaitcycle(viatheposteriorobliquesling),which then causes increased tension through the thoracolumbar fascia. Thisfunction is very important for rotation of the trunk and for force closurestabilizationofthelowerlumbarspineandtheSIJ.

Figure9.15.ThethoracolumbarfasciaandtheconnectiontotheGmax.

Thereisalsoaco-contractionofthedeepermusclesoflumbarstability—i.e.theTVAandthemultifidus.Thesemusclesco-contractwhenyoumovealimbandwere discussed in Chapter 3. As far as I am aware, there has been nothingpublishedrecentlyabouttheTVAandmultifidusbeingspecificallytriggeredbyengagementof theGmax.However, Ipersonallybelieve that theTVAmuscledefinitelyrespondstoGmaxcontraction,andIsuspect that themultifidusdoestoo,astheyallhaveanassociationwiththesacrotuberousligamentofthepelvis(eitherdirectlyorindirectly),whichassistsinforceclosureoftheSIJ.

CaseStudy

Thiscasestudy,Ihope,emphasizesthattherelationshipoftheglutestotheSIJisthekeylinkinthepatient’spresentingsymptoms.

Thepatientwasa34-year-oldwomanandaphysical trainer for theRoyalAir

Force.Shepresentedtotheclinicwithpainnear thesuperioraspectofher leftscapula (Figure9.16).Thepainwouldcomeon fourmiles (6.5km) intoa run,forcinghertostopbecauseitwassointense.Thediscomfortwouldthensubside,butquicklyreturnifsheattemptedtostartrunningagain.Runningwastheonlyactivitythatcausedthepain.Hercomplainthadbeenongoingforeightmonths,hadworsenedoverthepastthree,andwasstartingtoaffectherwork.Therewasnoprevioushistoryorrelatedtraumatotriggerthecomplaint.

Figure9.16.Diagramofthepatient’spainfularea—leftsuperiorscapula.

Afterseeingdifferentpractitioners,whoallfocusedtheirtreatmentontheuppertrapezius, shevisitedanosteopathwho treatedher cervical spineand rib area.

Thetreatmentsshehadreceivedwerebiasedtowardtheapplicationofsofttissuetechniques to the affected area, namely the trapezius, levator scapulae,sternocleidomastoid (SCM), scalenes, and so on. The osteopath had also usedmanipulative techniques on the facet joints of her cervical spine—C4/5 andC5/6. METs and trigger point releases were used in a localized area, whichofferedreliefatthetimebutmadenodifferencewhensheattemptedtorunmorethanfourmiles.Shehadnotundergoneanyscans(e.g.MRIorX-ray).

TakingaHolisticApproach

Let’snowassessthecasestudypatientgloballyratherthanlocally,rememberingthatthepainonlycomesonafterrunningfourmiles.

WhenIseeanewpatientforthefirsttime,nomatterwhatthepresentingpainis,Inormallyassessthepelvisforpositionandmovement,asIconsiderthisareaofthebodyinparticulartobethe“foundation”foreverythingthatconnectstoit.Ioften find in the clinic thatwhen I correct a dysfunctional pelvis,my client’spresenting symptoms tend to settle down. However, when I assessed thisparticularpatient,Ifoundherpelviswaslevelandmovingcorrectly.

IthenwentontotestthefiringpatternsoftheGmax(explainedearlier),whichIoftendowithpatientsandathleteswhoparticipateinregularsportingactivities.However,IonlytestthefiringpatternsequenceonceIfeelthatthepelvisisinits correctposition; the logichere is thatyouoftenget apositive result of themusclemisfiringwhenthepelvisisslightlyoutofposition.

Withthepatientinquestion,Ifoundabilateralweakness/misfiringoftheGmax,butthefiringontherightsideseemedabitslowerthanonherleftside.AsIhadnot foundanydysfunction in thepelvis, Ipursued this lineofapproacha littlefurther.

BeforewecontinueIwouldliketoputafewquestionstoyoutothinkabout:

•HowdoesaweaknessoftheGmaxontherightsidecausepaininthelefttrapezius?

• Is therea linkbetween theGmaxand the trapezius,and ifso,howis thispossible?

•Whatcanbedonetocorrecttheissue?

•Whathashappenedtocauseitinthefirstplace?

GmaxFunction

Remember fromearlier, theGmaxoperatesmainly as apowerfulhip extensorandalateralrotator,butitalsoplaysapartinstabilizingtheSIJbyhelpingittoforce close while going through the gait cycle. Some of the Gmax muscularfibersattach to the sacrotuberous ligament,which runs from the sacrum to theischialtuberosity,andthisligamenthasbeentermedthekeyligamentinhelpingtostabilizetheSIJ.

LinkingitAllTogether

Sowhat do we know?We know that the right side of the patient’s Gmax isslightlyslowerintermsofitsfiringpatternandthatthismuscleplaysaroleintheforceclosureprocessoftheSIJ.ThistellsusthatiftheGmaxcannotperformthisfunctionofstabilizingtheSIJ,thensomethingelsewillassistinstabilizingthe joint.The left latissimusdorsi is the synergist thathelps stabilize the rightGmax(Figure9.10)and,moreimportantly,theSIJ.Asthepatientparticipatesinrunning,everytimeherrightlegcontactsthegroundandgoesthroughthegaitcycle,theleftlatissimusdorsiisover-contracting.Thiscausestheleftscapulatodepress, and themuscles that resist the downward depressive pull will be theupper trapezius and the levator scapulae. Subsequently, thesemuscles start tofatigue; for the patient in question, this occurs at approximately fourmiles, atwhichpointshefeelspaininherleftsuperiorscapula.

Treatment

Youmight think the easyway to treat theweakness in theGmax is to simplyprescribe strength-based exercises.However, in practice this is not always thecorrectsolution,assometimesthetighterantagonisticmuscleisresponsiblefortheapparentweakness.Themuscleinthiscaseistheiliopsoas(hipflexor),anditsshorteningcanresultinaweaknessinhibitionoftheGmax.Myanswertothispuzzlewastolengthenthepatient’srightiliopsoasmuscle(Chapter7)toseeifitpromotedthefiringactivationoftheGmax,whileatthesametimeintroducingsimplestrengthexercisesfortheGmax.

Prognosis

Iadvised thepatient toabstainfromrunningand togetherpartner toassist inlengtheningtheiliopsoas,rectusfemoris,andadductorsusingMETs(Chapter7)twiceaday.Strengthandstabilityexercisesfortheoutercoremuscles(Chapter3)werealsoadvisedoncedailyuntilthefollow-ontreatment.Ireassessedher10days later and found the firing sequence of theGmax to be normal in the hipextension firing pattern test, and a reduction in the tightness of the associatediliopsoas,rectusfemoris,andadductors.Becauseoftheseencouragingresults,Iadvisedhertorunasfarasfeltcomfortable.Iwasnotsureifmytreatmentwasgoing to correct the problem, but she reported that she had no pain during orafter a six-mile (10km) run. The patient is still pain free and continues toregularly use the strengthening exercises for the Gmax and the lengtheningtechniquesfortheshort/tightmuscles.

Conclusion

Thiscasestudydemonstratesthatveryoftentheunderlyingcauseofaconditionorproblemmaynotbelocaltowherethesymptoms/painpresents,whichmeansthatallavenuesneedtobefullyconsidered.

I hope that the information from this case study has intrigued you enough tocontinuereading.Iwouldliketothinkthatwhenyounextassessandtreatoneofyour patients, you will look at them in a slightly different way to what younormallywould.

___________

Ithinkofthisbook(andallthebooksIhavewritten)astakingyouonwhatIcallajigsawpuzzlejourney—ifyoustickwithit,thepicturewilleventuallybecomealotclearer.

After reading this chapter and the above case study, you should have a betterunderstanding of the situation that if the glutes are weak or misfiring, theirfunction (the Gmax’s in particular) of tensing the thoracolumbar fascia isreduced,whichwillcauseanaturaloveractivationofthecontralaterallatissimusandtheipsilateralmultifidus.AweaknessinhibitionoftheGmaxandGmedwillover-stimulate other compensatory mechanisms throughout the whole of thekineticchain,allofwhichwillnaturallyinsomewayorotherhaveaneffecton

thefunctionalityandstabilityofthepelvis.

10TheLumbarSpineandItsRelationshiptothePelvis

Theaimofthischapteristogivethereaderaninsightintosomeoftheskeletalpathologies that can manifest in the lumbar spine, as well as the potentialunderlyingcauses.Letmegiveyouanexample:apatientpresentstoyourclinicwithlocalizedpaininthemusclesofthelumbarerectorspinae.Onexaminationyoufindthattherightinnominateboneisfixedinananteriorlyrotatedposition(themostcommon),whichcouldbecausedbyanoveractivationandsubsequentshortnessof theright iliopsoasandrectus femorismuscles (asdemonstrated inChapter7bythemodifiedThomastest).TheoriginoftherectusfemorismuscleisontheAIISoftheilium;becauseofthisattachment,themusclecannaturally“pull” the innominate bone in an anterior and inferior direction. This fixedanterior position of the innominate can cause an inhibition (switching-off)weaknessintherightGmaxandwasexplainedinmoredetailinChapter9.

IftheGmaxbecomesinhibitedbecauseoftheanteriorlyrotatedpositionoftheright innominate bone, it will not be able to provide the correct activationsequence when a hip extension action is demanded by the patient (e.g. inwalkingorrunning);thelumbarspineerectormusclewillbeoneofmanyareasthatwillstart toovercompensateforthisinhibitionweaknessoftheGmax(seeChapter 9). In time, an overcompensatory mechanism of the lumbar spineerectormusculature in particularwill cause the patient to feel tightness in thelowerback,aswellaspotentialpain.

Therearemanydifferentoptionsfor treating thisparticularpelvisdysfunction.Oneway(andwhichworksverywellformepersonally)istoutilizeasofttissuemethod, namely an MET, to normalize the iliopsoas and rectus femoris (thistechnique isdemonstrated inChapter7onMETs), inaddition toperformingaspecificMETtocorrecttheanteriorpositionoftheinnominate(seeChapter13on treatment of thepelvis).After havingnormalizedboth themuscles and theinnominate,youwould retest theGmax firing; if theGmax is still inhibited, acorrectivefiringpatternsequencecanbeinitiatedtopromotethereactivationoftheglutes.(Formoreinformationonglutesactivationandcorrection,thereader

isreferredtoGibbons(2014).)

Itwouldbelogicaltofirstcorrect(seeChapters11and12)any/allofthepelvisdysfunctions(iliosacral,sacroiliac,andsymphysispubis) thatarefound,beforecontinuing, assessing, and treatingdysfunctionof the lumbar spine (unless thespinalrotationis theprimarydysfunction).Perhaps thinkaboutwhyIsay this,beforereadinganyfurther.

Hopefully, youwill come to the conclusion that it is essential to address anyissues with an underpinning structure before tackling problems in other areasthatdependonthatstructure.Forexample,Iregardthepelvisasbeingsimilartothefoundationsthatarelaidbeforebuildingahouse;wewouldnotwanttobuildon topof the foundations if theywerenot level. I try touse thesameanalogywhenIlookatandassessthelumbarspinearea.Ifthepelvisisnotleveltostartwith,thenthelumbarspinecannotbeleveleither;thisareaofthespinalcolumnwill therefore automatically compensate in some way through changing itsnatural spinal curvatures, which could result in functional/structural scoliosis.This unnatural positional change to the lumbar spine as a compensationmechanismcanonlyleadtoonething,andyouwilleasilyguesswhatthatis—pain,ofcourse!

Iamconvincedthatmostofthespinalpathologiesdiscussedinthischapterareadirectorindirectconsequenceoftheoverallpositionandstabilityintegrationofthe pelvic girdle. It is very difficult, however, to prove this, especially since Ihaven’t been able to find any recent clinical research to back up what I amsaying.What I have stated has to be correct in oneway or another, however,because the fundamental foundation (i.e. the pelvis)must be themain area ofcompensation for all of thevarious typesofdysfunction thatmightbepresentwithin the body; this will have a direct knock-on effect on the entire kineticchain, and the lumbar spine is clearly part of that compensatory chainmechanism.

Let’sbealittlerealistichereforamoment.Bythetimeapatientwhopresentswithwhatmightbediagnosedasaspecificornon-specificbackpaincomestoseeyou,theyprobablyalreadyhavesomespinalpathologypresent.ThepatientmightalsohavehadconfirmationoftheirspinalpathologybyanMRIscan,X-ray, or some other diagnostic measures. Put simply, what I am saying in theabove statement is therefore the following: the patient’s presenting spinalpathologyalreadyexists,evenbeforetheywalkthroughyourclinicdoor!

Of the thousands of patients I have seen as a practicing sports osteopath andsportstherapist,Icanprobablycountononehandthosewhohaveconsultedmeforaninitialosteopathicassessmentandtreatmenttoactuallypreventtheonsetof spinal and pelvic pathology, or indeed any other structural and soft tissueailment.LetmereiteratewhatImeanbythat.Ibelievethat99.9%ofthepatientsandathleteswhohavevisitedmyclinicalreadyhaveapresentationofsymptomsofpain/dysfunction somewhere in theirbody, andmore than likelyhave someunderlyingformofspinalorpelvicdysfunction/pathologyalreadypresent—andthisisevenbeforewehavebeenformallyintroduced.

LumbarSpineAnatomy

Therearefiveindividualspinalsegmentsthatmakeupthelumbarvertebrae,andeachvertebracomprisesthefollowingstructures(Figure10.1):

•Vertebralbody

•Spinousprocess

•Transverseprocess(TP)

•Superior/inferiorfacetjoint

•Intervertebralforamen

•Spinalcanal

•Lamina

•Pedicle

•Intervertebraldisc:nucleuspulposus/annulusfibrosus

Figure10.1.Generalanatomyofalumbarvertebra(L3);a)superiorview,b)lateralview.

IntervertebralDiscs

Between adjacent lumbar vertebrae there is a structure known as anintervertebral disc; in total we have 23 of these soft tissue structures in thehumanvertebralcolumn.Adiscismadeupofthreecomponents:atoughoutershell,calledtheannulusfibrosus;aninnergel-likesubstanceinthecenter,calledthe nucleus pulposus; and an attachment to the vertebral bodies, called thevertebralendplate.Aswegetolder, thecenterof thediscstarts to losewatercontent,aprocessthatwillnaturallymakethedisclesselasticandlesseffective

asacushionorshockabsorber.

Figure10.2.Anatomyofthelumbarspineandtheintervertebraldiscs.

Nerve roots exit the spinal canal through small passageways between thevertebrae and the discs: such a passageway is known as an intervertebralforamen. Pain and other symptoms can developwhen a damaged disc pushesinto the spinal canal or nerve roots—a condition commonly referred to as aherniateddisc.

DiscHerniation

Herniateddiscsareoftenreferredtoasbulgingdiscs,prolapseddiscs,orevenslippeddiscs.Thesetermsarederivedfromthenatureof theactionof thegel-likecontentof thenucleuspulposusbeingforcedoutof thecenterof thedisc.Justtoclarify,thediscitselfdoesnotslip;however,thenucleuspulposustissue

thatislocatedinthecenterofthedisccanbeplacedundersomuchpressurethatitcancausetheannulusfibrosustoherniateorevenrupture,asshowninFigure10.3.The severityof thedischerniationmaycause thebulging tissue topressagainst one or more of the spinal nerves, which can cause local and referredpain, numbness, or weakness in the lower back, leg, or even ankle and foot.Approximately 85–95% of lumbar disc herniations will occur either at thelumbar segments L4–L5 or at L5–S1; the nerve compression caused by thecontactwiththedisccontentswillpossiblyresultinperceivedpainalongtheL4,L5,orS1nerverootpathway,asshowninFigure10.4.

Figure10.3.Discherniation.

Figure10.4.DermatomepathwayofpainforL4,L5andS1nerveroot.

DegenerativeDiscDisease

Degenerative disc disease (DDD) tends to be linked to the aging process andreferstoasyndromeinwhichapainfuldisccancauseassociatedchroniclowerbackpain,whichcanradiatetothehipregion.Theconditiongenerallyoccursasa consequence of some form of injury to the lower back and the associatedstructures, such as the intervertebral discs. A sustained injury can cause aninflammatory process and subsequent weakness of the outer substance of thedisc (annulus fibrosus),whichwill thenhaveapronouncedeffecton the innernucleus pulposus. This reactive mechanism will create excessive movement,becausethedisccannolongercontrolthemotionofthevertebralbodiesthatarelocatedaboveandbelowthedisc.Thisexcessivemovement,combinedwiththenaturalinflammatoryresponse,willproducechemicalsthatwillirritatethelocalarea,whichwillcommonlyproducesymptomsofchroniclowerbackpain.

Figure10.5.Degenerativediscdisease(DDD).

DDD has been shown to cause an increase in the number of clusters ofchondrocytes (cells that form the cartilaginous matrix and consist mainly ofcollagen)intheannulusfibrosus(consistingoffibrocartilage).Overaprolongedperiod of time the inner gelatinous nucleus pulposus can change tofibrocartilage,andithasbeenshownthattheouterannuluscanbecomedamagedinareasthatallowsomeofthenucleusmaterialtoherniatethrough,causingthedisc to shrink and eventually leading to the formation of bony spurs calledosteophytes.

Unlike the muscles in the back, the discs of the lumbar spine do not have a

naturalbloodsupplyandthereforecannothealthemselves;thepainfulsymptomsofDDDcan thereforebecomechronic,eventually leading to furtherproblems,suchasdiscalherniation,facetjointpain,nerverootcompression,spondylolysis(defectof theparsinterarticularis),andspinalstenosis(narrowingofthespinalcanal).

FacetJoints

Locatedwithinthelumbarspinearethefacetjoints(anatomicallyknownasthezygapophysealjoints);thesestructurescanberesponsibleforprovokingalotofpain.Thefacetjointslieposteriortothevertebralbody,andtheirroleistoassistthespineinperformingmovementssuchasflexion,extension,sidebending,androtation. Depending on their location and orientation, these joints will allowcertain types of motion but restrict others: for example, the lumbar spine islimitedinrotation,butflexionandextensionarefreelypermitted.Inthethoracicspine,rotationandflexionarefreelypermitted;extension,however,islimitedbythefacetjoints(butalsobytheribs).

Eachindividualvertebrahastwofacetjoints:thesuperiorarticularfacet,whichfaces upward and works similarly to a hinge, and the inferior articular facetlocatedbelowit.TheL4inferiorfacetjoint,forexample,articulateswiththeL5superiorfacetjoint.

Like all other synovial joints in the body, each facet joint is surrounded by acapsuleofconnectivetissueandproducessynovialfluidtonourishandlubricatethe joint.The surfacesof the joint are coatedwith cartilage,whichhelps eachjointtomove(articulate)smoothly.Thefacetjointishighlyinnervatedwithpainreceptors,makingitsusceptibletoproducingbackpain.

FacetJointSyndrome/Disease

Facet joints have a tendency to slide over each other, so they are naturally inconstantmotionwith thespine; likeall typesofweight-bearing joint, theycansimplywear out and start to degenerate over time.When facet joints becomeirritated (the cartilage can even tear), this will cause the bone of the jointunderneath the facet joint to start producingosteophytes, leading to facet jointhypertrophy,whichistheprecursoroffacetjointsyndrome/disease(Figure10.6)

andeventuallyleadstoaconditioncalledspondylosis.Thistypeofsyndromeordisease process is very common in many patients presenting with ongoingchronicbackpain.

Figure10.6.Facetjointsyndromeandspondylosis.

LumbarSpineasaCauseofPelvisDysfunctions

Ihavementionedonnumerousoccasionstheconceptofthepelvisandpossiblythehipjointbeingthekeyareasthatareresponsibleforthepresentationofpaininthelumbarspineandpelvicgirdleregions.However,therehavetobecertaintimes (and, of course, there are) that some other structures (apart from thosealreadymentioned)mightneedtobeincorporatedintothebiggerpictureinordertosolvetheproblem;thestructuresthatIamgoingtotalkaboutmightactuallyplayanevengreaterrole.Onceyouunderstandthenextconcept,Ihopeitwillhelp you to place the jigsaw puzzle pieces in the correct sequence, so that a

clearerpicturewillbegintoappear.

It could be that the underlying issue is hidden and dormant and not showingitselfasadysfunction:themusculoskeletalproblemislyingquietlyinthegrassandminding itsownbusiness.Let’sconsider foramoment thepossibility thattheproblemisactuallywithinthelumbarspine,andthisstructurecouldbethekeytosolvingthemystery,aswellasbeingthemainreasonformaintainingthepelvicdysfunctions.

Forexample,apatienthasongoingrecurrentpelvicdysfunctionsthatyouhavebeencorrectingtimeandtimeagaintonoavail;youconstantlyfeelasifyouarebanging your head against thewall, becausewhat you are doing (in terms oftreatment)doesnotseemtobethekeytosolvingtheproblem,whereasitmighthave been with other patients you have treated in the past. The problempotentiallylieswithinthelumbarspine,anditisthisskeletalstructurethatistheunderlying causative factor maintaining and controlling the ongoingdysfunctional pelvic pattern. If there is a rotational component at thelumbosacral junction(L5/S1), thishasbeenrecognizedasoneof thecausesofrecurrentpelvicmalalignment.

Let’slookatanexamplewherethelumbarspineistherootcause.Ifwehaveaclockwise rotation (i.e. to the right) of the 5th lumbar vertebra (L5), the right-sided TP will rotate backward (posteriorly). There are soft tissue attachmentsontotheL4andL5TPsfortheiliolumbarligament,andthisligamentoustissueattaches directly to the iliac crest. The induced rotation increases the tensionwithintheiliolumbarligament,andalsotheL5rotationtotherightwillforcetherightinnominatetorotateposteriorly;theleftTPofL5isrotatinganteriorlyandthiscreatesananteriorposition(anteriorrotation)oftheleftinnominate(Figure10.7).Farfan(1973)reasonedthat theshortertheTP,thelongertheiliolumbarligamentandthegreaterthetorsionalforce.

TheL5right inferiorfacetwillbe inarelativelyopenpositiononthesuperiorfacetofthe1stsacralvertebra(S1);the left inferiorfacet,however,willbeinaclosedpositiononthesuperiorfacetofS1.Iftheleftfacetjointiscompressed,and theposition ismaintainedandcontinued, itcannowbecomeapivotpoint(fulcrum).Thisfixation(left)oftheL5/S1facetjointwillnowstarttoencouragethesacrumtorotate to therightaxis(R-on-R),whichwilleventuallyforce thewholepelvisunitintoarightrotatedposition,asshowninFigure10.7.

Sohowdowegoaboutcorrectingadysfunctionofthelumbarspine?Well,theassessmentofthepelvisinChapter12containssnippetsofvaluableinformationthatwillhelpyouascertainifalumbardysfunctionexists.Onceyouhavereadandunderstoodhowtodeterminealumbardysfunctioninyourpatient,youwillthen need to read the appropriate text inChapter 13,which explains in detailhow tocorrectanypossibledysfunctions thatmaybe foundwithin the lumbarspinecomplex.

Note:Iwouldstillrecommendthatyoufirsttreatanypelvicdysfunctions,beforeembarkingonrealigningspecificdysfunctionsthatyoufindwithinthelumbarspinecomplex.

Figure10.7.RotationaleffectofL5onthesacrumandontheinnominate(viatheattachmenttotheiliolumbarligament).

11SacroiliacJointScreening

BeforeIsetaboutguidingyouthroughacomprehensiveassessmentprotocolforthe pelvis, I believe that it makes sense to look first at the standard testingprocedures forscreening theSIJ. In thiswaywemightbeable todetermine ifthe actual SIJ is responsible (or partly responsible) for a patient’s presentingsymptoms; the screening process, on the other hand,may lead us to concludethattheSIJisnotinvolved.

LetmegiveyouanexampleofwhyImightdo thescreening tests for theSIJfirst.Whenpatientspresent tomyclinicwithpain in theareaof, let’ssay, thelowerlumbarspineand/orpelvis,Iwillnaturallyalwaysscreenthehipjointsforany underlying pathology (as I demonstrated in Chapter 7 on the hip joint),becauseIpersonallyconsider thisareaof thebody(hip joint) topotentiallyberesponsibleinpartfortheirpresentingsymptomsofbackorpelvicpain.Inthiscase I can at least then decide if I need to investigate the hippathology/dysfunction a little further. These clinical findings would probablymakemereconsiderandaltermytreatmentstrategytonowfocusontheareaofthehipjointcomplexratherthanspecificallyontheareaofthelumbarspineorpelvis, especially if I wanted my treatment to have a longer-lasting effect ofreducingmypatient’songoingpainfulsymptomsintheirlowerbackandpelvis.

Schamberger (2013) talks about the concept of malalignment syndrome andconsiders that80–90%of all adultspresentwith their pelvisoutof alignment.Rotational malalignment is by far the most frequently seen, with an anteriorrotation to the right innominate bone and a compensatoryposterior rotation tothe left innominate bone by far the most common (in approximately 80% ofpatients).Thistypeofrotationalmalalignmentcanoccureitheronitsownorincombination with other presentations (upslip/out-flare/in-flare; see “PelvicGirdleDysfunctions” section inChapter12).Anupslippresentson its own inaround10%ofpatients,andincombinationwiththeothertypes(rotational/out-flare/in-flare) in another 5–10% of patients. Out-flares and/or in-flares arepresentinapproximately40–45%,eitherinisolationorincombinationwithone

orbothoftheothertypes.

Klein(1973)alsoshowsthatmalalignmentofthepelvisispresentin80–90%ofhigh-school graduates. Of these, around one-third are asymptomatic and two-thirds are symptomatic, where they present with, for example, lower back orgroinpain.Klein talks about three commonpresentations that account for90–95%ofthosesubjectsfoundtobeoutofalignment:

1. Rotational malalignment—either an anterior or a posterior innominaterotation,oracombinationofboth(approximately80–85%).

2.Out-flare/in-flare(40–50%).

3.Upslip(15–20%).

Remember, the history taking for your patient is one of the most importantcomponents when trying to decide on what you consider to be the actualcondition/dysfunctionthat thepatient ispresentingwith.It isverycommonforanexaminerduringaconsultationtoaskapatientwheretheirpainis.Suppose,in the particular case of assessing the pelvis, the patient points to the areainferior and medial to the PSIS (Figure 11.1(a)), and is able to do thisconsistentlytwiceandalsowithinaradiusof0.4”(1cm)eachtime;accordingtoFortinandFalco(1997),thisisapositivesignofSIJdysfunction.

Figure11.1.(a)TheFortinfingertest,asdemonstratedbythepatientpointingtotheareaofpain.

The above is an example ofwhat is commonly called theFortin finger test; Iconsider this test tobeofvalue,butonly incombinationwith theprovocationtestsdescribedbelow,especiallytheFABER(Patrick’s)test.

Schamberger (2013)mentions that localized painmay arise from one or bothSIJs:thosewithhypomobilityor“locking”ofoneSIJnotinfrequentlycomplainofpainfromtheregionoftheother,supposedly“normal,”SIJ.Oneexplanationforthispainistheincreasedstressplacedonthis“normal”jointanditscapsuleandligamentsasit triestocompensateforthelackofmobilityoftheimpairedSIJ.

In the 1997 study, the Fortin finger test was used as a means of identifyingpatients with lower back pain and SIJ dysfunction. Provocation-positive SIJinjectionswereusedtoconfirmordiscounttheapplicabilityofthisclinicalsignfortheidentificationofpatientswithSIJdysfunction.Atotalof16subjectswerechosen from 54 consecutive patients by using the Fortin finger test. All 16patients subsequently had provocation-positive joint injections, validating SIJabnormalities.Theseresults indicate thatapositivefindingof theFortinfingertest, a simple diagnostic measure, successfully identifies patients with SIJdysfunction.

Fortinetal.(1994)carriedoutanearlierstudyonpainpatternmappingfortheSIJ and injected the contrast material Xylocaine into the actual SIJ in 10volunteers. These authors reported that their sensory examination immediatelyafter the injection revealed an area of buttock hypoesthesia extendingapproximately 4” (10cm) caudally (inferiorly) and 1.2” (3cm) laterally to thePSIS,asshowninFigure11.1(b).Thisareaofhypoesthesiacorrespondedtotheareaofmaximalpainnoteduponadministrationoftheinjection.

Figure11.1.(b)ThereferralpatternoftheSIJfromFortinetal.’s1994study.

In termsofSIJ referralpatterns,however, therehasbeena lotofdebateabouttheexactlocationtowhichtheSIJrefers:Fortinsaid4”(10cm)caudallyby1.2”(3cm) laterally to the PSIS. In contrast, a study conducted by Slipman et al.(2000) called “Sacroiliac joint pain referral zones” recorded significantdifferencesfromFortin’sfindings.Usingfiftyconsecutivepatientswhosatisfiedclinical criteria and demonstrated a positive diagnostic response to afluoroscopically guided SIJ injection, Slipman’s study yielded the followingresults. Forty-seven patients (94.0%) described buttock pain, and thirty-six(72.0%) described lower lumbar pain. Twenty-five patients (50.0%) describedassociated lower-extremity pain. Fourteen patients (28.0%) described leg pain

distal to theknee,groinpainwasdescribed in sevenpatients (14.0%),and sixpatients (12.0%) reported foot pain. Eighteen patterns of pain referral wereobserved. A statistically significant relationship was identified between painlocationandage,withyoungerpatientsmorelikelytodescribepaindistaltotheknee. It was concluded that pain referral from the SIJ does not appear to belimitedtothelumbarregionandbuttock.

SIJProvocative/ScreeningTests

Based on very rigorously reviewed research, there are numerous ways ofscreening the SIJ. I, however, currently utilize only five of these provocationtests—thosewhichIconsidertobeofrealvaluetotheclinicianandwhichareused on a day-to-day basis throughout the UK (and the rest of the world) tocommonly diagnose SIJ disorders. These SIJ provocation tests, when used incombination rather than in isolation, can be very accurate, as the feedbackresponsefromtheSIJcanbeverysensitiveandspecific,especiallywhengivinginformationabout thepotentialeffectivenessofanSIJdysfunction.These testsarenotallspecificintheirapplicationtotheSIJ,becausetheyalsostressthehipjointandthelumbosacralregion.Compressivetypesoftestingmotionaremorelikelytoascertainpaindirectlyfromwithinthejoint,whereasdistractiontypesoftestingwillprovokepainfromthecorrespondingligamentsandjointcapsule.

ThepresenceofanSIJdysfunctioncanbeassumedifoneachievesthreeoutoffivepositiveresultswiththefollowingtests:

1.FABER

2.Compression

3.Thighthrust

4.Distraction

5.Gaenslen

1.FABERTest

You may recall that I discussed the FABER (flexion, abduction, external

rotation)testinChapter7,asitiscommonlyusedtoscreenforanyunderlyinghip pathology; however, it is also a very effective test for ascertaining SIJdysfunction. Themain reasonwhy this test can help the therapist identify thepresenceofanSIJdysfunction is the fact that the test inducesamotionof theinnominateboneinaposteriorandexternaldirectionrelativetothesacrum;thisinnominate motion encourages sacral nutation and subsequently stresses theassociated ligaments (sacrotuberous, sacrospinous, and interosseous). Theposteriorlyrotatedinnominatepositionalsobecomesaleverthatcanbeusedtocompress the SIJ posteriorly and open the joint anteriorly, which will thenstretchtheanteriorcapsuleandassociatedligaments.

The therapistplaces thepatient’ship intoapositionof flexion,abduction,andexternalrotation.Theoppositesideofthepelvis(attheASIS)isstabilized,andagentle, steadily increasing pressure is applied to the same-side knee of thepatient,exaggeratingthemotionofhipflexion,abduction,andexternalrotation,asshowninFigure11.2.Ifthereisarestriction(inthehipjointmainly)orpainposteriorly in theareaof theSIJ,apathologicalchange/dysfunctionwithin theSIJmightbeindicated.

Figure11.2.FABERtesttoscreenforSIJdysfunction.

2.CompressionTest

The patient is placed in a side-lying position, facing away from the therapist,with a pillow between the knees for comfort. The therapist applies a gradualdownwardpressure through theanterior aspectof the innominate,between thegreater trochanter of the femur and the iliac crest, to check if pain in thecorrespondingSIJispresent,asshowninFigure11.3(a–b).

Figure11.3.(a)CompressiontesttoscreenforSIJdysfunction.

Figure11.3.(b)Close-upviewofthecompressiontest.

3.ThighThrustTest

The patient lies in a supine position with one hip flexed to 90 degrees. Thetherapist stands on the same side as the flexed leg and stabilizes the patient’spelvisbyapplyingpressuretotheoppositeASIS.Graduallyincreasingpressureis then applied through the axis of the femur, to determine if pain is presentwithintheSIJ,asshowninFigure11.4(a–b).

Figure11.4.(a)ThighthrusttesttoscreenforSIJdysfunction.

Figure11.4.(b)Close-upviewofthethighthrusttest.

4.DistractionTest

Thepatientliesinasupinepositionwithapillowundertheirkneesforsupport.Witharmscrossedandelbowsrelativelystraight,thetherapistplacestheirhandson the anterior aspects of the patient’s left and rightASISs of the innominatebones.Agradualpressureisthenappliedlaterally,toencourageadistractionoftheSIJ,asshowninFigure11.5(a–b).Thepresenceofanypainisnoted.

Figure11.5.(a)DistractiontesttoscreenforSIJdysfunction.

Figure11.5.(b)Close-upviewofthedistractiontest.

5.GaenslenTest

Thepatient lies in a supine positionnear the left edgeof the couch.They areaskedtoflextherighthipbypullingtheirrightkneetotheirchest,amovementwhich rotates the right innominate posteriorly, while allowing the leftinnominatetorotateanteriorly;thisparticularactionhastheeffectoflockingtheSIJ at the same time.The therapist slides the left lower leg off the couch andapplies a gradual extension force to the already extended left leg, whilesimultaneouslyapplying(throughthepatient’shands)aflexionforcethroughtherightleg,asshowninFigure11.6(a–b).

Figure11.6.(a)GaenslentesttoscreenforSIJdysfunction.

Figure11.6.(b)Close-upviewoftheGaenslentest.

12AssessmentofthePelvis

Once you have screened the SIJ by following the five provocation tests asrecommendedinChapter11,youwillatleastbeabletoconfirmordiscountthepresence of pain and possible dysfunction directly locatedwithin theSIJ.Thenextstepwillbetocarryoutanassessmentofthepelvis.

The assessment procedure I will present in this chapter is very similar to theexaminationprotocolthatIpersonallyfollowwithmyownpatientsatmyclinicin Oxford; however, you are not expected to initially follow every singleprocess, especially during the first consultation. It could take a lot of time foryoutogatherall theinformationfromtheindividualtests;moreover,oncethathas been done, youwould need to assimilate all that necessary information inordertocomeupwithaplanofaction.

Iamsurethattherearenumeroustherapistsouttherewhocanhelppatientswithonlyonesession,andIbelievethatisthesameforme.Thatsaid,Ithinkitstilltakesafewphysicaltherapysessionstotrulyhaveagoodunderstandingofthepatient’s individual musculoskeletal biomechanical framework. That is why Imight not include all the tests I demonstrate in this chapter duringmy initialconsultation, as someof the specific testing criteriamightbemore relevant inthesecond,oreventhirdorfourth,follow-onsession.

I hope that youwill use this text, and specifically this chapter, time and timeagainasareferencepoint,especiallywhenyouarefacedwithapatientforthefirsttimewhopresentswithpelvisandlumbarspinepathology.Iwouldlovetothinkthatthisbookwillassistyougreatlyintryingtounderstandthisfascinatingareaaswellasincorrectinganypresentingpelvicmalalignments.

AssessmentProcedure:Part1

Thefollowingassessmenttestswillbecoveredinthissection:

•Pelvicbalance

•Mensactivestraightlegraise

•Standingforwardflexion

•Backwardbending

•Seatedforwardflexion

•Stork

•Hipextension

•Lumbarsidebending

•Pelvicrotation

TableA1.3inAppendix1willbeusefulfornotingdowntherelevantpositionallandmarksforyourpatientinthestandingposition.Similarly,TableA1.4canbeusedtorecordtheclinicalfindingsforanytypeofpelvicdysfunctionthatexists.

PelvicBalanceTest

Withthepatientstanding,thecomparativelevelsofthefollowingarenoted:

•Pelviccrest(posteriorview)

•Posteriorsuperioriliacspine(PSIS)

•Greatertrochanter

•Lumbarspine

•Glutealfolds

•Poplitealfolds

•Leg,foot,andankleposition(anterior/posteriorview)

•Pelviccrest(anteriorview)

•Anteriorsuperioriliacspine(ASIS)

•Pubictubercle

PosteriorView

Thepatientisaskedtostandwiththeirweightequallydistributedonbothlegs.Thetherapistsitsorkneelsbehindthepatient,andplacestheirhandsonthetopoftheiliaccresttoascertainthelevel,asshowninFigure12.1(a–b).

It is very common to find the right innominate slightly higher if there is apresentationofaright-sidedanteriorrotation(themostcommonfinding)oraniliosacralupslip.Becareful,however—theright-sideinnominatecouldactuallyappearlower,eventhoughitisstillinananteriorrotation:thiscouldbebecauseofananatomicallylongerleftleg(trueLLD).Inthesittingandthelyingpronepositions,ontheotherhand,theiliaccrestmightactuallybehigherontherightsidethatisfixedinananteriorlyrotatedposition,becausetheeffectoftheLLDhasnowbeenremovedfromtheequation.

Figure12.1.Pelvicbalancetest:(a)Posteriorviewofthepelviccrest—handpositionforascertainingthelevel.

Figure12.1.(b)Close-upviewofthehandposition.

ThetherapistthenplacesthepadsoftheirthumbsunderthePSISandcomparesthelevels,asshowninFigure12.1(c).

Figure12.1.(c)HandpositionforcomparingtheheightofthePSISontheleftandrightsides.

Next, the therapist places their hands (fingertips) on top of the greatertrochanters, again to determine the height, as shown in Figure 12.1(d). Thetherapistthenpalpatestheglutealfoldsandtheischialtuberosities,asshowninFigure12.1(e).

Figure12.1.(d)Handpositionforascertainingtheheightofthegreatertrochanter.

Figure12.1.(e)Handpositionforascertainingtheleveloftheglutealfoldandthepositionoftheischialtuberosity.

The therapist observes the position of the lumbar spine, gluteal folds, and

popliteal (knee) folds forasymmetry, thenobserves the relativepositionof theleg, foot, and ankle, as shown in Figure 12.1(f), looking in particular for anexternalrotationofthelowerlegandforover-pronation(pesplanus),supination(pes cavus), or a neutral position (pes rectus). (Think back to Chapter 5 onLLD.)

Figure12.1.(f)Observationofthelumbarspine,glutealfold,andpoplitealfold,aswellastherelativepositionoftheleg,foot,andankle.

AnteriorView

Thepatientisaskedtostandwiththeirweightequallydistributedonbothlegs.

Thetherapistsitsorkneelsinfrontofthepatient,andplacestheirhandsonthetopoftheiliaccresttoascertainthelevel,asshowninFigure12.1(g).

Figure12.1.(g)Anteriorviewofthepelviccrest—handpositionforascertainingthelevel.

ThetherapistthenplacesthepadsoftheirthumbsundertheASISandcomparesthelevels,asshowninFigure12.1(h).

Figure12.1.(h)HandpositionforcomparingtheheightoftheASISontheleftandrightsides.

Thetherapistcanalsopalpatetheheight/levelofthepubictuberclestoascertaintheirposition,asshowninFigure12.1(i).

Figure12.1.(i)Handpositionforascertainingtheheightofthepubictubercle.

Note: The most common finding in terms of initial observation is the right leg in a slight position ofexternalrotationandtherightfootinarelativepositionofpronation,comparedwiththeleftside(relativesupination). If theseobservationsaremade, it ispossible thata rotationalmalalignmentdysfunctionofarightanteriorinnominaterotation,withacompensatoryleftposteriorinnominaterotationispresent.Ifyouobtainsimilarfindingsontheopposite(left)side,aleftanteriorinnominaterotationwitharightposteriorinnominaterotationdysfunctionpossiblyexists(lesscommon).

Ifeithertheiliaccrestorthegreatertrochanterislowerononeside,thismeansananatomicallyshorterleg;ifthegreatertrochantersarelevelbuttheiliaccrestisasymmetric,thiscanequatetoapelvicdysfunction.

Figure12.2.MensASLR:thepatientalternatelyliftseachlegandindicateswhichfeelsheavier.

MensActiveStraightLegRaiseTest

Mens et al. (1999, 2001, 2002) have developed a diagnostic test for SIJdysfunction.Theystudied the relationshipbetween theactive straight leg raise(ASLR)testandmobilityofthepelvicjointswithandwithouttheapplicationofa pelvic belt. The sensitivity and specificity of the test proved to be high forpatientswithpelvicgirdlepain(PGP).TheyalsofoundthatthetestwassuitablefordiscriminatingbetweenpatientswithPGPandhealthyindividuals.

TestProcedure

Thepatientisaskedtoadoptasupineposition;whentheyarerelaxed,theyareasked to lift one of their legs an inch (2.5cm) or so off the couch. This isrepeatedonthecontralateralside(oppositeside)andthenbackontheipsilateralside(sameside)approximatelythreeorfourtimes,asshowninFigure12.2.Thepatient is thenrequested tosaywhetherornot themovementof the individualleg lift increases theirSIJsymptoms.Thepatient isalsoaskedwhich leg feelsheavierorsimplyhardertoliftoffthecouch.

The starting movement of the leg lift is performed by the contraction of theiliacusandrectusfemorismuscles,whichinitiallyinducesananteriorrotationofthe innominate; this movement reduces the tension in the correspondingsacrotuberousligamentandhencedecreasesformclosure.Theanteriorrotationcould also indicate decreased activation of the dynamic stabilizers (forceclosure).

Mens et al. (1997) described how a decreased ability to actively perform astraight leg raise while lying supine seemed to correlate with an abnormallyincreasedmobilityofthepelvicgirdle.

Tocontinuewiththeassessmentprocess,Iwilladdsixcomponentstoassistinthe formand forceclosure.However,before Idemonstrate these, Ineed togothroughanexampletohelpyouunderstandthefollowingprocess.Imaginethatwhenyouinitiallyobservedthepatientliftingtheirleg,theleftlegwasdeemedtobe theheavier leg; that simplymeans thecontralateral sidewillnowbe theright leg (lighter leg) and the ipsilateral side will obviously be the left leg(heavierleg)inthisparticularcase.

Snijdersetal. (1993a)made the followingobservation.Provided the localand

global systems (inner and outer cores) are functioning normally, the overalleffect of carrying out a right-sided ASLR is a stabilization of both thelumbosacral junction and the right SIJ, which in turn allows amore effectiveloadtransferfromthespinetothelegonthatside.

Thesixadditionalcomponentsare:

1.Contralateral(oppositeside)contractionoftherightlatissimusdorsioftheposterior oblique sling increases force closure, as shown in Figure 12.3.With simultaneous contraction of the right latissimusmuscle, the left legshouldnowfeellighterwhenlifted.

Figure12.3.Posteriorobliqueslingactivationwhileliftingtheleftleg.

2.Contralateral(oppositeside)contractionoftherightanteriorobliqueslingincreases force closure, as shown in Figure 12.4. With simultaneouscontractionoftherightobliquemuscles,theleftlegshouldnowfeellighterwhenlifted.

Figure12.4.Anteriorobliqueslingactivationwhileliftingtheleftleg.

3. Activation of the inner core muscles, TVA, increases force closure, asshowninFigure12.5.Withsimultaneouscontractionof theTVA, the leftlegshouldnowfeellighterwhenlifted.

Figure12.5.Innercoreactivationwhileliftingtheleftleg.

4.Contralateral(oppositeside)posteriorrotationoftherightinnominatebone(opposite side) decreases force closure, as shown inFigure12.6.The leftlegshouldnowfeelheaviertolift.

Figure12.6.Posteriorinnominaterotation(oppositeside)whileliftingtheleftleg.

5.Ipsilateral(sameside)posteriorrotationoftheleftinnominatebone(sameside) increasesforceclosure,asshowninFigure12.7.Theleft legshouldnowfeellighterwhenlifted.

Figure12.7.Posteriorinnominaterotation(sameside)whileliftingtheleftleg.

6.Bilateralcompressionof the innominateboneswill increaseformclosure,asshowninFigure12.8.Theleftlegshouldnowfeellighterwhenlifted.

Figure12.8.Bilateralcompressionoftheinnominatewhileliftingtheleftleg.

Without appropriate bracing of the deep abdominal muscles, the hip flexormuscles (such as the iliacus) can pull the ilium anteriorly, creating a counter-nutated position of the SIJ.Counter-nutation is typical for unloaded situationssuchaswhenlyingsupine,asdemonstratedbyMensetal.(1999).

Shadmehr (2012) suggested there is reduced tonicity in the erector spinae,Gmax, biceps femoris, and external oblique muscles during ASLR testing ofpatientswithSIJpain.

StandingForwardFlexionTest(IliosacralDysfunction)

Duringforwardbendingofthetrunk,theleftandrightinnominatebonesandthepelvic girdle rotate as a whole in an anterior direction on the femur, as Iexplained in Chapter 2. Initially, the innominate bones rotate anteriorly toroughly60degreesas the sacrumgoes throughnutation.ThisROMisnormaland occurs because the posterior structures (posterior oblique muscles,sacrotuberousligament,thoracolumbarfascia,andhamstrings)becometautandwillnaturallylimitsacralnutation.Thesacrumisnowheldinwhatisknownas

relative counter-nutation, which causes an unstable position of the SIJ. Thecommonreasonforexcessivecounter-nutation,andthesubsequentinstabilityoftheSIJ,isgenerallyshortenedandtighthamstrings.

TestProcedure

Thepatientisaskedtostandwithequalweightonbothlegs.Thetherapistplacestheir hands onto the patient’s innominate bones, with the pads of the thumbslightlyplacedjustinferiortothelevelofthePSIS,asshowninFigure12.9.

Figure12.9.Standingforwardflexiontest:thetherapistplacestheirthumbsinferiortothePSIS.

Thepatientisthenaskedtofullyflexthetrunkslowlytowardthefloor,asfarastheycanwithoutbendingtheknees,whilethetherapist’scontacttothePSISismaintained.Thetherapistobservesthemotionoftheinnominatebones,butpaysextraattentiontothemotionofeachPSIS,asshowninFigure12.10.

Figure12.10.Thetherapistobservestheirthumbsasthepatientforwardbends.

Flexionofthespinecarriesthebaseofthesacrumanteriorly,andmotionisthenintroduced to the SIJs. There is a natural pause before the sacrum takes theinnominate intoanterior rotation; this iswhyyoushould feel the leftandrightPSISsriseequallyinacephalic(superior)direction,asshowninFigure12.11.

Figure12.11.Close-upviewofthetherapist’sthumbsasthepatientadoptsaforward-bentposition.

Ifonethumbisseentomovemoresuperiorly(cephalically)duringflexion,thiscouldbean indication that the innominatebone is fixed to the sacrumon thatside, as shown in Figure 12.12; this is known as an iliosacral dysfunction.Anotherway that thishasbeendescribed is that the iliosacral jointhas lockedtoo early on that side, causing thePSIS to rise sooner than normal, comparedwiththeotherside.

Figure12.12.Therightthumbisseentobeinahigher(cephalic)position,comparedwiththeoppositeside,indicatinganiliosacraldysfunctionontherightside.

False-PositiveResult

A false-positive result might be noted if the contralateral (opposite side)hamstring is held in a shortened and subsequently tight position, thus limitingthemotion of the opposite innominate bone. For example, the right-side PSIStraveling further than that on the left during the standing forward flexion testcould be caused by the left hamstrings being held in a shortened and tightposition;inotherwords,theleftinnominateboneisbeingheldback(fixed)bytheshorthamstringmuscles.

Moreover, if the ipsilateral (same side)QLmuscle is held in a shortened andtightposition,thistoowillalsogiveafalse-positiveresult,butonthesameside.Forexample,iftheright-sidePSISwasseentotravelfurther,theQLontherightsidemightbeheldinashortenedposition;asaresult,thismusclewillbepullingtheinnominateboneforwardsoonerratherthanlater,asshowninFigure12.13.

Figure12.13.Thepositionoftherightthumbishigherthanthatontheoppositeside,possiblyindicatingatightnessoftherightQLmuscle.

Note:Thestandingforwardflexiontestdoesnottellyoutheactualnatureofthedysfunction,i.e.whetheritisarotation,flare,orslip;itonlyguidestheexaminerastothesideonwhichtheinnominateboneisfixedinrelationtothesacrum.Wewilldecidelateroninthischapter,throughfurthertestingandpalpation,whattype of iliosacral dysfunction exists. Chapter 13 will then show you how to correct all these iliosacraldysfunctions that are commonly found in patients. For now, I would simply get used to practicing thestandingforwardflexiontest,asIconsiderthistobeoneofthemainteststouseinyourownclinicsetting.

BackwardBendingTest

Thepatientisaskedtostandwithequalweightonbothlegs.Thetherapistplaces

theirhandsonthepatient’sinnominatebones,withthepadsoftheleftandrightthumbs lightlyplaced just inferior to the levelof thePSIS.Thepatient is thenasked to fullyextend their trunkbackward,while the therapist’scontact to thePSISismaintained.Thetherapistobservesthemotionoftheinnominatebones,butpaysextraattentiontothemotionofeachPSIS.Normally,thePSISisseentomoveveryslightlycaudally(inferiorly),asshowninFigure12.14(a–b).

Figure12.14.Backwardbendingtest:(a)ThetherapistplacestheirthumbsinferiortothePSISandasksthepatienttobackwardbend.

Figure12.14.(b)Close-upviewofthetherapist’sthumbsasthepatientbackwardbends.

Duringbackwardbending,theinnominatebonesandsacrumremaininthesameposition, and so there should be no relative change felt in the position of thethumbs;however,thesacrumshouldbeseenandfelttonutateslightlyinordertomaintainstabilityoftheSIJduringthebackwardbendingmotion.

SeatedForwardFlexionTest(SacroiliacDysfunction)

Before one performs the seated forward flexion test, it is very important toascertain the position of the iliac crest, as shown in Figure 12.15(a).Schamberger (2013)mentions that sitting is likely to present problems, as theischial tuberosities are at different levels, raised on the side of the anteriorrotationand/oranupslip,andloweronthesideoftheposteriorrotationand/oradownslip.Ithasbeensuggestedthat,witharightanteriorrotationoranupslip,therightischialtuberositycaneasilyendup0.4”(1cm)offtheseatingsurface,theweightnowbeingborneprimarilybythelefttuberosity.

Figure12.15.Seatedforwardflexiontest:(a)Thetherapistplacestheirfingersontopoftheiliaccresttoascertaintheposition.

Position1

Thepatientisaskedtositontheedgeofacouch,withtheirfeetflatonthefloor,orinacomfortablepositiononthecouch.Thetherapistplacestheirhandsonthepatient’sinnominatebones,withthepadsofthethumbslightlyplacedjustbelowtheleveloftheleftandrightPSIS,asshowninFigure12.15(b).

Figure12.15.(b)ThetherapistplacestheirthumbsinferiortotheleftandrightPSIS.

Thepatientisthenaskedtoslowlyfullyflextheirtrunk,byrollingtheirchintotheirchest,andcontinueasfaras theycan,with theirhandsontheirkneesforsupport,asshowninFigure12.15(c).

Figure12.15.(c)Thetherapistobservestheirthumbsasthepatientforwardbendsintheseatedposition.

Thetherapistobservesthemotionoftheinnominatebones,aswellasfocusingon the specific motion of the PSIS. If one of the thumbs, which is locatedinferior to the PSIS, is seen to move more superiorly (cephalically) duringflexion,thiscouldmeanthatthesacrumisfixedtotheinnominateboneonthatside, as shown in Figure 12.15(d); this is known as a unilateral sacroiliacdysfunction.

Figure12.15.(d)Thetherapistobservesthattheirrightthumbtravelsmorecephalicallythantheirleftthumb,indicatinganSIJdysfunctionontherightside.

Position2

With the patient in the neutral position, the therapistmoves the pads of theirthumbsfromtheoriginalposition(inferiortothePSIS)totheposterioraspectofthe sacral apex, and in particular to the ILA, in order to ascertain thelevel/position,asshowninFigure12.16(a).

Figure12.16.(a)ThetherapistplacestheirthumbsonthesacralapexandobservestherelativepositionoftheILA.

NoteifonesideoftheILAisasymmetriccomparedwiththeoppositeILA;thisinformation will be used as part of the process of assessing for sacroiliacdysfunction.Thepatient is thenaskedtoforwardbendandthemotion/positionoftheILAisobserved,asshowninFigure12.16(b).

Figure12.16.(b)ThetherapistobservestherelativepositionoftheILAasthepatientforwardbends.

Note: The seated forward flexion test does not tell youwhat type of SIJ dysfunction is present: it onlyguidesyouastowhichsidethesacrumisfixed(inrelationtotheinnominatebone).Thetestremovestheinfluenceofthelegsandpelvisonthesacrum(becauseofthesittingposition),andallowsyoutodecideifanactualSIJfixationispresent.(PleasebeawarethattheQLmuscle,ifheldinashortenedposition,isstillcapableofgivingafalse-positiveresultforthesameside.)

IliosacralorSacroiliac

Supposeyourrightthumb,whichislocatedinferiortothePSIS,travelsfurther(cephalically) than the left thumbinboth thestandingforwardflexion testandtheseatedforwardflexiontest;inotherwords,theleftthumbremainslowerthantheright thumb.Thismeansyouhavefoundbothaniliosacralandasacroiliacdysfunctionontherightsideatthesametime.Iftherightthumbisseentomoveonly during the standing forward flexion test, however, this indicates thepresenceofaniliosacraldysfunctionontherightside.Ontheotherhand,iftherightthumbisseentomoveonlyduringtheseatedforwardflexiontest, thenasacroiliacdysfunctionontherightsideispresent.

StorkTest(One-Legged)

StorkTest(One-Legged)

Thestorktest(alsoknownastheGillettest)consistsoftwoelements:theupperpoleandthelowerpole.

Test1:UpperPole

With the patient standing, the therapist sits or kneels behind the patient. Thetherapistplacestheirlefthandontopofthepatient’sleftinnominatebone,andthepadof their left thumbunder the inferior part of thePSIS.The therapist’srighthandispositionedontherightinnominatebone,whilethepadoftherightthumb is incontactwith the levelofS2 (this is in linewith thecorrespondingPSIS),asshowninFigure12.17.

Figure12.17.Storktest—upperpole:thetherapistplacestheirleftthumbinferiortothePSIS,andtheirrightthumbonS2.

Thepatient is asked to lift their left hip into full flexion, to at least above thelevelof thehip joint.The therapist’s lefthand remains incontactwith the leftinnominateandmonitors themovement: the left thumbon thePSISshouldbeseentorotateposteriorly,medially,andinferiorly(caudally),withrespecttotherightthumb,whichstillmaintainscontactwithS2,asshowninFigure12.18(a–b).

Figure12.18.(a)Thetherapistobservesfornormalinferiormotionoftheinnominatebonewhilethepatientflexestheirhip.

Figure12.18.(b)Close-upviewofthetherapist’shandandthumbincontactwiththePSISandS2.

Note:Iconsiderthatthespecificmovementofthestorktestindicatestheabilityoftheinnominatebonetoposteriorly rotate on the sacrum, even though research does not actually confirm this hypothesis.Mosttherapists Ihave talked to in thepast say thatwhen theyperformthestork test, theysimply lookfor themovementdescribedearlier(inferiormotionofthethumb),andif themovementisrestrictedinanyway,then an iliosacral dysfunction is present. Again, this test does not tell you the type of the iliosacraldysfunction;itonlysignalsthatoneispresentandthatitislocatedonthesidethattestspositiveinthestorktest.

If the standing forward flexion test and also the stork test are positive on thesameside,youknowthatthereisaniliosacraldysfunctionpresent;thefollowingtests in this chapterwill help you determine the type of this dysfunction. Thecontralateral(opposite)sideisthentestedforcomparison.

A test is positive when the thumb located on the PSIS is not seen to movemediallyandinferiorly,orisseentomoveinacephalicdirection,asshowninFigure12.19(a–b).

Figure12.19.(a)Thealteredmotionoftheinnominateboneshowsadysfunctionispresent.

Figure12.19.(b)Close-upviewofthealteredmotionoftheleftinnominatebone.

Test2:LowerPole

With the patient standing, the therapist sits or kneels behind the patient. Thetherapistplacestheirlefthandontopofthepatient’sleftinnominatebone,whileplacingthepadoftheirleftthumbundertheinferiorpartoftheposteriorinferioriliac spine (PIIS). The therapist’s right hand is positioned on the rightinnominatebone,whilethepadoftherightthumbisincontactwiththeleveloftheS4(neartothesacralhiatus),asshowninFigure12.20.

Figure12.20.Storktest—lowerpole:thetherapistplacestheirleftthumbinferiortothePIIS,andtheirrightthumbonS4.

Thepatientisaskedtoliftthelefthipintofullflexion,toatleastabovethelevelof the hip joint. The therapist’s left hand remains in contact with the leftinnominate andmonitors themovement: the left thumbon thePIIS should beseentorotateanteriorlyandlaterally,withrespect totheright thumb,whichispalpatingtheleveloftheS4,asshowninFigure12.21.

Figure12.21.Thetherapistobservesfornormalanteriorandlateralmotionoftheinnominatebonewhilethepatientflexestheirhip.

AtestispositivewhenthethumblocatedonthePIISisnotseentomove,orisseentomoveinacephalicdirection,asshowninFigure12.22.

Figure12.22.Thealteredmotionoftheinnominateboneshowsadysfunctionispresent.

Note:ThesespecifictestsfortheupperandlowerpolesaresensitivetothemotionoftheSIJaswellastothemotionoftheiliosacraljoint(asmentionedearlier).Otherauthorsconsiderthatiftheupperpoletestspositive,aposterior(backward)torsionoftheSIJdysfunctionispresent,andifthelowerpoletestspositive,ananterior(forward)torsionofthesacroiliacdysfunctionexists.However,itisverydifficulttoprovewiththese tests thatanSIJdysfunction isactuallypresent,as the research regarding theirvalidity iscurrentlylimited. Even so, I think that these tests will give the therapist some important palpatory feedback thatmightbeusefulinmakinganoveralldiagnosisanddevelopingasubsequenttreatmentplan.

HipExtensionTest

With the patient standing, the therapist sits or kneels behind the patient. Thetherapistplaces their righthandon topof thepatient’s right innominate,whileplacingthepadoftheirrightthumbundertheinferiorpartoftherightPSIS.Thetherapist’slefthandispositionedontheleftinnominate,whilethepadoftheleftthumb is incontactwith the levelofS2 (this is in linewith thecorrespondingPSIS),asshownearlierinFigure12.17.

The patient is asked to lift their right hip into full extension, as far ascomfortable.The therapist’shand remains incontactwith the right innominateboneandmonitorsthemovement:therightthumbonthePSISshouldbeseento

rotate superiorly and laterally (cephalically), with respect to the left thumb,whichispalpatingthelevelofS2,asshowninFigure12.23.Thisindicatestheability of the innominate bone to anteriorly rotatewith respect to the sacrum.Thecontralateral(opposite)sideisthentestedforcomparison.

Figure12.23.Hipextensiontest:withtheirrightthumbinferiortothePSIS,thetherapistobservesfornormalsuperiorandlateralmotionoftheinnominatebonewhilethepatientextendstheirhip.

A test is positive when the thumb located on the PSIS is not seen to movesuperiorly and laterally, or is seen tomove in a caudal direction, as shown inFigure12.24.

Figure12.24.Thealteredmotionoftheinnominateboneshowsadysfunctionispresent.

LumbarSideBendingTest

Thepatientisaskedtostandwiththeirfeetshoulder-widthapart.Thetherapistsitsorkneelsbehind thepatient,andplaces theirhandson topof thepatient’siliaccrests,withthepadsofthethumbsontheposteriorpartofthePSIS.

Thepatientisaskedtosidebendtotheleft(withoutforwardflexingtheirspine)as far as comfortable.The therapistobserves the lumbar spineand looks for asmooth “C” curve with a fullness of the erector spinae on the side of theconvexity(rightsideinthiscase);thisfullnessisseenonthesideoppositetothe

inducedsidebending,becauseofTypeI,orneutral,spinalmechanics,asshowninFigure12.25(a).

Figure12.25.Lumbarsidebendingtest:(a)Anormalmotionisseenbyafullnessoftheerectorspinaeontherightsideasthepatientsidebendstotheleft.

A positive finding during the observation is either fullness on the side of theconcavity (same side as the side bending), as shown in Figure 12.25(b), or apossible straightening of the lumbar curve. These positive findings tend toindicateanon-neutralspinalmechanicstypeofdysfunction(TypeII).

Figure12.25.(b)Analteredmotionisseenbyafullnessoftheerectorspinaeontheleftside(sameside)asthepatientsidebendstotheleft.

Note:Whenlookingat thelumbarcurvature, thetherapistshouldalsobeawareofthepalpatoryfindingsforthePSIS.Thenormalmotionoftrunksidebendingtotherightwillinducealumbarrotationtotheleft,andthisinturnwillinduce(throughthenormalTypeIneutralspinalmechanics)arotationofthesacrumtotheopposite(right)side.

In simple terms, if thepatienthasnormal lumbosacralmotion,when they sidebendtheirlumbarspinetotherightside,acoupledrotationtotheleftside(TypeImechanics/neutral) is induced. As a result of the lumbar spine side bendingrightandrotatingleft,thesacrumshouldalsobefelttogothroughtheoppositemotion, i.e.asidebendingto theleft,whichwill inducearotationthis timetotheright.Thismovementofthesacrumcanbepalpatedthroughthelightcontactof your right thumb, which is positioned on the right-side PSIS. This is allbecauseof thefact that the lumbarspinewillhaverotated to the left (oppositesidetothebending,becauseofTypeImechanics).

PelvicRotationTest

Whenyouassessthepatientinthestanding-erectposition,itisverycommonto

considerthepelvistobeinanasymmetricalposition.Ifthepatientpresentswitha typical rotationalmalalignmentsyndrome,youmaynotice thepelvis tohaverotated in an anticlockwise (left) direction, especially if they present with themost common finding of a right anteriorly rotated innominate and a leftposteriorly rotated innominate,asshown inFigure12.26(a); it isusual for thisincreased rotation to be anywhere between 5 and 10 degrees. If you now askyourpatient torotate their trunkto theright,asshowninFigure12.26(b),youwill notice further right rotation (approximately 45 degrees), comparedwith aleftrotationofaround35degreeswhenthetrunkisrotatedtotheleft,asshowninFigure12.26(c).

Figure12.26.Pelvicrotationtest:(a)Themostcommonmalalignmenttypeofsyndrome—right

anteriorinnominaterotationwithacompensatoryleftposteriorinnominaterotation.

Figure12.26.(b)Thepatientisaskedtorotatetotherightside(clockwise)andapproximately45degreesisseen.

Figure12.26.(c)Thepatientisaskedtorotatetotheleftside(anticlockwise)andapproximately35degreesisseen.

In the above example, the reason why rotation of the trunk to the right side(clockwise)isgreaterthantotheleft(eventhoughthepelvishasrotatedslightlytotheleftsidebecauseofthepresentingdysfunction)isthattheleftinnominatebone already starts out in a posteriorly rotated position (because of thedysfunctional pattern). This basically means that the left-side innominate iscapable of rotating further in an anterior direction, to its available end ROM,thanitwouldifitactuallystartedoutinanormalposition.Thesameistruefortheright-sideinnominate,whichhasalreadyanteriorlyrotated;therightsideisnowcapableoftravelingthroughagreaterROMinaposteriordirection,giving

theappearanceoffurtherrotationtotherightside(clockwise).

Schamberger(2013)alsosaysthatonaccountofthewedgingofthesacrum,theleft innominate already flares slightly inward, and the right slightly outward.Overall,thistranslatesintomoredegreesofclockwiserotation.

Note:Ifthepelvispositionappearedtobeneutral,withnoobviousasymmetry/rotationpresent(contrarytotheexampleabove),onewouldexpectpelvicrotationofthetrunktotheleftside(anticlockwise)toequaltheavailablerotationofthetrunktotherightside(clockwise).

AssessmentProcedure:Part2

PalpatoryAssessment—PatientProne

In thispartof theassessmentcriteriawewillbe looking forasymmetryof theanatomicallandmarks,asoutlinedbelow.Thepatientisaskedtoadoptapronepositiononthecouch.Thetherapiststandsnexttothepatientandobservesforthelevelsofthefollowingareasusingtheirdominanteye:

•Glutealfold

•Ischialtuberosity

•Sacrotuberousligament

•Inferiorlateralangle(ILA)ofthesacrum

•Posteriorsuperioriliacspine(PSIS)

•Sacralsulcus

•Lumbarspine(L5)

•Iliaccrest

•Greatertrochanter

TableA1.5inAppendix1canbeofvaluetothetherapistfornotingdownanyasymmetriesfoundduringthepronepalpatoryassessment.

GlutealFoldandIschialTuberosity

First observe the level of the gluteal fold and then lightly palpate this area toascertain the position. From the gluteal fold,move your thumbs in a cephalicdirectionuntilcontactwiththeischialtuberosityismade.Placeyourthumbsinahorizontalplaneagainsttheinferioraspectoftheischialtuberosity,andnotethelevel,asshowninFigure12.27.

Figure12.27.Palpationoftheglutealfoldandischialtuberosityforsymmetry.

SacrotuberousLigament

After the ischial tuberosity has been palpated, the thumbs are now directedmediallyandcephalicallyuntilthesacrotuberousligamentisfound,asshowninFigure12.28.Gentlypalpatetheligament,feelingforincreasedtensionorlaxityas well as increased tenderness, as these can be associated with sacroiliac oriliosacraldysfunction.

Figure12.28.Palpationofthesacrotuberousligament.

ILAoftheSacrum

Next, if you lightly palpate the ischial tuberosity and follow it toward theproximalcomponentofthesacrotuberousligament,itwillnaturallytakeyoutothe ILA. Another way of finding it is to locate the sacral hiatus and palpateapproximately 0.8” (2cm) lateral to this area—thiswill be the ILA landmark.Place thepadsofyour thumbsover theposterior areaof the ILA tocheck forasymmetry,asshowninFigure12.29.

Figure12.29.Palpationoftheinferiorlateralangle(ILA)forsymmetry.

PSIS

From the landmarkof the ILA,nowplaceyour thumbs inacephalicdirectionuntiltheymakecontactwiththebonylandmarksoneitherside—i.e.thePSIS,asshowninFigure12.30(a).Fromthisposition,lookateachofthecontactthumbsonthePSISandnotedownanyasymmetrythatisfound.

Figure12.30.(a)PalpationofthePSISforsymmetry.

IliacCrest

FromthePSIS,itisadvisabletoascertainthepositionoftheiliaccresttocheckthe levelby lightlyplacing the fingerson topof thecrest, as shown inFigure12.30(b).

Figure12.30.(b)Palpationoftheiliaccrestforsymmetry.

SacralSulcus

Thesacralsulcusistheareathatisnaturallyformedbythejunctionofthesacralbasewiththecorrespondingiliumoneitherside.Youmightnoticeanoverlyingdimplethatwillcorrespondtothesacralsulcus:theseleftandrightdimplesareknownas thedimplesofVenus.Fromthepositionof thePSIS, the thumbsarenowdirected(gently)atanangleof45degreesmediallytowardthejunctionofL5/S1, until the sacral base is contacted. It is best to wait a moment for thetissuestosettledownbeforedecidingontheappropriateposition.Youaretryingtodeterminewhatistermedthedepthofthesacralsulcus(locatedbetweenthesacral base and the PSIS); the normal depth is approximately 0.4–0.6” (1.0–1.5cm), but it is usually less, because of the soft tissues overlying the sulcus.Normalfindingsarethatthethumbspalpateasequal,orlevel,withinthesacralsulcus/base,asshowninFigure12.31.

Figure12.31.Palpationofthesacralsulcusforsymmetry/depth.

SacralRotation

Imagine for a moment that when you palpate the sacral sulcus you convinceyourselfthatyourthumbslookasymmetric:forexample,therightthumbseemsto sink (palpate) deeper and the left thumb palpates shallowwithin the sacralbase.Thisfindingmightpossiblyindicateeitherananterior(orforward)sacralbase(nutated)onthedeeperrightside,oraposterior(orbackward)sacralbase(counter-nutated)ontheshallowerleftside.Eitherway,thesacruminthiscasewouldstillbe“rotated”totheleft,asshowninFigure12.32.

Figure12.32.Palpationofthesacralsulcusforsymmetry—therightthumb(inthiscase)appearsdeeperandtheleftthumbappearsshallower.

Inthearticle“Sacroiliacjointmechanicsrevisited”byJordan(2006),Iwasveryinterested to read in particular about the area of palpation for identifying thedepthofthesacralsulcus.Theclinicianmentionedthatwhenonepalpatesintothesacralsulciandchecksfortherelativesacralsulcusdepth,therelativedepthdoesnot reflect the sacral position, but rather themultifidusmuscle thickness,even inpetitepatients. Inaddition,overlying themultifidus is the lumbosacralfascia,averythicklayerofcollagenousconnectivetissue,whichcanfeelquitesolid and bemistaken for bone. If one side of themultifidusmuscle is morecontracted than the other, a greater cross-sectional area is produced, andconsequentlythesacralsulcuswillnaturallyappearshallower.

Truethoughthismaybe,pleaserememberthatpalpationofthesacralsulcusisonlyonecomponentoftheassessmentprocess.Youcanthinkoftheassessmentprocessasajigsawpuzzle,andpalpationofthissulcuswillonlybeonepieceofthepuzzle.AsIhavesaidbefore,therearelotsofotherpiecesinthepuzzle,sotrynottorelyonjustonepiece.

WhileIamonthesubjectoftherelativedepthofthesacralsulci,onealsohasto

consider the position of the innominate bone. For example, if the right sacralsulcuspalpatedasshallow, thiscouldindicateananteriorly rotatedinnominateontheright(iliosacraldysfunction,andacommonfinding).Adifferenttypeofrotational malalignment can also relate to the opposite finding: if the sacralsulcuspalpatedasdeeperontherightside,thiscouldcorrespondtoaposteriorlyrotatedinnominateboneontheright(alesscommonfinding).

Rememberfromearlierthatthemostcommonmalalignmentconditionfoundisrotational, and typically this will be a right anterior rotation, along with acompensatory left posterior innominate rotation. In terms of palpation for thedepth of the sacral sulci with this common finding, the right thumb wouldpalpateshallowandtheleftthumbwouldpalpatedeep,eventhoughthesacrumisinarelativelyneutralpositionbycomparison.Inthiscaseitistheinnominatebonethatisthedysfunctional(iliosacral)structure,buttheimpressionofarightrotatedsacrumisgiven(eventhoughitisnotrightrotated),mainlybecausetheleft side of the sacral sulcus palpates as deeper as a result of the posteriorlyrotatedleftinnominatebone.

IhavealreadydiscussedinChapters2and4thatweknowthesacrumiscapableofsidebendingwithacoupledmotionofrotation,sincethisiswhatyoursacrumundergoesduringthewalkingcycle,asyoushiftyourweightfromonelegtotheother.ThesacralmotionfollowsTypeImotion,andsidebendingandrotationarecoupledtotheoppositeside:wecallthistypeofmovementtorsion.So,forexample,iftheleftsacralbaseisposterior,thesacrumwillbeleftrotated,orlefttorsioned,andsidebenttotheright.If,whenwepalpatethesacralbaseaswellas the position of the ILA in a neutral position (patient prone), we findasymmetry of the sacral base and also of the ILA, then we can safely say adysfunctionoccursandthereissomeSIJfixation.

Thequestion Iaskyou is this:howdoyoudeterminewhich is the fixedside?Well,youhavealreadypartlyansweredthisquestionwithoutactuallyrealizingit.Why?Becauseyouhave alreadyperformed the seated forward flexion test,and this particular SIJ test will indicate the side of the body on which thedysfunction is located. Suppose, for example, the left side tests positive (leftthumb travels cephalically, compared with the right thumb) during the seatedforwardflexiontest;inaddition,whenyoupalpatetheleftsacralsulcus,theleftthumbsinksfurther intothesulcusthantheright thumb(i.e. itpalpatesdeeperon the left side). You then know that the sacrum has to be in a position ofanterior/forwardnutationontheleftside,becauseithasrotatedtotherightand

side bent to the left, as in what we call a R-on-R sacral torsion (see Figure12.33).

Figure12.33.Anterior/forward(nutated)sacraltorsionR-on-R.X=Anteriorordeep. =Posteriororshallow.

Let’s look at another scenario: the seated forward flexion test still gives apositiveresultontheleftside,butthistimetheleftsacralsulcusnowpalpatesasshallow instead of deep. Hopefully, you now know that the left side of thesacrumisinapositionofcounter-nutation:thesacrumhasrotatedtotheleftandsidebent to the right, as in aL-on-R sacral torsion (posterior/backward sacraltorsionontheleft),asshowninFigure12.34overleaf.

Figure12.34.Posterior/backward(counter-nutated)sacraltorsionL-on-R.X=Anteriorordeep.

=Posteriororshallow.

Posterior/Backward(Counter-Nutated)FixedSacralTorsion

Let’smove on to the next part of the assessment,whichwill continue on thethemeofsacraltorsion.Wewillnowbelookingatconfirmingordiscountingtheactual presence of a sacral dysfunction/torsion by asking the patient to simplybackwardandforwardbendtheirtrunk,toascertainwhathappenstothedepthofthesacralsulci.

Let’scontinuewiththeconceptoftheaboveexample,wheretheleftsacralbase

isposteriorinneutral.Fromthisposition,younowaskyourpatienttoforwardbend their trunk,and thesacraldysfunctionappears todisappear (your thumbsbecome level). When you ask your patient to perform a backward-bendingmotion(sphinxtest—explainedlater)therotationseemstoincrease:thepositionofthesacralbasebecomesworse—i.e.theleftthumbappearsshallowerontheleft side (or the sacral sulcus palpates as deeper on the right side). This willconfirmthattheleftsacralbaseisfixedposteriorly,whichiswhatwecallaL-on-Rsacraltorsion.Why?Thinkaboutitforaminute.Asyouaskthepatienttoextendtheirlumbarspine,thesacrumshouldbilaterallyanteriorlynutate(think“opposite motion to that of the lumbar spine”). If the left side is fixed in abackward/posterior position, this means that the left side will be unable toanteriorly nutate (to go forward), so it must be fixed in a counter-nutatedposition(posteriororbackwardsacral torsion).Anotherwayof lookingat it isthat inbackwardbending, the left sacralbase stayswhere it is—inaposteriorfixed position; however, the right sacral base moves further into an anteriorposition as the patient backward bends, therebymaking the rotation appear toworsen(increase).

Whenyouask thepatient toperformaforwardbendingmotion, the leftsacralbasewillstayfixedposteriorly(counter-nutatedontheleft),astherightsideofthe sacrum is able to continue itsmotion and rotatebackposteriorly (counter-nutateon theright); thesacralsulcuswillnowappear tobecomelevel,so thattherotationseemstodisappear.

SphinxTest/TrunkExtension

Onemaneuver I particularly like to askmy patients to perform, as a guide toascertainingthepresenceofaposteriortorsionofthesacrum,isthesphinxtest.Thepatientisaskedtoadoptapronepositiononthecouch.Standingnexttothepatient,placethepadsofyourthumbsorindexfingersdirectlyovertheleftandrightsacralbases,withyourdominanteyefacingthepelvis.

The test is rather simple: ask thepatient to raise themselvesonto their elbows(i.e.asphinxposition),asinreadingabook.Ifaposteriorsacraltorsionexists,the sacral sulcuswill be asymmetrical (posterior sacrumon the shallow side).ThesacraltorsionwillbeaL-on-Rifthesacralsulcusisshallowontheleftside(or the right sacral sulcus is deeper), as shown in Figure 12.35; likewise, thesacraltorsionwillbeaR-on-Lifthesacralsulcusisshallowontherightside(ortheleftsacralsulcusisdeeper).

Figure12.35.Sphinxtest:aL-on-R(posterior/backward)sacraltorsionisindicated(theleftthumbbecomesshallowerinthiscase).

Note:Ifthesacralsulcusdiminishesornormalizes(becomeslevel)duringthesphinxtest,ananteriorsacraltorsionispresent.ThisforwardtorsionwilleitherbeaR-on-RoraL-on-L(thiswillbeexplainedin thesection“Anterior/Forward(Nutated)FixedSacralDysfunction”).

LumbarFlexionTest

Let’scontinuewiththecaseofaL-on-Rsacraltorsion(leftsideofthesulcusisfixedincounter-nutation).Afterthepatienthasadoptedthesphinxpositionandthe levelof the sacral sulcushasbeennoted,youask thepatient toperformaforward bendingmotion of the trunk (lumbar flexion). Because the left sacralbaseinthisexampleisfixedposteriorly, therightsideofthesacrumisabletorotatebacknormally in aposteriordirection (counter-nutation); thiswillmakethe sulci appear to become level, so that the rotation seems to disappear, asshowninFigure12.36(a).

Figure12.36.(a)Forwardflexiontestforthelumbarspine:aL-on-R(posterior/backward)sacraltorsionisindicated(boththumbsnowbecomelevel).

Ifyoupreferthepatienttoflextheirlumbarspinefromapronepositionratherthanasittingposition,youcanask themtositbackonto theirheelswith theirarmsstretchedforward,asshowninFigure12.36(b).

Figure12.36.(b)Alternativelumbarflexiontest:aL-on-R(posterior/backward)sacraltorsionisindicated(boththumbsnowbecomelevel).

Anterior/Forward(Nutated)FixedSacralDysfunction

Let’s lookatanotherexampleofa forwardsacral torsion.This time,whenwepalpate the left sacral sulcus in a neutral position (patient prone), the thumbappearstosinkdeeperonthatside;inaddition,theseatedforwardflexiontestispositiveontheleftside.Becauseofthesetwofindings,wecanalmostconcludethat a R-on-R forward sacral torsion is present.Wewill now confirm this byasking thepatient to forwardbend,withyour thumbs in light contactwith thepatient’ssacral sulci.The left sacralbaseappears togetworse (deeper) in thisposition, as shown in Figure 12.37, and becomes level in a backward-bent(sphinx)position,asshowninFigure12.38.

ThismeansthattheoppositeofwhatIsaidatthebeginningispresent:wehaveananteriorlynutatedfixationontheleftside(R-on-R).Why?Whenyourpatientforwardbends,theirleftsacralbasestaysfixedinananteriorlynutatedposition,but their right sacral base moves further into posterior nutation (counter-nutation), which will thus make the rotation appear to worsen (left thumbappears tosinkevendeeper).Whenthepatient isasked tobackwardbend, the

leftsacralbaseisstillfixedinananteriorlynutatedposition;however,therightsacralbaseisabletomoveintoitsnormalanteriorlynutatedposition.Thisnowshows that the dysfunctional rotation of the sacrum seems to disappear, andpalpationofthesacralsulcusoneachsidenowindicatestheyarelevel.

Figure12.37.Forwardflexiontest,indicatingaR-on-R(anterior/forward)sacraltorsion(leftthumbbecomesdeeper).

Figure12.38.Sphinxtest,indicatingaR-on-R(anterior/forward)sacraltorsion(boththumbsbecomelevel).

LumbarSpine(L5)

SpringTest

The patient is asked to adopt a prone position on the couch, and the therapiststands facing the patient. The therapist observes the lumbar spine for thefollowingpositions:flatback(flexed),increasedlordosis(extended),orneutral.If the patient has a relatively flat back, this indicates the lumbar spine is in aposition of flexion, and the sacrum will be in a position of relative counter-nutation.Ifthepatienthasalordoticposture,thismeansthelumbarspineisnowin a position of extension, and the sacrum will be in a position of relativenutation. After observing the positions of the lumbar and sacral spines, thetherapistplacestheheeloftheirdominanthanddirectlyoverthespinousprocessofL5andexertsagentlebutfirmpressuretowardthecouch,asshowninFigure12.39.

A positive test iswhere there is firm resistance to the applied pressure toL5,withnoobviousmovementintheunderlyingtissues;afirmresistanceindicates

alockingoftheL5facetsintoaflexedposition.Thisfindingdemonstratesthateitherthesacrumhasbilaterally(onbothsides)counter-nutated,oraunilateral(one-sided)posterior/backwardsacraltorsion(L-on-RorR-on-L)ispresent.

Figure12.39.Lumbar(L5)springtest:eitheraposteriororananteriorsacraltorsionisindicated.

Ifthespringtestisnegative(thereissomeavailablemotion,i.e.spring)andthelumbar spine appears to have an increased lordosis (curvature increased), theneither the sacrumhasbilaterallynutated,oraunilateral anterior/forward sacraltorsion(L-on-LorR-on-R)ispresent.

Note:Thespring testwillalsobenegative if thepatient is inaneutralposition,as there issomenaturallordosisofthelumbarspineinthiscase.

L5Position—Neutral

Once you have decided on the relevant position of the sacral base forascertaining any underlying sacral torsions, position your thumbs and directthemtotheleveloftheL5spinousprocess.FromthespinousprocessoftheL5vertebra, direct the pads of the thumbs and place them equally and lateral(approximately 1–1.4”, or 2.5–3cm) to theL5 spinous process; this placement

shouldbeinlinewiththecorrespondingleftandrightTPs,sothattherelevantpositionofL5 is identified. Ifashallowside ispalpated, let’ssayon the rightside,theninthisparticularcaseweknowthattheL5vertebrahasrotatedtothatside(right),asshowninFigure12.40(a–b).

However, thinkbacktoChapter6: justbecauseL5hasrotatedto theright,wedon’t know whether the right-side facet joint of L5/S1 is fixed in a closedposition,orwhethertheleft-sidefacetjointofL5/S1isfixedinanopenposition.As I have already explained in Chapter 6, we would need to ascertain theposition of the L5/S1 facet joint by the use of specific motions, whereby thepatientisaskedtoperformextensionandflexionmovementsofthetrunk.

Figure12.40.(a)PalpationforthepositionofL5:theshallowsideisseenontheright,indicatingarightrotationoftheL5vertebra.

Figure12.40.(b)Close-upviewofthepositionofL5,withtheshallowsideontheright.

Note:Generallyspeaking, thepositionofL5 isparticularlydependenton thepositionof thesacralbase.TheL5 vertebrawill be in a different position for each of the four sacral torsion positions discussed inearlierchapters.

RememberfromearlierthatL-on-LandR-on-Rsacralmotionsareclassifiedasnormal physiological motions of the sacrum, which will elicit typical Type Ispinalmechanics(sidebendingandrotationarecoupledtotheoppositeside)ofthelumbarspineduringthegaitcycle.However,myownthoughtprocesstellsme that if the sacrum is fixed in a forward/nutated (Examples 1–2 below) orbackward/counter-nutated (Examples 3–4 below) torsional position for asignificantperiodoftime, thenthroughthenaturalcompensatoryprocessesthelumbar spine in somewayhas to alter its position andpossibly adoptType IIspinalmechanics;inthiscasethesidebendingandrotationarenowcoupledtothesameside(either in flexionor inextension),asexplainedby thefollowingexamples.

Example1

AL-on-LsacraltorsiontypicallycausestheL5vertebratoadoptneutralTypeI

spinal mechanics of right rotation with left side bending. If the sacraldysfunctionhasbecomechronic,however,thealteredpositionofthesacrumcanpotentiallychangethepositionoftheL5vertebra:thisisknownasanERS(R)—theL5/S1facetjointisclosedontherightside.

Why? The motion of the L5 vertebra will be opposite (right) to the nutatedmotionofthesacrum(left),whichmeanstheL5vertebrawillbeinapositionofextension, side bending, and rotation to the right side, i.e. an ERS(R). Putsimply,thesacrumisrotatinginananterior(nutated)directiontotheleft,soL5willrotateinaposteriordirectiontotheright.ThisrightrotationofthelumbarspineisinpartclassifiedasnormalTypeImechanicsbecauseoftheinducedleftrotation of the sacrum; however, if the lumbar spine increases its lordoticcurvatureasaresultoftheforward(nutated)sacraltorsion,theL5vertebrawillbe forced intoType IImechanics and subsequentlydevelop thepositionof anERS(R).

Example2

AR-on-R sacral torsion potentially causes theL5 vertebra to adopt a positionknownasanERS(L)—theL5/S1facetjointisclosedontheleftside.

ThemotionofL5willbeoppositetothatofthesacrum,sothevertebrawillbein anERS(L)position.Why?Put simply, the sacrum is rotating in an anteriordirectiontotherightside,whichmeansL5willrotateinaposteriordirectiontotheleftside.

Example3

AL-on-RsacraltorsionsacraltorsionpotentiallycausestheL5vertebratoadoptapositionknownas anFRS(R)—theL5/S1 facet joint isopenon the left side(remember,itisthesideoppositetothesideofrotation).

Themotion of the L5 vertebra will be opposite to that of the sacrum, so thevertebrawillbeinanFRS(R)position.Why?Putsimply,thesacrumisrotatingin a posterior (counter-nutated) direction to the left side,whichmeans the L5vertebrawillrotateinananteriordirectiontotherightside.

Example4

AR-on-LsacraltorsionsacraltorsionpotentiallycausestheL5vertebratoadoptapositionknownasanFRS(L)—theL5/S1facetjointisopenontherightside(remember,itissideoppositetothesideofrotation).

Themotion of the L5 vertebra will be opposite to that of the sacrum, so thevertebrawillbeinanFRS(L)position.Why?Putsimply,thesacrumisrotatinginaposterior (counter-nutated)direction to therightside,whichmeans theL5vertebrawillrotateinananteriordirectiontotheleftside.

ExceptionstotheAboveRule

Pleasebearinmind,fromthediscussionofspinalmechanicsinChapter6,thatin exceptional circumstances themotion of theL5 vertebra can also be to thesame side as the sacral torsion. For instance, it is commonwith very chroniclumbarspine/pelvicdysfunctionstofindthesacrumrotatedtotherightsideandtheL5vertebrarotatedtothesameside;likewise,itispossibleforaleftrotationof thesacrum tocause theL5vertebra to rotate to thesameside.Anexample(explainedinChapter10)oftheaboveiswhereyouhaveaprimarylumbarspinedysfunction that causes the sacrum to rotate to the same side as the vertebralrotation;inthiscasethelumbarspinedysfunctionwillneedtobetreatedfirst.

IliacCrest—PosteriorView

Placeyourhandsontopofeachofthepatient’siliaccrestsandnotetherelevantpositions.AhighersidemightindicateashortnessoftheQL,apelvicrotation,orevenaniliosacralupslip,asshowninFigure12.41.

Figure12.41.Palpationforthepositionoftheiliaccrest:ahighersideisindicatedontheright.

GreaterTrochanter

Frompalpatingtheiliaccrests,nextdirectyourhandstothegreatertrochanter,tocheckforrelevantlevels,asshowninFigure12.42.

Figure12.42.Palpationforthepositionofthegreatertrochanter.

PalpatoryAssessment—PatientSupine

Thepatient isasked toadopta supinepositionon thecouch,and the therapiststandsnexttothepatientandobserves,usingtheirdominanteye,forthelevelsinthefollowingareas:

•Anteriorsuperioriliacspine(ASIS)

•Iliaccrest

•Pubictubercle

•Inguinalligament

•Medialmalleolus

Table A1.6 in Appendix 1 can be used to note down any asymmetries foundduringthesupinepalpatoryassessment.

ASIS

AfterinitiallyobservingtheleveloftheASIS,palpatetheinferioraspectoftheASIStoascertaintheposition,asshowninFigure12.43.

Figure12.43.PalpationforthepositionoftheASIS.

IliacCrest—AnteriorView

From the ASIS, place your hands on top of the iliac crests to check for theposition,asshowninFigure12.44.

Figure12.44.Palpationforthepositionoftheiliaccrest.

PubicTubercleandInguinalLigament

Ask thepatient to relax and inform them (also requesting their consent) aboutwhat is about to happen in this procedure. Using the heel of your hand, andstartingwithlightcontactfromtheabdominalarea,gentlymovecaudallydownuntilthepubictubercleisfeltbeneaththehand.Placethepadsofthethumbsorindexfingersontopofeachofthepubictubercles(symphysispubisjoint)andcheckfortheposition,asshowninFigure12.45(a).Apositivefindingisifoneofthepubictuberclesappearsineitherasuperiororaninferiorposition,whencomparingthemwitheachother.

Figure12.45.Palpationforthepositionof(a)thepubictubercle.

Onceyouhavepalpatedtheleftandrightpubictubercles,letyourthumbsdriftlaterally and superiorly, to contact the inguinal ligament,which attaches fromthepubic tubercle to theASIS.Anotherpositivefindingforadysfunction is ifthesofttissuestructureoftheinguinalligamentistenderonpalpation,asshowninFigure12.45(b)overleaf.

Figure12.45.Palpationforthepositionof(a)thepubictubercle,and(b)theinguinalligament.

MedialMalleolus(LegLength)

Beforethepositionof themedialmalleoli(leglength) isascertained,graspthepatient’s legs above the ankles and ask the patient to bend both knees to 90degrees.Nextask them to lift theirpelvisoff thecouch twoor three times,asshowninFigure12.46(a),andthentostraightentheirlegs(thishastheeffectofencouraging the pelvis to become level). After this, take hold of the patient’sanklesandplaceyourthumbsundertheirmedialmalleoli,toidentifywhichlegappearslonger,shorter,orlevel,asshowninFigure12.46(b).

Figure12.46.(a)Patientliftstheirpelvisoffthecouchtwoorthreetimes,toencouragelevelingofthepelvis.

Figure12.46.(b)Palpationforthepositionofthemedialmalleoli(leglength).

SupinetoLongSittingTest(BacktoSupine)

TheaimofthistestistodeterminetherelevanceoftheSIJtoanapparentortrueLLD.The patient lies in a supine position and the therapist compares the twomedial malleoli, to see if there is any difference in position. Let’s say, forinstance,when thepatient is in a supine lyingpositionyounotice that the leftmedial malleolus appears to be shorter and that the right medial malleolusappearstobelonger,asshowninFigure12.46(c).

Figure12.46.(c)Withthepatientinthesupinepositiontheleftmedialmalleolusappearsshorterandtherightmedialmalleolusappearslonger.

Ask the patient to sit up, while keeping their legs extended. Compare thepositionofthemedialmalleoliagain,toseeifthereisanychange,asshowninFigure12.46(d).Ifthereisaposteriorinnominatepresentontheleftside,thelegthat appeared shorter will now lengthen as the patient sits up. If there is ananterior innominatepresentontheright, thelegthatappearedlongerwillnowshortenduringthesitting-upmotion.

Figure12.46.(d)Observationofthepositionsofthemedialmalleoli(leglength)afterthesupinetolongsittingtest.Therightlegappearsshorterandtheleftlegappearslonger,confirmingrightanteriorandleftposteriorinnominaterotations.

Fromthelongsittingposition,itwouldmakesensetoaskthepatienttoliebackdown, so that they adopt the starting supine position, and to observe whathappenstothemedialmalleoliduringthismaneuver.Ifyounoticethattherightleg in the longsittingposition appears tobeshorter than the left, and that therightlegappearstobelongerthantheleftinthesupinelyingposition,thenyouhaveprobablyconfirmedarightanteriorinnominaterotationwithaleftposteriorinnominaterotation.

Schamberger (2013)hasageneral rule for remembering thisprocess—the rule

ofthefiveLs,whichrelatestothesideoftheanteriorlyrotatedinnominate:

“LegLengthensLying,LandmarksLower”

So let’s recapon that thought process just for amoment.Schamberger (2013)calls the test thesitting–lying test rather thanwhat I call it, the supine to longsitting test.What Schamberger says is basically the same, but in reverse. Helooks at the patient’s medial malleoli in a long sitting position to start with,notingtheposition,andobservesifonemalleolusappearstoget“longer”whenthepatient liesbacktoadoptasupineposition.If, for instance, it isfoundthatthe right-sidemalleolusappears toget longer (comparedwith the left side), asshowninFigure12.46(e),thentherightsideismorethanlikelytobelockedinan anteriorly rotated position (think back to the rule of the five Ls), with acompensatoryleftposteriorlyrotatedinnominate.

Figure12.46.(e)Observationofthepositionsofthemedialmalleoli.Therightlegappearsshorterinlongsitting,andappearslongerinsupinelying,indicatingarightanteriorrotation.

TrueLLD

IfatrueLLDexists,therightlegwillappearlongerbothinthesupinepositionandinthelongsittingposition,asshowninFigure12.46(f).Rememberthatallthe pelvic landmarks are higher on the side of the longer leg, but only in astandingposture;thebonypelviclandmarkswillbelevelwhensittingandlying,asshowninthefigure.

Figure12.46.(f)Observationofthepositionsofthemedialmalleoli.Therightlegappearslongerbothinlongsittingandinsupinelying,indicatingatrueLLDoftherightleg.

Upslip

An upslip on the right side, for example,means that the right legwill appearshorterinthesupinelyingposition,andsubsequentlyshorterinthelongsittingposition,asshowninFigure12.46(g).Youwillnoticethatthepelviclandmarksare all cephalic on the right side compared with the left side, indicating apossiblerightiliosacralupslip.

Figure12.46.(g)Observationofthepositionofthemedialmalleolusforarightupslip.Therightlegappearsshorterinboththesupineandlongsittingposition.

Out-Flare/In-Flare

When a patient presentswith an out-flare or an in-flare iliosacral dysfunction,therewill be no difference between themedialmalleoli in the supine or longsittingpositions.

ThetestsdemonstratedabovecanhelpindifferentiatingbetweenatrueLLDandasacroiliac/iliosacraldysfunction.Thereasonwhythesupinetolongsittingandbacktosupinetestisofvalueisthatinasupinepositiontheacetabulumliesinananteriorposition relative to the ischial tuberosity, and thatonmoving from

the supine to the long sitting position, the pelvis tilts forward and eventuallypivotsover the ischial tuberosity.Asaresultof thismotion, the legsappear tolengthenequallyifthereisnodysfunctionpresent.Ifarotationaldysfunctionispresent,however, thepelvismovesindependentlyoneachsideratherthanasasingleunit,andhencetheleglengthappearstoeithershortenorlengthen.

Schamberger(2013)mentionsthatashiftinleglengthdemonstratedinthelongsitting to supine lying test serves as a probable indicator of the presence of a“rotationalmalalignment”andisusefulfordifferentiatingitfromananatomical(true)LLDandanupslip;nevertheless,acoexistinganatomicalLLD,anupslip,or both cannot be ruled out. The test also provides the person doing theassessmentwithaneasywayofdeterminingwhichsidehasrotatedanteriorlyorposteriorly.

Justtoconfusethepicturealittle,asinrealityitisneverasstraightforwardasitseems(andIapologizeforthat),Schamberger(2013)alsosays:“Aknowledgeofwhichiliaccrest ishigherwhenstandingisnothelpfulforpredictingwhichlegwillbelongerinlongsittingorsupinelying.Nordoesithelpustodeterminethesideofan‘anteriorrotation’or‘upslip’.”

Thefactof thematter is thatdifferencesasmuchas0.8–1.6”(2–4cm)maybeobservedtoreversecompletelywhenchangingfromthelongsittingpositiontothesupineposition;yet,withrealignment,mostofthepeopleaffectedwillturnouttohavelegsofequallength!

Rememberthatonly6–12%ofusactuallyhaveevidenceofananatomical(true)LLDof0.2”(5mm)ormore,onceinalignment,asdemonstratedbyArmourandScott(1981)andbySchamberger(2002).

PelvicGirdleDysfunctions

According to some authors (myself included), at least 14 potential differentdysfunctionscanoccurwithin thepelvicgirdlecomplex. It is alsocommon tofind musculoskeletal dysfunctions coexisting between all of the three areas—iliosacral,sacroiliac,andsymphysispubis joints—andpossiblyalloccurringatthesametime.

IliosacralDysfunction(Fixation)

IliosacralDysfunction(Fixation)

Thefollowingsixiliosacraldysfunctionsorfixationsarepossible:

•Anteriorlyrotatedinnominate

•Posteriorlyrotatedinnominate

•Superiorshear(cephalic)—upslip

•Inferiorshear(caudal)—downslip

•Innominateout-flare

•Innominatein-flare

Tables12.1and12.2overleafsummarizeallofthespecifictestingandpalpatoryfindingsforeachofthesixtypesofiliosacraldysfunction.

DysfunctionLeftside

Standingflexiontest

Medialmalleolus ASIS PSIS

Sacralsulcus

Ischialtuberosity

Sacrotuberousligament

Anteriorrotation

Left Left Longleft Inferior Superior Shallowleft

Superior Laxleft

Posteriorrotation

Left Left Shortleft Superior Inferior Deepleft

Inferior Tautleft

Out-flare Left Left Nochange

Lateralleft

Medialleft

Narrowleft

Nochange

Nochange

In-flare Left Left Nochange

Medialleft

Lateralleft

Wideleft

Nochange

Nochange

Upslip Left Left Shortleft Superiorleft

Superiorleft

Nochange

Superior Laxleft

Downslip Left Left Longleft Inferiorleft

Inferiorleft

Nochange

Inferior Tautleft

Table12.1.Iliosacraldysfunctions—leftside.

DysfunctionRightside

Standingflexiontest

Medialmalleolus ASIS PSIS

Sacralsulcus

Ischialtuberosity

Sacrotuberousligament

Anteriorrotation

Right Right Longright Inferior Superior Shallowright

Superior Laxright

Posteriorrotation

Right Right Shortright Superior Inferior Deepright

Inferior Tautright

Out-flare Right Right Nochange

Lateralright

Medialright

Narrowright

Nochange

Nochange

In-flare Right Right Nochange

Medialright

Lateralright

Wideright

Nochange

Nochange

Upslip Right Right Shortright Superiorright

Superiorright

Nochange

Superior Laxright

Downslip Right Right Longright Inferiorright

Inferiorright

Nochange

Inferior Tautright

Table12.2.Iliosacraldysfunctions—rightside.

Anteriorly/PosteriorlyRotatedInnominate

WheneverIamgivinglecturesformycoursesaroundtheworld,theterminologyofanteriorandposteriorrotationalcomponentsofthepelvisalwayscropsup;wecan therefore almost take it for granted that these rotations are a commondysfunctionalpatternscenariofortheinnominatebonetofollow.Hopefully,bynow you will know that the rotation is classified as an iliosacral (and notsacroiliac)dysfunction,asitistheinnominatebonethathasrotatedwithrespecttothesacrum.

Ifyou lookatTables12.1and12.2,youwillnotice that the indicatedanteriorandposteriorrotationsalterthepositionsoftheASIS,PSIS,andmedialmalleoli(leglength).Thesetypesofiliosacraldysfunctionareinitiallyfound(aswellasby observation and other testing procedures) by the key test known as thestandingforwardflexiontest.Forexample,ifthestandingforwardflexiontestispositive on the left side, and on palpation, when compared with the oppositeside, the left ASIS is superior, the left PSIS is inferior, and the left medialmalleolus (leg length) is shorter, then you have now found a left posteriorrotation of the innominate. This dysfunction would be classified as a leftiliosacralposteriorrotation,asshowninFigure12.47.Ontheotherhand,ifthestandingforwardflexiontestispositiveontherightside,butthistimetherightASISis inferior, therightPSISissuperior,andtherightmedialmalleolus(leglength)appearslonger,thenonecanassumearightiliosacralanteriorrotation

(themostcommon)ispresent,asshowninFigure12.48.

Figure12.47.Posteriorrotationoftheinnominatebone.

Figure12.48.Anteriorrotationoftheinnominatebone.

Let’sgothroughathoughtprocessforjustamomentandassumethatthepatienthasthemostcommonpresentation:arightanteriorinnominaterotationandaleftcompensatoryposteriorinnominaterotation,sothattherightSIJisconsideredtobelocked,asshowninFigure12.49(a).InthisFigureyoucanseethreethings:(1) the right pubic bone has displaced inferiorly (caudally) comparedwith theright side; (2) the sacrumhas compensated for the rotationalmalalignment byrotatingleftontheleftobliqueaxis(L-on-L);and(3)thelumbarspinehasalsocompensatedbyrotatingintotheconvexitytotheleftside.

Withthemostcommonpresentationofarightanteriorinnominaterotationandacompensatory left posterior rotation, you will see in Figure 12.49(b) that apatient demonstrating a reachingmotion toward their toes on the right side isabletodothiswithnorestriction;however,ontheleftside,asshowninFigure12.49(c),thepatientisclearlypreventedfromtouchingtheirtoes.

Figure12.49.(a)Presentationofthemostcommonrotationalmalalignmentsyndrome—rightanteriorandleftposteriorrotation.Thecompensationsareshownbyboththesymphysispubisjointandthesacrumhavingrotatedleftontheleftobliqueaxis(L-on-L),andbythelumbarspinealsohavingrotatedleftintothespinalconvexity.

Figure12.49.(b)Thepatient’sreachtotherightisnormal.

Figure12.49.(c)Thepatient’sreachtotheleftisimpaired.

Figure12.49.(d)Afterrealignmenttreatmentoftherotationoftherightinnominatebone,thepatientcannowreachtotheleft.

Figure12.49(d)demonstratesanimprovementafterarealignmenttechniquehasbeenperformed(Chapter13).Thereasonwhythepatienthadarestrictiontotheleftsideisthattheleftinnominateislockedintoaposteriorrotation,andthatthereachingforwardtypeofmotion(asshowninthefigures)demandsananteriormotionoftheinnominatebone.Thetreatmenttechnique(asdiscussedinChapter13)istocorrecttherightanteriorinnominaterotationandnottheleftposteriorinnominate rotation; this will then encourage the compensatory left side(posteriorlyrotated)tocomebacktoaneutralposition.

CaseStudy

CaseStudy

On looking at the excellent book by Schamberger (2013) on malalignmentsyndrome, I was interested to read that the author was a very fit marathonrunner, but he himself had suffered from right heel pain that had lastedmanyyears. His ankle and foot were in a position of over-pronation, especially theright foot; he had tried orthoses but they failed to correct the position. Everytime he ran, the pain impaired his heel-strike and push-off, and he began tonoticewastinginallofhisrightlegmuscles;moreover,hisrightthighmuscles—especiallythequadriceps—wouldache.Hehadaninjectionoflocalanestheticinto the area of the heel pain, but this did not even give him any short-termrelief.

As time passed, the heel pain persisted. At some point he went to a medicalconference, where one of the speakers talked about the sacrotuberous andsacrospinous ligaments referring pain to the leg, and especially to the heel, asshown inFigure12.49(e).Thatsameafternoon,Schambergerwascheckedoutbyanosteopath,whonoticedthathewasoutofalignmentandsaidthathisrightinnominate was rotated anteriorly; the osteopath proceeded to perform acorrectiveMETtechnique(Chapter13)tocorrecttherightanteriorrotation.Theapplied technique was very simple and miraculously made the heel paindisappearcompletely,becauseofthefactthatSchambergerwasnowrealigned.Thebestpartwastocome,aslaterthatdayheranfor12miles(20km)and,forthefirsttimeinyears,finishedtherunwithoutanacheinhisrightthighmusclesoranypaininhisheel.

Figure12.49(e).Referralpatternforthesacrotuberousandsacrospinousligaments,specificinparticulartotheareaoftheheelbone.

Superior/InferiorShear—Upslip/Downslip

Aniliosacralupslip (superiorshear,alsoknownashipboneshear)dysfunctionnormally relates to some type of trauma or accident: perhaps the person inquestionhashadamotoraccident,tumbleddownsomestairsfromaheightandlandedononesideoftheirischialtuberosity,fallenfromaheight(suchasfroma horse), or even simplymissed a stepwhen running orwalking. It has evenbeen considered that a strain of the QLmuscle sustained while picking up aheavyloadfromthefloorcouldberesponsibleforanupslip.

Williams and Warwick (1980) found that the degrees of freedom of the SIJnormally permit approximately 2 degrees of upward (cephalic) and downward(caudal)translationoftheinnominaterelativetothesacrum.Thesedysfunctionstendtobelesscommon(approximately10–20%,comparedwitharound80%forinnominaterotations)inpatientswhopresentwithchronicbackandpelvicpain.Thistypeofdysfunctionneedstobecorrectedbytreatment,asitisverydifficultforthepatienttoself-correctit(averyeffectivetreatmentprotocolforthiswillbedemonstratedinChapter13).

The initial diagnosis is indicated by the standing forward flexion test. Inaddition,onthesidethattestedpositiveinthistest,theanatomicallandmarksoftheASIS,PSIS,iliaccrest,andpubicbone(potentiallya0.08–0.12”,or2–3mm,step deformity could be palpated at the symphysis pubis joint), aswell as theischialtuberosity,willallappeartobecephalicorsuperior(comparedwiththeoppositeside),asshowninFigure12.50(a).Onthehigher(dysfunctional)side,thesacrotuberousligamentwillbelaxandthemedialmalleolus(leglength)willappeartobeshorter.

Figure12.50.(a)Upslip(superiorshear)oftheinnominatebone.

Anupslipcancoexistwitharotation(anterior)and/oranout-flare/in-flareoftheinnominate bone, which means that some of the palpatory landmarks can be“hidden”;itwillthereforebelessobviousthatanupslipispresent,asshowninFigure 12.50(b). This type of dysfunction is possible, especially if thecorrespondingkneejointisstraightbutthehipisnotinaneutralpositionwhenthetraumaissustained,asthismightcausearotationalforcetotheinnominate,aswellasproducinganupslip.

Figure12.50.(b)Upslipis“hidden”asaresultoftheanteriorrotationoftheinnominatebone.

Throughhis experiences,Schamberger (2013)discovered that thehigh sideofthepelvisinstandingorsittingdoesnotalwayscorrespondwiththesideoftheupslip.Forexample,theiliaccrestishighontherightsideinstanding,sitting,andlyingprone;inthosewithaleftupslippresent,withtheleftiliaccresthighin lying, it is usually the right iliac crest that is high in standing and sitting.Thesefindingssuggest that theupslipmaybeassociatedwithsomerotationofthepelvis.Inotherwords,ifsomeonepresentsinthiscasewitharightupslip,incombinationwith a right anterior and left posterior rotation, then some of thelandmarksmayalter:thestepdeformityofthesymphysispubisjointdisappears,theASISbecomes levelcomparedwith theoppositeside,and thePSISon the

rightbecomesaccentuatedcomparedwiththeleftside.Schambergersaysthatacorrectionoftherotationalmalalignmentwillrevealtheunderlyingrightupslip,withallthelandmarksontherightsideofthepelvisnowinasuperiorpositionrelativetothoseontheleft.

If you suspect that your patient has an iliosacraldownslip (inferior shear), theinitial diagnosis is carried out through a standing forward flexion test: on thesidethattestspositive,theanatomicallandmarksoftheASIS,PSIS,iliaccrest,andischialtuberositywillallappeartobecaudalorinferior(comparedwiththeoppositeside).Onthelow(dysfunctional)side,thesacrotuberousligamentwillbetautandthemedialmalleolus(leglength)willappeartobelonger,asshowninFigure12.51overleaf.

Dysfunctionsofthistypetendtobeself-correctingwhenyouwalk.Ifyouthinkaboutitlogically,ifadownslipissuspectedontherightside,whentheweightisplacedontotherightleg,theright-sidebackofthepelvisisnaturallypushedtoaneutralposition;ingeneral,therefore,notreatmentisactuallyrequired.

Figure12.51.Downslip(inferiorshear)oftheinnominatebone.

InnominateOut-Flare/In-Flare

Out-flareandin-flarerefertothemovementoftheinnominatebonesinoutwardand inward directions respectively. An out-flare motion is considered to becombinedwith the anterior rotation of the innominate bone, while an in-flaremotionisconsideredtobecombinedwithaposteriorrotationoftheinnominatebone;thisisbecausetheinnominatesneedtoperformthisspecifictypeofrotarymotionduringthegaitcycle,aswellasduringforwardbendingofthetrunk.

DonTigny(2007)statedthatSIJdysfunctionisessentiallycausedbyananterior

rotationoftheinnominatebonesandanout-flarerelativetothesacrum.In-flareoccurswith a posterior rotation of the innominate bone relative to the sacrumandwithsacralnutation.AccordingtoKapandji(1974),duringtheinitial50–60degreesforwardflexionof thetrunkwhenstandingup, thesacrumnutatesandtheiliarotateanteriorlyandflareoutward.

ThinkbacktoearlierwhenyouwerepalpatingtheASIS:Imentionedthatitisimportanttolookatyourthumbsforequalsymmetryofthetwobonylandmarksoftheinnominatebones,andtonotedownifyoufoundanyasymmetry.Ifyounoticeadifferencebetween the twosides,younowneed to imaginea straightlinedownthecenterofthebody,whichtypicallypassesthroughtheareaoftheumbilical (belly button). Now compare how far each thumb is from thecenterlineoftheumbilicus.Ifyouobservethatyourleftthumbonthepatient’srightASIS seems further away from theumbilicus than theopposite side,youhave probably discovered an in-flare or an out-flare, as shown in Figure12.52(a).

Howdoyoudecidewhattypeofdysfunctionispresent?Yes,youhaveguessedcorrectly—thegoodoldstandingforwardflexiontestandalsothestorktest. Ifthese two tests are positive, for example on the patient’s right side, you havenow foundan iliosacralout-flare, as shown inFigure12.52(b).Conversely, ifthestandingforwardflexiontestandthestorktestwerepositiveontheleftside,you would conclude that an iliosacral in-flare is present, as shown in Figure12.52(c).

Figure12.52.(a)PalpationassessmentfromtheASIStotheumbilicus,lookingforanout-flare/in-flare.

Figure12.52.(b)Iliosacralout-flareoftheinnominatebone.

Figure12.52.(c)Iliosacralin-flareoftheinnominatebone.

DeStefano (2011) is a particularly interesting read, and includes the followingabstract:

“The two dysfunctions out-flare and in-flare are quite rare and they are onlyfoundinthoseSIJsthathavealteredconvex-to-concaverelationshipstoS2withconvexity on the sacral side and concavity on the ilia side. They can only bediagnosed after the correction of any hipbone rotational dysfunction that ispresent.”

SacroiliacDysfunction

SacroiliacDysfunction

Thefollowingsacroiliacdysfunctionsarepossible:

•L-on-Lanteriorsacraltorsion

•R-on-Ranteriorsacraltorsion

•L-on-Rposteriorsacraltorsion

•R-on-Lposteriorsacraltorsion

•Bilaterallynutatedsacrum

•Bilaterallycounter-nutatedsacrum

Tables12.3, 12.4 and12.5 summarize all of the specific testing andpalpatoryfindingsforallofthesacraltorsionsandsacraldysfunctions.

L-on-Lsacraltorsion(forward/nutation)

R-on-Rsacraltorsion(forward/nutation)

Deepsacralsulcus Right Left

Shallowsacralsulcus Left Right

ILAposterior Left Right

L5rotation Right—ERS(R) Left—ERS(L)

Seatedflexiontest Right Left

Lumbarspring Negative Negative

Sphinx(extension)test Sulcilevel Sulcilevel

Lumbarflexiontest Rightsacralsulcusdeep Leftsacralsulcusdeep

Lumbarlordosis Increased Increased

Medialmalleolus(leglength)

Shortleft Shortright

Table12.3.Anterior/forwardsacraltorsions(normalphysiologicalmotion).

L-on-RsacraltorsionR-on-Lsacraltorsion

(backward/counter-nutation) (backward/counter-nutation)

Deepsacralsulcus Right Left

Shallowsacralsulcus

Left Right

ILAposterior Left Right

L5rotation Right—FRS(R) Left—FRS(L)

Seatedflexiontest Left Right

Lumbarspring Positive Positive

Sphinx(extension)test

Leftsacralsulcusshallow(rightsacralsulcusdeeper)

Rightsacralsulcusshallow(leftsacralsulcusdeeper)

Lumbarflexiontest Sulcilevel Sulcilevel

Lumbarlordosis Decreased Decreased

Medialmalleolus(leglength)

Shortleft Shortright

Table12.4.Posterior/backwardsacraltorsion(non-physiologicalmotion).

Bilaterallynutatedsacrum(forward)

Bilaterallycounter-nutatedsacrum(backward)

Standingflexiontest Negative Negative

Seatedflexiontest Positivebilateral Positivebilateral

Stork(Gillet)test Positiveonbothsides Positiveonbothsides

Sacralbase Leftandrightanterior Leftandrightposterior

ILA Leftandrightposterior Leftandrightanterior

Lumbarspringtest Negative Positive

Lumbarlordosis Increased Decreased

Medialmalleolus(leglength)

Equal Equal

Table12.5.Bilaterallynutatedandcounter-nutatedsacrum.

Iwouldliketorecapjustforamoment.Bythetimeyouhavegottothisstageof

thebookyoushouldknowthatadysfunctionoftheSIJcanresultfromhowthepelvis (innominates) impacts on the sacrum, and, vice versa, from how thesacrumimpactsonthepelvis(innominates).IfthepelvisisfixedontheSIJ,then(as explained in previous chapters) we call it an iliosacral dysfunction; if thesacrumisfixedonthepelvis,thenwecallitasacroiliacjointdysfunction.

Let’s look at trying to find sacral torsions in away that is different from (buthopefullysimplerthan)theoneIhavealreadyexplained.Yourpatientislyinginaproneposition,andhopefullyinapositionofneutral;yourthumbsaresittingnicelywithin the left and right sacral sulci. In thisposition,you feel thatyourright thumb is shallow and your left thumb is deeper.What does this mean?Thinkaboutitbeforereadingon—yes,eithertherightsideofthesacralbaseisposteriorandalsorightrotated,ortheleftsideisanteriorbutagainrightrotated.Ifthesacralbaseisrotatedinneutral,itthereforehastobedysfunctional:eitherthe right side is fixedposteriorly (counter-nutation)or the left (deeper) side isfixedanteriorly(nutation).

HowtoDecideontheFixation?

With the patient still prone and our thumbs sitting on the left and right sacralsulci,wecanaskthepatienttobackwardbend(comeupontotheelbows,asinreadingabook),andforwardbend(askthepatienttotilttheirpelvisposteriorlyor to perform the lumbar flexion test, as shown previously) from the positionthey are in. If the rotation increases (getsworse) in a backward-bent position(right thumbbecomesshallowerand left thumbbecomesdeeper),and then therotationisseentodisappearinaforward-bentposition,youknowthattherightsidehastobefixedinaposteriorpositionandrotatedtotheright,asinaR-on-Lsacraltorsion.Thisisbecausewhenyouaskyourpatienttobackwardbend,thesacrumhastobeabletogoinananteriordirection,whichitcannotdo.Therightfixed sacrum therefore now becomes a fixed pivot point, and so is unable toperformthisforwardmotionbecauseofthefactthattherightsacralbaseisfixedposteriorly;hencetherotationlooksworse.

With these types of posterior fixation you will notice a reduction in lumbarlordosis(backflattens),andtheL5spring testwill feel firmtopalpationwhenpressureisapplied(positivetest).

Let’s look at the other scenario whereby the left sacral base is fixed in ananterior position (nutation). We again ask the patient to perform backward

bending and forward bending motions. This time, however, the forward-bentpositiongivestheappearanceoftherotationincreasing,andthebackward-bentpositionseemstomakethesacralbasebecomelevel.Thisisbecauseduringtheforwardbendingmotion, theleftsacralbasestaysfixedanteriorly,soitcannotmoveinaposteriordirection;itthereforebecomesapivotpoint,butthepatient’srightsacralbasemovesfurtherinaposteriordirectionandsubsequentlymakestherotationappeartobecomeworse.ThistypeofdysfunctioniscalledaR-on-Rsacraltorsion.

With these types of anterior fixation, you will notice an increase in lumbarlordosis, and the L5 spring test will indicate some spring when pressure isapplied(negativetest).

Tip:Asimpleruleofthumbfordeterminingwhichsideisfixedisasfollows. If the sacral rotation increases when the patient backwardbends, then theside that thesacrumhas rotated to (theshallowside)willbethesidethatisfixedposteriorly.Thisdysfunctionisacounter-nutatedsacraltorsionasinaL-on-RsacraltorsionoraR-on-Lsacraltorsion.

If, however, with your patient still in the backward-bent position, the sacralrotationbecomeslevel(itseemstodisappear),thenthesideoppositetothesideofrotation(thinkbacktotheneutraltestofsacralsulcus)isthesidethatisfixedanteriorly.ThisisanutatedsacraltorsionasinaR-on-RsacraltorsionoraL-on-Lsacraltorsion.

I like the way this is interpreted in DeStefano (2011), which contains thefollowingstatement(overleaf)regardingsacraltorsions:

“Forward torsions become asymmetric in forward bending and becomesymmetricinbackwardbending.Theposteriortorsionsarethereverse,theygetmoreasymmetricinbackwardbendingandsymmetricinforwardbending.”

BilaterallyNutated/Counter-NutatedSacrum

Ihaveleftbilateralsacralnutation(forward)andbilateralsacralcounter-nutation(backward)till theendofthediscussion,sincetheyonlyoccurveryrarelyandare also often missed by an examiner. Most of the initial tests (such as thestandingforwardflexiontest)willturnouttobenegative,andalsothelevelsof

the sacral base and the ILA will be level; however, the stork test willdemonstrateabilateralrestrictionandisofvaluetotheoveralldiagnosis.Thesesacral dysfunctions are generally related to the 5th lumbar vertebra (L5); forinstance,if thesacrumisbilaterallynutated,itwillcauseanextensionpositionofL5,whereasifthesacrumisbilaterallycounter-nutated,L5willbeheldinaflexedposition.Theconsequenceswillbe thechangein lordosiscurvatureandthepositiveornegativeresultfromthelumbarspringtest.

SymphysisPubisDysfunction

The pubic bone tends to be either superior or inferior, although some authorsdiscuss other types of potential symphysis pubis dysfunction (SPD). Here wewillfocuson:

•Superiorpubis

•Inferiorpubis

Tables12.6and12.7summarizeallofthespecifictestingandpalpatoryfindingsforSPDs.

Superiorpubis Inferiorpubis

Standingforwardflexiontest Left Left

Pubictubercle Superior Inferior

Inguinalligament Tenderonpalpation Tenderonpalpation

Table12.6.Symphysispubisdysfunctions—leftside.

Superiorpubis Inferiorpubis

Standingforwardflexiontest Right Right

Pubictubercle Superior Inferior

Inguinalligament Tenderonpalpation Tenderonpalpation

Table12.7.Symphysispubisdysfunctions—rightside.

Tobehonest, I feel that thisareaof thepelvicgirdle (thesymphysispubis) is

probably the least assessed and consequently the least treated, and this alsoappliestome,especiallywhenIamwithmyownpatients.Iwouldsaythatsometherapists more than likely tend to focus on the area of the pain, withoutrealizing thatpartof theproblempotentially lies inadifferentarea.Recall thewisewordsofDr.IdaRolf:“Wherethepainis,theproblemisnot.”ThiscouldnotbeanytruerthanwhenlookingfordysfunctionwithintheSPJ.

CaseStudy

WhenanexcellentphysiotherapistandapersonalfriendofminecalledGordonBosworthwasmentoringme inmy early osteopathy studies, I remember himassessing a youngmalewhowas part of theOlympic bobsleigh team; he hadwhathadbeendiagnosedasatypicalgroinstrainoftheadductorlongusmuscleand the team doctor had recommended treatment through the use of a steroidinjection.

The patient decided not to have the injection but to see the team’sphysiotherapist (Gordon) instead. I remember actually watching the patientbeingassessed(inasimilarwaytothatmentionedinthischapter);Gordoncametothedecisionthatthispatienthadaniliosacraldysfunctionontherightsideandcorrected that dysfunction using the techniques I will be demonstrating inChapter 13. I then watched Gordon assess the SPJ and once again he said adysfunctionwas present and then proceeded to correct the underling issue byusing a specific MET for the SPJ (also explained in Chapter 13). Afterperformingtherealignmenttechniques,heretestedtheareaofthepainbydoinga resisted adductor test; tomy surprise, the pain had completely disappeared.From that moment on, I knew that this joint demanded a bit more love andattention,asitcouldjustbethekeytosolvingtheoverallproblem.

When trying to decide on the side that is dysfunctional, the first thing that isrelevantisthestandingforwardflexiontest.Soif,let’ssay,thestandingforwardflexion test ispositiveon the left side,youknow that adysfunction ispresentandthatitislocatedspecificallyontheleftside.Thesecondthingtoconsiderispalpationof the bony landmarks: if youpalpate the area of the pubic tubercleandyoudeterminetheleveltobecephalic/superiorcomparedwiththeoppositeside, you know that a superior pubis condition exists (only if the standingforwardflexiontest ispositiveonthatside).Thethirdthingthatalsoconfirmsthediagnosisistendernessoftheinguinalligamentonpalpation.

HowtoDecideWhichDysfunctionExists

OutofallthetestsIhaveshownyou,Iconsiderthekeyonestobethestandingandseatedforwardflexion.Isaythatbecausethesetestsspecificallyindicatetheside of the body on which the dysfunction is present. If your patient bendsforwardinthestandingposition,andtheleftsideofthePSIStravelsfurtherthantherightside,theconclusionisthattheyhaveeitheraniliosacraldysfunctionoraSPDontheleftside.However,ifthestandingflexiontestisnegative(i.e.thethumbs move symmetrically when the patient forward bends), but you noticethatyourleftthumbmovesmorecephalicallythanyourrightthumbduringtheseated forward flexion test, the indications are that a sacroiliac dysfunction ispresentontheleftside.

The standing and seated forward flexion tests do not actually tell youwhat iswrong, in terms of the actual dysfunction that is present: they only give yousomeofthenecessaryinformationregardingthesideonwhichthedysfunctionexists. It thereforemakes sense, especially as a startingpoint, to treat the sidethat tests positive in the standing/seated forward flexion tests. During theexaminationprocess,youmaynoticethatwhatyouconsidertobethesideofthefixation might not actually be the painful side for the patient’s presentingsymptoms.Thesidethatispresentingwithpaincouldbethesidethatisdoingall the motion (hypermobile) and is compensating for the side that is fixed(hypomobile).

Asasortofrecap(whichIhopewillhelpyoutounderstandexactlywhatIamtryingtoputacross),let’sthinkaboutwhatIsaidinthepreviousparagraph.Ingeneral, if the standing flexion test is positive for the left side, then thedysfunctionispresentonthatsameside,possiblyindicatinganiliosacralorevenanSPD.Thistestwillbepartoftheprocessthatwillhelpyouascertainwhatthedysfunctionisandformulateatreatmentplan.If,however,theseatedflexiontestispositive, this indicatesasacroiliacdysfunctionon the testedsideandnotaniliosacral dysfunction or SPD. Just to complicate matters somewhat, you canhave a standing forward flexion test indicating positive on the left side(iliosacral/pubic dysfunction), and a seated forward flexion test indicatingpositiveontheright(SIJdysfunction),bothatthesametime.

Unfortunately, it is never as easy as it might seem. Remember whatSchamberger(2013)says:aniliosacralupslip(inisolation)andatrueLLDhaveno correlation to the standing forward flexion test. With a right upslip, for

example, the right PSIS remains higher than the left to an equal extentthroughout the full rangeof flexioncarriedout ineitherastandingorasittingposition.Basically,itwouldappeartobeafalsepositivebecauseofthemotionoftherightPSIS;however,theleftPSIStraveledanequaldistance,makingthetestnegative.Pleasebearthesethingsinmindwhenyouarereadingothertextsabout the lumbopelvic complex, and try to be a little open-minded, especiallywhenyouareassessingyourownpatientsandathletes.

TheNextStep

Ihopethatnowyouhavereachedthisstageofthebook,thejigsawpuzzlepiecesare forming a recognizable picture. Perhaps the picture is not absolutely clearyet,butifyouhaveunderstoodwhatIamtryingtosay,thensomeimageshouldat least have developed in yourmind. Be honestwith yourself: if you do notquite understand the content of each of the chapters, then I suggest you readthem again, or at least certain parts, before continuing to Chapter 13 andbeginningtoactuallytreatcommonpelvicdysfunctions.

Isaythatbecauseifyoutrulydonotunderstandtheconceptsandtheunderlyingbiomechanics of the pelvic girdle, then howwill you be able to treat patientseffectively?Thatsaid,thetechniquesIdemonstrateinthenextchapterareverysafe toperform,as themajorityof themaresoft tissue techniques, specificallyMETs. It would therefore be acceptable if you wanted to practice them on acolleaguefirst,beforeactuallyusingthemonrealpatientswithrealsymptoms.Iwouldstill recommend thatyouhaveagoodunderstandingofall thepotentialdysfunctions that your patient could present with to your clinic, before youunreservedlysaythatyouareaneffectivetherapistandthatwhatyouplantodointermsoftreatmentwillbeofvaluetoyourpatient.

13TreatmentofthePelvis

Asyouwillprobablyhaveguessedbynow,thisisthefinalchapterofthebookandIhopeyouhaveenjoyedreadingalloftheotherchaptersleadinguptoit.Ithinkitmakesperfectsense tofinish thebookwithachapter thatconcentratesononeofthemostimportantareas,namelythetreatmentofallthevarioustypesof pelvic girdle and lumbar spine dysfunctions that have been previouslycoveredanddiscussedextensivelythroughoutthistext.

The focus of this particular chapter will therefore be on the application ofspecific realignment techniques for treating the threemain areas of the pelvis:symphysis pubis, iliosacral, and sacroiliac types of dysfunction. These are themost common presentations typically found when assessing athletes andpatients.

AttheendofthischapterIwillalsoincludeatreatmentstrategyfortheareaofthelumbarspine,becausethelumbarspineisanaturallyoccurringconnectiontothe pelvis. I always say the following to my students: if you have a primarypelvicgirdledysfunction,theremustbesomeformofcompensatorymechanismcontinuing on throughout the area of the lumbar spine, and even the thoracicspineandthecervicalspinewillbeinvolvedinthecompensationprocess;theseareas couldbe apotential site of pain and anatural concern for yourpatients.Onceyouhaveapplied someof the realignment techniques that I amabout todemonstrate for thepelvicgirdle, itwouldbesensible tomakeabsolutelysurethatthelumbarspineisalsoinarelativelylevelpositionthroughtheappropriatetreatmentprotocolsdiscussedattheendofthischapter.

In previous chapters I discussed in great detail how to thoroughly assess thethreeareasof thepelvicgirdle inorder toconfirmordiscount theexistenceofany presentingmalalignment syndromes.We now need to put everything thathasbeentaughtintopracticebyapplyingthefollowingtechniquestocorrectandnormalize thevariousmusculoskeletaldysfunctions thatyoumight findduringyourinitialassessment/screeningprocess.

TreatmentStrategy

Other experts in this complex field of manual medicine start the treatmentstrategybyinitiallycorrectingthepositionofthelumbarspine.Theythenmoveon to dysfunctions that are found within the iliosacral area, followed by theregion of the sacroiliac, and finishing off with a treatment of the symphysispubisjoint.

In DeStefano (2011), Greenman’s suggestion of the treatment sequence is:symphysis pubis, hipbone shear (upslip is considered a hipbone shear)dysfunction,sacroiliacdysfunction,andiliosacraldysfunction.

My personal preference is the following (and I like to think it is similar toGreenman’sapproach,asIwas taughthismanualmedicineprinciplesearlyoninmyosteopathytraining).Iwouldrecommendstartingthecorrectivetreatmentwiththesymphysispubisjoint,followedbytreatmentofiliosacraldysfunctions(upslipfirst),andthenmovingontosacroiliacdysfunctions.Iwouldfinishthetreatment,ifIfeltitwasnecessary,withanycompensatorydysfunctionsthatarepresentwithintheregionofthelumbarspine.

GreenmaninDeStefano(2011)recommendstreatingthesymphysispubis jointearly on during the assessment process. The reason for this is that SIJdysfunctionsaretypicallyfoundinapatientintheproneposition;ifasymphysispubisdysfunctionispresentatthefrontofthebody,thepatientisnotsymmetricin the prone position, resting on the tripod formed by the twoASISs and thesymphysispubis.

Greenman also suggests treating superior shear (upslip) after the symphysispubis, ashe found that thepresenceof shear restricts all othermotionswithinthat SIJ: therefore, he says shear deserves attention early on in the treatmentprocess.Hementionsthatyouneedtohavetwosymmetrichipbonesavailableinordertoassessthepositionofthesacrumbetweenthesetwobones.

Intermsofassessingandtreatingpatients,Iconsidermyconcept/approachtobesimilartoGreenman’s.WhenIgivelecturestomystudentsaboutthepelvisandSIJ, I like to recommend Greenman’s Principles of Manual Medicine(DeStefano2011),asIthinkitisagreatbookforassistingstudentsinlearningaboutthisarea.However,Ialsohighlyrecommendotherphysicaltherapybookstomystudents(seeBibliography),suchasthosebytheexpertsLee,Vleeming,

and Schamberger. I would like to think that in time, if students of physicaltherapyendeavortoreadsome,orindeedallofthebooksIhaverecommended(aswellasthisbook),theywillhopefullybeabletocompetentlyassess,identify,andtreattheirownpatientsandathletesintheirownclinicalsettings.

Note: The realignment techniques demonstrated in this chaptermainly consist of soft tissue techniques,specificallyMETs, asexplained inChapter7.However, since I amanosteopathandhave trained in theskillofspinalmanipulation, theword“thrust”or thewords“high-velocity thrust” (orabbreviationHVT)will be mentioned from time to time. These advanced techniques should only be incorporated into thetreatmentplanifonehasthenecessarytrainingandqualificationstoperformthem.

Most of the techniques Iwill showyou are very safe to perform in your ownclinic.Ifyouareunsureofwhichtechnique(dependingonyourskill levelandqualifications)isbestappliedtoyourpatient,IwouldfollowthesofttissueMETapproachinitially,asgenerallythesetechniqueswillcausenoharmbutareveryeffective at correcting any malalignment presentations, especially when usedproperly.However,therewillcomeatimewhenyouwillfeelathrusttechnique(HVT) isneeded,soyouhaveachoice:eitheryoucan train in theappropriatefieldofmanualtherapy,e.g.osteopathyorchiropractic,oritmightbeeasier(inmyopinion)tosimplyreferyourpatienttoasuitablyqualifiedpractitionerwhoisskilledintheartofspinalmanipulation.

Part1:TreatmentProtocolforSymphysisPubisDysfunctions

Symphysis pubis dysfunctions (SPDs) are very common but are generallyneglected in terms of treatment by the physical therapist; I feel that this isprobably because of the lack of symptomatic pain within the SPJ. The pubicbone tends to be either superior or inferior (although other types of potentialdysfunctionarediscussedbysomeauthors).Forthistext,wewillfocuson:

•Superior/inferiorSPD

•LeftsuperiorSPD

•RightinferiorSPD

Diagnosis:Superior/InferiorSPD

Treatment:MET/Thrusttechnique(shotguntechnique)

Position:Supine

Thepatient adoptsa supinepositionwith thekneesandhipsbentand the feetflat.Thetherapiststandsat thesideof thecouchandplacestheirhandsontheoutsidesofthepatient’sknees.

Thepatientisaskedtoabducttheirhipsagainstaresistancefor10seconds,asshown in Figure 13.1(a), which causes an RI effect in the adductors; thisisometric contraction is repeated approximately three times.The therapist thenplaces a clenched fist between the patient’s knees, and the patient is asked tosqueezethefisttightly(adduction),asshowninFigure13.1(b).Thismotionofadduction is generally enough to cause a realignment of the symphysis pubisjoint—it is very common for a noise (due to cavitation) to be heard from thejoint,indicatingarelease.Thereisnodirectthrustinvolvedwiththistechnique,soitisverysafetoperform.

Figure13.1.(a)Thepatientabductstheirhipsagainstaresistanceappliedbythetherapist.

Figure13.1.(b)Thetherapistplacestheirclenchedfistbetweenthepatient’skneesastheyadductfirmly.

Ifthereisnosignofcavitationusingtheabovetechnique,andyoustillconsiderthe joint to be dysfunctional, a thrust/HVT technique is appropriate.After thepatienthasabductedthehipthreetimes,asinFigure13.1(a),thetherapistplacestheirhandsontheinsidesofthepatient’sknees,asshowninFigure13.2(a),oreven their forearms (if easier), as shown inFigure13.2(b).Thepatient is thenasked to adduct quickly and strongly against the applied resistance. As thepatient adducts, the therapist can apply a rapid abductionmotion, as shown inFigure 13.3. If a dysfunction is present, this specific technique will cause acavitation of the symphysis pubis joint; hence this technique is known as theshotgun.

Figure13.2.(a)Thetherapistplacestheirhandsbetweenthepatient’skneesastheyadductfirmly.

Figure13.2.(b)Thetherapistplacestheirforearmsbetweenthepatient’skneesastheyadductfirmly.

Figure13.3.Thetherapistquicklyseparatesthepatient’skneeswhiletheyarestilladducting.Anoiseissometimesheardasthesymphysispubisjointundergoescavitation.

Diagnosis:LeftSuperiorSPD

Treatment:MET

Position:Supine

Thepatientadoptsasupinepositionandliesattheedgeofthecouchwiththeirarmsplacedacrosstheirbodyforextrasupport.Thetherapiststandsonthesamesideas thedysfunctionandplaces thepatient’s left legso that ithangsoff thecouch.Thetherapiststabilizestherightsideofthepatient’spelviswiththeirlefthand,andplacestheirrighthandabovetheleftpatella,tostabilizethepatient’sleftleg,asshowninFigure13.4.

Figure13.4.Thetherapistsupportsthepatient,whoseleftleghangsoffthecouch.

Fromthisposition,thepatientisaskedtoflextheirlefthipagainstaresistanceapplied for 10 seconds by the therapist, as shown in Figure 13.5. On therelaxationphase,thetherapistguidesthepatient’sleftlegintofurtherextension,as this will encourage the left side of the symphysis pubis joint to moveinferiorly,asshowninFigure13.6.

Figure13.5.Thepatientliftstheirlefthipintoflexionagainstaresistanceappliedbythetherapist.

Figure13.6.Afterthe10-secondcontraction,thetherapisttakesthelegintofurtherextension,

whichencouragestheleftsideofsymphysispubistomoveinferiorly.

Diagnosis:RightInferiorSPD

Treatment:MET

Position:Supine

Thepatientadoptsasupinepositionandliesattheedgeofthecouchwiththeirarmsplacedacrosstheirbodyforextrasupport.Thetherapiststandsonthesideoppositetothedysfunction.

Thetherapistthenflexesandadducts,withaslightinternalrotation,thepatient’sright leg; this motion will encourage superior motion of the right side of thesymphysispubis.Using thepatient’s legas a lever, the therapist lifts the rightsideofthepatient’spelvisoffthecouch,sothattheycanplacetheirlefthandonthepatient’srightPSISwhileputtingtheheelofthesamehandontotheischialtuberosity,asshowninFigure13.7.

Figure13.7.Thepatient’srighthipisguidedintoflexion,adduction,andinternalrotation.

The therapist lowers the pelvis down onto their hand; from this position thepatient is asked to extend their right hip against a resistance applied for 10secondsbythetherapist,asshowninFigure13.8.Ontherelaxationphase, thetherapistencouragesthepatient’srightlegintofurtherflexion,whileatthesametimepressure isapplied to the ischial tuberosity,as shown inFigure13.9; thiswillencouragetherightsideofthesymphysispubisjointtomovesuperiorly.

Figure13.8.Thepatientextendstheirhipagainstaresistanceappliedbythetherapist.

Figure13.9.Thetherapistguidesthepatient’slegintofurtherflexionwhileapplyingpressuretotheischialtuberosity.

Part2:TreatmentProtocolforIliosacralDysfunctions

Thefollowingiliosacraldysfunctionsarepossible:

•Anteriorlyrotatedinnominate

•Posteriorlyrotatedinnominate

•Superiorshear(cephalic)—upslip

•Inferiorshear(caudal)—downslip

•Iliosacralout-flare(lateralrotationofinnominate)

•Iliosacralin-flare(medialrotationofinnominate)

Diagnosis:RightAnteriorlyRotatedInnominate(MostCommon)

Treatment:MET

Position:Sidelying

Technique1

Thepatientadoptsaside-lyingpositionandthetherapiststandsonthesamesideas the dysfunction.The patient’s hip and knee are flexed to approximately 90degrees and brought over the edge of the couch. The therapist stabilizes thepatient’s right innominatewith their left hand and palpates the patient’s PSISwiththeirrighthand,asshowninFigure13.10(a).

Figure13.10.(a)Thetherapistcradlesthepatient’skneeandhipat90degreeswhilecontrollingtheinnominatebone.

Thetherapistfine-tunesthispositionbypalpatingthePSISwiththeirrighthandastheyflexthepatient’shipuntilabarrier(pointofbind)isfeltatthelevelofthePSIS.Fromthispositionandusingapproximately20%effort,thepatientisaskedtoextendtheirhip(Gmaxandhamstrings)againstaresistanceappliedbythetherapistfor10seconds,asshowninFigure13.10(b).

Figure13.10.(b)Thepatientextendstheirhipagainstaresistanceappliedbythetherapist.

After thecontraction,andoncomplete relaxation, the right innominatebone isguidedbythetherapist’slefthandintoaposteriorlyrotatedposition,whileatthesametimethehipandkneearebeingflexed,asshowninFigure13.10(c).Thisisrepeated(normallythreetimes)untilanewbarrierhasbeenachieved.

Figure13.10.(c)Thetherapistguidesthepatient’sinnominateboneintoaposteriorlyrotatedpositionasthekneeandhiparebeingflexed.

Diagnosis:LeftAnteriorlyRotatedInnominate(LessCommon)

Treatment:MET

Position:Sidelying

Technique2

(Analternativetechniquetocorrectaleftanteriorinnominaterotation)

This is a similar technique to that explained above,with a fewmodifications:thistimethedysfunctionrelatestoaleftanteriorinnominateratherthanarightanterior innominate. The patient adopts a side-lying position and the therapiststandsonthesamesideasthedysfunction.Thepatient’suppertorsoisplacedina right rotation, as this induces tension down to the lumbosacral junction andpreventsunnecessarymotionofthelumbarspine.Next,thetherapistplacesthepatient’s lefthip into flexion,and thepatient’sposterior thigh is restedagainstthetherapist’ship(thepatienthookstheirleftlegaroundthetherapist),asshown

in Figure 13.11(a). The patient’s right lower leg is placed in an extendedposition.

Figure13.11.(a)Thepatient’storsoisplacedinarightrotation.Thetherapistcradlesthepatient’shipat90degreeswhilepalpatingtheleftPSIS.

ThetherapistpalpatesthePSISandencouragesflexionofthehipuntilapointofbindisfelt.Fromthispositionandusingapproximately20%effort,thepatientisthen asked to extend their hip (Gmax and hamstrings) against a resistanceappliedfor10secondsbythetherapist,asshowninFigure13.11(b).

Figure13.11.(b)Thepatientextendstheirhipfor10secondswhilethetherapistpalpatestheleftPSIS.

On complete relaxation, the left innominate bone is guided into a posteriorlyrotatedpositionbythetherapist’srighthand,whileatthesametimethehipandkneearebeingflexed,asshown inFigure13.11(c).This is repeated(normallythreetimes)untilanewbarrierhasbeenachieved.

Figure13.11.(c)Thetherapistguidesthepatient’sinnominateboneintoaposteriorlyrotatedpositionasthekneeandhiparebeingflexed.

Diagnosis:RightAnteriorlyRotatedInnominate(MoreCommon)

Treatment:MET

Position:Sidelying

Technique3

(Analternativetechniquetocorrectarightanteriorlyrotatedinnominate)

The following technique is another alternative method for correcting anteriorinnominaterotation,inthiscaseontherightside.Thistimethetherapiststandsbehind the patient and cradles the right innominate with both hands, as thepatientholdsontotheirkneesat90degrees.

From thisposition, the therapist fines-tunes the innominatebone inaposteriorrotation direction, in order to isolate the position of bind. The patient is thenaskedtoresisthipextensionagainstpressureappliedbytheirownhandsfor10

seconds,asshowninFigure13.12.

Figure13.12.Thetherapistcradlesthepatient’sinnominatebone,andthepatientholdstheirkneesat90degrees.Thepatientthenextendstheirhipagainstaresistanceappliedbytheirownhands.

Afterthe10-secondcontraction,andoncompleterelaxation,thepatientisaskedto slowly pull their right hip into full flexion at the same time as their rightinnominateisbeingguidedbythetherapistintoaposteriorlyrotatedposition,asshowninFigure13.13.

Figure13.13.Thetherapistguidesthepatient’sinnominateintoaposteriorlyrotatedposition,asthepatientflexestheirhip.

Diagnosis:LeftPosteriorlyRotatedInnominate(Common)

Treatment:MET

Position:Prone

Technique1

Thepatientadoptsapronepositionandthetherapiststandsonthesamesideasthedysfunction.Thepatientisaskedtolifttheirleftlegafewinches,sothatthetherapist can place their right arm under the patient’s left thigh; the therapistinterlockstheirhands,sothattheirforearmrestsonthepatient’sleftPSIS.

The therapist fine-tunes this position by slowly extending and adducting thepatient’s hip joint until a barrier is felt. From this barrier, the patient is thenasked to gently flex the hip of the affected side against a resistance for 10seconds,asshowninFigure13.14.

Figure13.14.Thetherapistsupportsthepatient’slegwhilecontrollingtheinnominatebonewiththeirforearm.Thepatientthenflexestheirhipagainstaresistanceappliedbythetherapist.

On complete relaxation, the therapist takes the extended leg further into hipextensionandadduction,whilegentlyencouraginganteriorinnominaterotationwiththeirforearm.Thiscombinedmovementofthehipjointandpelvisinducesan anterior rotationof the innominatebone, as shown inFigure13.15.This isrepeated(normallythreetimes)untilanewbarrierhasbeenachieved.

Figure13.15.Thetherapistguidesthepatient’sinnominateboneinananteriorrotationdirection,asthehipisextendedandadductedatthesametime.

Diagnosis:RightPosteriorlyRotatedInnominate(LessCommon)

Treatment:MET

Position:Prone

Technique2

(Analternativetechnique,foralesscommonrightposteriorinnominaterotation)

Somepatients’legscanbeextremelyheavy;becauseoftheincreasedweightoftheleginthiscase,Iconsiderthefollowingalternativetechniquealittleeasiertoperform.

This time the therapist stands on the side (the left side) opposite to thedysfunction(therightsideisfixedposteriorly).Thepatientisaskedtolifttheirleft lega few inches, so that the therapist canplace their righthandunder thepatient’srightknee,whilethelefthandrestsjustatthelevelofthepatient’sright

PSIS.

The therapist fine-tunes this position by slowly extending and adducting therighthipuntil abarrier is felt.From thisbarrier, thepatient is asked togentlyflextherighthipagainstaresistanceappliedbythetherapistfor10seconds,asshowninFigure13.16.

Figure13.16.Thetherapistsupportsthepatient’sleg,whilecontrollingtheinnominatebonewiththeirhand.Thepatientthenflexestheirhipagainstaresistanceappliedbythetherapist.

On complete relaxation, the therapist takes the right leg further into hipextension and adduction, while applying pressure with their left hand to thepatient’s right PSIS. This combinedmovement induces an anterior rotation oftherightinnominatebone,asshowninFigure13.17.Thisisrepeated(normallythreetimes)untilanewbarrierhasbeenachieved.

Figure13.17.Thetherapistguidesthepatient’sinnominateinananteriorrotationdirection,asthehipisextendedandadductedatthesametime.

Diagnosis:RightSuperiorShear(Cephalic)—Upslip

Treatment:MET/Mobilization/Thrusttechnique

Position:Prone

Thepatientadoptsapronepositionandthetherapiststandsonthesamesideasthedysfunction.Thepatient isasked toslidedown thecouchuntil theirkneesarejustofftheedge.Thepatientisthenaskedtolooktooneside(any)andnotto hold on to anything. The therapist straddles the patient’s right leg andinternallyrotates thepatient’s thightocauseaclose-packedpositionof thehipjoint,asshowninFigure13.18.

Figure13.18.Thetherapiststraddlesthepatient’srightlegandinternallyrotatestheirhipinordertoestablishaclose-packedpositionofthehipjoint.

The therapist’s right hand palpates the patient’s right PSIS as their left handstabilizes either the sacrum or the left thigh. With their thigh, the therapistslowlystarts togrip thepatient’sright leg,whileapplyingsometractionto thelegbyinducingacaudalpulltotherightleguntilthebarrierisreached.

Atthebarrier,anMETisappliedbyaskingthepatienttohitchtheirpelvisupbyactivating their QLmuscle for 10 seconds against a resistance applied by thestraddlingofthetherapist’slegs,asshowninFigure13.19.

Figure13.19.UsingtheirQLmuscle,thepatienthitchesthepelvisupinacephalic/superiordirectionfor10seconds.

Afterthecontraction,andduringtherelaxationphase,anewbarrierisfoundbygentlyapplyingacaudal/inferior traction to the leg,as shown inFigure13.20.Thistechniqueisrepeatedthreetimes.Amobilizationoramanipulation(thrust)technique can also be performed from this position, to encourage acaudal/downwardmovementoftherightinnominatebone.

Figure13.20.Thetherapistperformsatraction/mobilizationoramanipulation(thrust)techniquetotheleginacaudaldirectionaftertheinitialMETcontraction/treatment.

Diagnosis:LeftSuperiorShear(Cephalic)—Upslip

Treatment:MET/Mobilization/Thrusttechnique

Position:Supine

The patient adopts a supine position,with their right knee bent at 90 degrees(thispreventsunnecessarymotionof the right innominatebone).The therapiststands on the same side as the dysfunction and internally rotates the patient’sthightointroduceaclose-packedpositionofthelefthipjoint.

The therapistgentlygrips thepatient’s lower legwith theirhandsandstarts toapplylighttractiontotheleftlegbyinducingacaudalpulltoengagethebarrier.At the barrier, amobilizing technique,MET, or high-velocity thrust (HVT) isperformedtoencourageacaudal/downwardmovementoftheinnominatebone,asshowninFigure13.21.

Figure13.21.ThetherapisthasthechoiceofperforminganMET,amobilization,oramanipulationtechniquefromthisspecificposition.

Diagnosis:RightIliosacralOut-Flare(LateralRotationofInnominate)

Treatment:MET

Position:Supine

Thepatientadoptsasupinepositionandthetherapiststandsonthesamesideasthedysfunction.The therapist flexes thepatient’s righthipandknee, then liftsthepelvistotheleftusingthelegasalever,sothattheycanplacetheirhandonthepatient’s rightPSIS.The therapist lowers thepatient’spelvisdownuntil itrestsontheirhand,andthenadductsthepatient’shipwiththeirrighthanduntilabarrierisfeltfortheinternalrotationoftheinnominatebone.

From thispositionofbind, thepatient is asked to externally rotate andabduct

theirhipfor10seconds,asshowninFigure13.22.

Figure13.22.Thetherapistputsthepatient’srighthipintoflexionandplacestheirhandonthepatient’sPSIS.Thepatientthenexternallyrotatesagainstaresistanceappliedbythetherapist.

Ontherelaxationphase,anewbarrierofinternalrotationisachieved,whileatthesametimethetherapistisapplyingatractiontechniquetothepatient’srightPSIS,asshowninFigure13.23

Figure13.23.Thetherapistguidesthepatient’srighthipintointernalrotationwhileapplyingtractiontothePSIStoencourageaneutralpositionoftheinnominate.

Diagnosis:LeftIliosacralIn-Flare(MedialRotationofInnominate)

Treatment:MET

Position:Supine

Thepatientadoptsasupinepositionandthetherapiststandsonthesamesideasthedysfunction.Thetherapistexternallyrotatesandflexesthepatient’slefthip;thepatient’s left foot isplacedjustabove their rightknee.Stabilizing therightsideofthepatient’spelviswiththeirrighthand,andthepatient’sleftkneewiththeirlefthand,thetherapistencouragesexternalrotationuntilabarrierisfelt.

Fromthispositionofbind,thepatientisaskedtointernallyrotatetheirhipfor10seconds,asshowninFigure13.24.

Figure13.24.Thetherapistplacesthepatient’slefthipintoexternalrotation,andreststhepatient’sleftfootontheoppositeknee.Thepatienttheninternallyrotatesagainstaresistanceappliedbythetherapist.

Ontherelaxationphase,anewbarrierofexternalrotationisachieved,asshowninFigure13.25.

Figure13.25.Thetherapistguidesthehipintoexternalrotationandencouragesaneutralpositionoftheinnominate.

Part3:TreatmentProtocolforSacroiliacDysfunctions

Thefollowingsacroiliacdysfunctionsarepossible:

•L-on-Lanterior(forward)sacraltorsion

•R-on-Ranterior(forward)sacraltorsion

•L-on-Rposterior(backward)sacraltorsion

•R-on-Lposterior(backward)sacraltorsion

•Bilateralanteriorsacrum(nutated)

•Bilateralposteriorsacrum(counter-nutated)

Diagnosis:L-on-LAnterior(Forward)SacralTorsion

Treatment:MET

Position:Sims

Inthisdysfunctionthesacrumhasrotatedleft(sidebentright)ontheleftobliqueaxis,andtherightsacralbasehasanteriorlynutated,asshowninFigure13.26.

Figure13.26.Left-on-left(L-on-L)sacralmotion/torsion.X=Anteriorordeep. =Posteriororshallow.

Thepatientadoptsapronepositiononthecouch,while thetherapiststandsonthe right side of the couch and flexes the patient’s knees to 90 degrees. ThetherapistturnsthepatientontotheirlefthiptoachievewhatisknownastheSimsposition,asshowninFigure13.27.Notethatthepatient’sleftarmisheldbackandtherightarmisheldforward.

Figure13.27.Thetherapistbendsthepatient’skneesto90degreesandplacesthepatientintheSimsposition.

With the patient’s knees placed on the therapist’s left thigh, the lumbosacraljunctionispalpatedusingthelefthand,whilealeftrotationofthepatient’strunkisintroduceduntilL5isfelttorotatetotheleft,asshowninFigure13.28.

Figure13.28.Thetherapistfine-tunesthepositionandintroducesarotationofL5totheleft.

Fromthisposition,thetherapistpalpatesthelumbosacraljunctionandtherightsacral base with their right hand, then, using the patient’s legs as a lever,introducesaflexionmotiontothetrunkuntilabarrierisfelt,asshowninFigure13.29.

Figure13.29.Usingthepatient’slegsasalever,thetherapistflexesthepatient’strunkuntilabarrierisfeltatthelumbosacraljunction.

Thepatientisaskedtopushtheirlegstowardtheceilingagainstthetherapist’sresistancefor10seconds(whichactivatestherightpiriformismuscle),asshowninFigure13.30.

Figure13.30.Thepatientpushestheirlegstowardtheceiling,asthismotionactivatestherightpiriformismuscle.

On the relaxation phase, the therapist takes the patient’s legs toward the flooruntil they feelmovementposterior to the rightsacralbase,asshown inFigure13.31.

Figure13.31.Thetherapistpalpatestherightsacralbaseandfeelsforposteriormotionasthepatient’slegsaredirectedtowardthefloor.

Note: The Sims techniqueworkswell, as it challenges the sacral position to correct itself by using themotion of the lumbar spine aswell as themotion from the lower limbs to facilitate the correction. Forexample,withaL-on-Ltypeofdysfunction,weknowthattherightsacralbasehasmigratedforwardintoafixedpositionofnutation,sotherestrictionisduetotherightsacralbasebeingunabletocounter-nutate.The first process in the technique is flexion of the lumbar spine,which encourages an extension of thesacrum. Second, left rotation is introduced to the lumbar spine, which encourages right rotation of thesacrum(amovementitcannotperform).ThethirdphaseisthecombinationofthemotionandMETofthelegs;thisintroducestherightpiriformismuscle,toassistinrestoringthesacralposition.

Diagnosis:R-on-RAnterior(Forward)SacralTorsion

Treatment:MET

Position:Sims

In this dysfunction the sacrum has rotated right (side bent left) on the rightobliqueaxis,andtheleftsacralbasehasanteriorlynutated,asshowninFigure13.32.

Figure13.32.Right-on-right(R-on-R)sacralmotion/torsion.X=Anteriorordeep. =Posteriororshallow.

Thepatientadoptsapronepositiononthecouch,while thetherapiststandsonthe left side of the couch and flexes the patient’s knees to 90 degrees. Thetherapist turns the patient onto their right hip into the Sims position (left armforward,rightarmback),asshowninFigure13.33.

Figure13.33.Thetherapistbendsthepatient’skneesto90degreesandplacesthepatientintheSimsposition.

With the patient’s knees placed on the therapist’s right thigh, the lumbosacraljunction ispalpatedusing therighthand,whilea right rotationof thepatient’strunk is introduced until L5 is felt to rotate to the right, as shown in Figure13.34.

Figure13.34.Thetherapistfine-tunesthepositionandintroducesarotationofL5totheright.

From this position, the therapist palpates the lumbosacral junction and the leftsacral base with their left hand, then, using the patient’s legs as a lever,introducesaflexionmotiontothetrunkuntilabarrierisfelt,asshowninFigure13.35.

Figure13.35.Usingthepatient’slegsasalever,thetherapistflexesthepatient’strunkuntilabarrierisfeltatthelumbosacraljunction.

Thepatientisaskedtopushtheirlegstowardtheceilingagainstthetherapist’sresistancefor10seconds(whichactivatestheleftpiriformismuscle),asshowninFigure13.36.

Figure13.36.Thepatientpushestheirlegstowardtheceiling,asthisactivatestheleftpiriformismuscle.

On the relaxation phase, the therapist takes the patient’s legs toward the flooruntil they feelmovement posterior to the left sacral base, as shown in Figure13.37.

Figure13.37.Thetherapistpalpatestheleftsacralbaseandfeelsforposteriormotionasthepatient’slegsaredirectedtowardthefloor.

Note:TheR-on-RsacraltorsionisthesameconceptastheL-on-Lsacraltorsion.TheSimstechniqueagainworkswell,asitchallengesthesacralpositiontocorrectitselfbyusingthemotionofthelumbarspineaswell as themotion from the lower limbs to facilitate thecorrection.Forexample,withaR-on-R typeofdysfunction,weknow that this time the left sacralbase is fixed forward inapositionofnutation, so therestrictionisduetothesacralbasebeingunabletocounter-nutateontheleftside.Thefirstprocessinthetechniqueistoinduceflexionofthelumbarspine,whichencouragesanextensionofthesacrum.Second,right rotation is introduced to the lumbarspine,whichencourages left rotationof thesacrum(remember,thisisamovementitcannotperform).ThethirdphaseisthecombinedeffectofthemotionandtheMETofthelowerlegs;thisintroducestheleftpiriformismuscle,toassistinrestoringthesacralposition.

Diagnosis:L-on-RPosterior(Backward)SacralTorsion

Treatment:MET

Position:Sidelying

In this dysfunction the sacrum has rotated left (side bent right) on the rightobliqueaxis,andtheleftsacralbasehasposteriorlycounter-nutated,asshowninFigure13.38.

Figure13.38.Left-on-right(L-on-R)sacraltorsion.X=Anteriorordeep. =Posteriororshallow.

The patient adopts a side-lying position on their right side, with their kneesinitiallyflexedtoapproximately45degrees,whilethetherapiststandsfacingthepatient. Palpating the lumbosacral junctionwith their right hand, the therapistgentlypullsthepatient’srightarmcaudally(whichintroducessomeextensiontothelumbarspine,aswellasrightsidebendingandleftrotationtothetrunk)untilL5isfelttobegintorotatetotheleft,asshowninFigure13.39.

Figure13.39.ThetherapistpalpatesL5andfeelsforleftrotation,asthepatientisguidedintoposition.

From this position, the therapist places the patient’s right lower leg intoextensionwiththeirrighthand,whilemonitoringtheleftsacralbasewiththeirlefthanduntilananteriormotionof thesacralbase is felt,asshown inFigure13.40.

Figure13.40.Thetherapistpalpatestheleftsacralbaseforanterior(forward)motion,asthepatient’slowerlegisguidedintotheextensionposition.

Next, the therapist maintains contact with L5 as they lower the patient’s left(top)legoffthesideofthecouch,sothatitfacestowardthefloor,andappliespressuretothedistalfemur,asshowninFigure13.41.

Figure13.41.ThetherapistpalpatesL5asthepatient’sleftlegisguidedtowardthefloor.

Thepatient is then asked to push their left (top) leg toward the ceiling for 10seconds against the therapist’s resistance, as shown in Figure 13.42. On therelaxationphase, twocomponentsare introduced:(1) the therapistcontinues toencouragetheleftlegtowardthetreatmentcouch/floorforafewseconds,and(2)while stillmonitoring the left sacral base, the therapist places thepatient’sright (bottom) leg into further extension, as shown in Figure 13.43. Thisresistance/relaxation procedure is repeated three to five times until an anteriormotionoftheleftsacralbaseisfelt.

Figure13.42.Thepatientliftstheirleftlegagainstthetherapist’sresistance,asthisnowintroducestheleftpiriformismuscle,whichwillassistinrestoringthesacralposition.Ontherelaxationphasethetherapistappliesadownwardpressure.

Figure13.43.Whilemonitoringtheleftsacralbase,thetherapistencouragesfurtherextensionofthepatient’sright(bottom)leg.

Note:Thistechniqueworkswell,asitchallengesthesacralpositiontocorrectitselfbyusingthemotionofthelumbarspineaswellasthemotionfromthelowerlimbstofacilitatethecorrection.Forexample,withaL-on-R typeofdysfunction,weknow that the left sacralbasehasmovedposteriorly, i.e. it has counter-nutated,sotherestrictionisduetotheleftsacralbasebeingunabletonutateforward.Thefirstprocessinthetechniqueistopromoteextensionofthelumbarspine,whichencouragesaforwardnutationmotionofthesacrum.Second,leftrotationisintroducedtothelumbarspine,whichencouragesrightrotationofthesacrum(themovementitcannotperform).Inthethirdphase,weaddthemotionandthespecificMETof

the top leg being lowered (after the initial 10-second contraction), because this now introduces the leftpiriformismuscleaswellas increasingsidebendingof thelumbarspinetotheright,whichwillassist inrestoringthesacralposition.Inaddition,theextensionofthelowerlegpromotesfurthernutationoftheleftsacralbaseandsubsequentcorrectionofthedysfunction.

Diagnosis:R-on-LPosterior(Backward)SacralTorsion

Treatment:MET

Position:Sidelying

Inthisdysfunctionthesacrumhasrotatedright(sidebentleft)ontheleftobliqueaxis, and the right sacral base has posteriorly counter-nutated, as shown inFigure13.44.

Figure13.44.Right-on-left(R-on-L)sacraltorsion.X=Anteriorordeep. =Posteriororshallow.

The patient adopts a side-lying position on their left side, with their kneesinitiallyflexedtoapproximately45degrees,whilethetherapiststandsfacingthepatient. Palpating the lumbosacral junction with their left hand, the therapistgentlypullsthepatient’sleftarmcaudally(whichintroducessomeextensiontothelumbarspine,aswellasleftsidebendingandrightrotationtothetrunk)untilL5isfelttobegintorotatetotheright,asshowninFigure13.45.

Figure13.45.ThetherapistpalpatesL5andfeelsforrightrotation,asthepatientisguidedintoposition.

Fromthisposition,thetherapistplacesthepatient’sleftlowerlegintoextensionwiththeirlefthand,whilemonitoringtherightsacralbasewiththeirrighthanduntilananteriormotionofthesacralbaseisfelt,asshowninFigure13.46.

Figure13.46.Thetherapistpalpatestherightsacralbaseforanterior(forward)motion,asthepatient’slowerlegisguidedintotheextensionposition.

Next, the therapistmaintains contactwithL5 as they lower the patient’s right(top)legoffthesideofthecouch,sothatitfacestowardthefloor,andappliespressuretothedistalfemur,asshowninFigure13.47.

Figure13.47.ThetherapistpalpatesL5asthepatient’srightlegisguidedtowardthefloor.

Thepatient is thenaskedtopushtheirright(top) legtowardtheceilingfor10seconds against the therapist’s resistance, as shown in Figure 13.48. On therelaxationphase, twocomponentsare introduced:(1) the therapistcontinues toencouragetherightlegtowardthetreatmentcouch/floorforafewseconds,and(2)whilestillmonitoringtherightsacralbase,thetherapistplacesthepatient’sleft (bottom) leg into further extension, as shown in Figure 13.49. Thisresistance/relaxation procedure is repeated three to five times until an anteriormotionoftherightsacralbaseisfelt.

Figure13.48.Thepatientliftstheirrightlegagainstthetherapist’sresistance,asthisnowintroducesthepiriformismuscle,whichwillassistinrestoringthesacralposition.Ontherelaxationphasethetherapistappliesadownwardpressure.

Figure13.49.Whilemonitoringtherightsacralbase,thetherapistencouragesfurtherextensionofthepatient’sleft(bottom)leg.

Note:Thistechniqueworkswell,asitchallengesthesacralpositiontocorrectitselfbyusingthemotionof

thelumbarspineaswellasthemotionfromthelowerlimbstofacilitatethecorrection.Forexample,withaR-on-Ltypeofdysfunction,weknowthattherightsacralbasehasmovedposteriorly, i.e. ithascounter-nutated,sotherestrictionisduetotherightsacralbasebeingunabletonutateforward.Thefirstprocessinthetechniqueistopromoteextensionofthelumbarspine,whichencouragesaforwardnutationmotionofthesacrum.Second,rightrotationisintroducedtothelumbarspine,whichencouragesleftrotationofthesacrum(themovementitcannotperform).Inthethirdphase,weaddthemotionandthespecificMETofthe top leg being lowered (after the initial 10-second contraction), because this now introduces the rightpiriformismuscle aswell as increasing sidebendingof the lumbar spine to the left,whichwill assist inrestoring the sacral position. In addition, the extension of the lower leg promotes further nutation to therightsacralbaseandsubsequentcorrectionofthedysfunction.

Diagnosis:BilateralAnteriorSacrum(Nutated)

Treatment:MET

Position:Sitting

Inthisdysfunctionthesacrumhasbilaterallynutated,asshowninFigure13.50.

Figure13.50.Bilateralnutationofthesacrum.

Thepatientadoptsasittingpositiononthecouch,withtheirfeetapart,whilethetherapist stands facing the patient’s back. Palpating the sacral apexwith theirrighthand, the therapist introduces flexion to thepatient’s trunkwith their lefthanduntilthesacrumisfelttobegintomove,asshowninFigure13.51.

Figure13.51.Thetherapistpalpatesthesacralapexandmonitorsmotion,asthetrunkofthepatientisbeingflexed.

Fromthisposition,thepatientisaskedtolifttheirupperbacktowardtheceilingagainstaresistanceappliedbythetherapist,asshowninFigure13.52.

Figure13.52.Thepatientperformstrunkextensionagainstaresistanceappliedbythetherapist.

After 10 seconds, and during the relaxation phase, the therapist introducesfurthertrunkflexion,whileatthesametimeencouragingposteriorsacralmotion(counter-nutation)withtheirrighthand,asshowninFigure13.53.

Figure13.53.Thetherapistintroducesfurtherflexionandatthesametimeencouragesthesacrumintocounter-nutation.

Diagnosis:BilateralPosteriorSacrum(Counter-Nutated)

Treatment:MET

Position:Sitting

In this dysfunction the sacrum has bilaterally counter-nutated, as shown inFigure13.54.

Figure13.54.Bilateralcounter-nutationofthesacrum.

Thepatientadoptsasittingpositiononthecouch,withtheirfeetapart,whilethetherapist stands facing the patient’s back. Palpating the sacral base with theirrighthand,thetherapistintroducesextensiontothepatient’strunkwiththeirlefthanduntilthesacrumisfelttobegintomove,asshowninFigure13.55.

Figure13.55.Thetherapistpalpatesthesacralbaseandmonitorsmotion,asthetrunkofthepatientisbeingextended.

From this position, the patient is asked to flex their trunk against a resistanceappliedbythetherapist,asshowninFigure13.56.

Figure13.56.Thepatientperformstrunkflexionagainstaresistanceappliedbythetherapist.

After 10 seconds, and during the relaxation phase, the therapist introducesfurther trunkextensionandat thesame timeencouragesanteriorsacralmotion(nutation)withtheirrighthand,asshowninFigure13.57.

Figure13.57.Thetherapistintroducesfurtherextensionandatthesametimeencouragesthesacrumintonutation.

Part4:TreatmentProtocolforLumbarSpineDysfunctions

ImentionedearlierthatIconsiderlumbarspinedysfunctionstobecausedbyacompensatory mechanism associated with underlying malalignments of thepelvis.Inmyopinion,dysfunctionsofthelumbarspineareasecondarytypeofdysfunction resulting from a primary dysfunction within the pelvic girdlecomplex; hence themain reasonwhy I leave treating the lumbar spine till theend.Thereareexceptionstotherules,ofcourse,wherethelumbarspineistheprimary cause rather than the compensatory secondary cause. Either way, therealignmenttechniquesIwilldemonstrateshortlywillbeofvalue,astheywillassistyouincorrectingthepresentationsthatwillcommonlybefoundwithinthelumbarspine.

Iwouldliketokeepthingssimpletostartwith,eventhoughthissubjectmatterisbynomeanssimpletounderstand.Forthefirstexample,whenIsaythatthefacetjointisfixedinaclosedposition,thisrelatestothespecificpositionoftheinferior facet joint being closed in extension, side bending, and rotation(normallytooneside)onthesuperiorfacetofthevertebraimmediatelybelow.ThinkbacktothediscussionofspinalmechanicsinChapter6.Ireferredtothissituation as anERS, which is a Type II dysfunction (non-neutral mechanics),because the rotation and side bending are coupled to the same side but in anextendedposition,eithertotheleft(ERS(L))ortotheright(ERS(R)).

The opposite motion, and the second example, therefore has to be where thefacetjointisnowfixedinanopenposition;inthiscasethemotionisrelatedtothe specific position of the inferior facet joint being open in flexion, sidebending,androtation(normallytooneside)onthesuperiorfacetofthevertebraimmediately below. This type of spinal dysfunction is referred to as anFRS,which is also a Type II dysfunction (non-neutral mechanics), because therotationandsidebendingarecoupledtothesamesidebutthistimeinaflexedposition,eithertotheleft(FRS(L))ortotheright(FRS(R)).

Note:Regarding the position of a facet jointwhich is fixed in an open position, remember from earlierchaptersthatthejointwillbeopenontheoppositeside.Forexample,anFRS(L),i.e.flexion,rotation,andsidebendingleft,indicatesthatthefacetjointisfixedopenontherightside.

Thefollowinglumbarspinedysfunctionsarediscussed:

•L5ERS(L)

•L4ERS(R)

•L5FRS(L)

Diagnosis:L5ERS(L)

Treatment:MET

Position:Sidelying

This specific spinal dysfunction relates to the inferior facet joint of the L5vertebrabeingfixedinapositionofextension,rotation,andsidebendingtotheleftsideon thesuperior facetof theS1vertebra.Thisbasicallymeans that theleftfacetjointofL5/S1isfixedinaclosedposition,asshowninFigure13.58.The subsequentmotion restrictionwill affectmovements on the side oppositethefixation,namelyflexion,rightrotation,andrightsidebending.

Figure13.58.L5ERS(L)onS1.

Thepatient adoptsa side-lyingposition facing the therapist,with theposteriorTPofthedysfunctionalL5towardthecouch(i.e.dysfunctionsidedown—inthiscase,leftsidedown).WhilepalpatingtheinterspinousspaceofL4/5withtheirlefthand,thetherapistcradlesthepatient’sleftarmandintroducesflexionandrightrotationofthepatient’strunkdowntotherelevantlumbarlevel,asshown

inFigure13.59.

Figure13.59.ThetherapistpalpatestheinterspinousspaceofL4/L5andintroducesflexionandrightrotationofthelumbarspinedowntothatlevel,topreventover-lockingofL5/S1.

The therapist cradles both of the patient’s legs and introduces the hips intoflexion, while at the same time palpating with the left hand the L5/S1interspinousspaceformotion,asshowninFigure13.60.

Figure13.60.ThetherapistintroduceshipflexiontobothlegsastheypalpatetheL5/S1interspinousspaceformotion.

Fromthisposition, thepatient isaskedtopushboth their feet towardthefloor(sidebendingleft),asindicatedbythearrowinFigure13.61,for10secondsatacontractionofbetween10and20%ofmaximum.

Figure13.61.Thepatientpushesbothfeettowardthefloorfor10seconds.

After thecontraction,andduring therelaxationphase, the therapistencouragesthepatient’slegstowardtheceiling,asthismotionintroducesrightsidebendingofthelumbarspine,asshowninFigure13.62.ThismovementsubsequentlyhastheabilitytoopentheleftL5/S1facetjoint,whichisfixedinaclosedposition.

Figure13.62.Afterthecontractionthetherapistintroducesrightsidebendingbyusingthemotionfromthelegstowardtheceilingtoopentheleftfacetjoint.

Diagnosis:L4ERS(R)

Treatment:MET,Thrusttechnique(HVT)

Position:Sidelying

This specific spinal dysfunction relates to the inferior facet joint of the L4vertebra being fixed in a position of extension, right rotation, and right sidebending on the superior facet of L5. This basicallymeans that the right facetjoint of L4/5 is fixed in a closed position, as shown in Figure 13.63. Thesubsequent motion restriction will affect movements on the side opposite thefixation,namelyflexion,leftrotation,andleftsidebending.

Figure13.63.L4ERS(R)onL5.

Thepatient adoptsa side-lyingposition facing the therapist,with theposteriorTPofL4towardtheceiling(i.e.dysfunctionsideup—inthiscase,rightsideup).While palpating the interspinous space of L3/4 with their right hand, thetherapist introduces flexion and right rotationof the lumbar spine down toL4withtheirlefthand,asshowninFigure13.64.

Figure13.64.ThetherapistpalpatestheinterspinousspaceofL3/L4andintroducesflexionandrightrotationofthelumbarspinedowntoL4.

Next, the patient’s right hand is placed onto their right hip to stabilize theposition.ThetherapistpalpatestheL4/5interspinousspacewiththeirrighthand

andfeelsforspecificmotionasthepatient’sbottomlegistakenintoflexion.

Thepatient’stoplegisflexedandthefootisplacedinthecreaseoftheleftknee.The therapist places their right hand through the natural gap formed by thepatient’s hand on their hip and palpates the L4/5 interspinous space. Thepatient’s trunk is guided gently toward the floor by the therapist’s left hand,whichisplacedonthepatient’sleftkneeandcontrolsthemotion,asshowninFigure13.65.

Figure13.65.ThetherapistpalpatesL4andfine-tunesthepositionbyusingthepatient’stopleg.

Oncethepositionhasbeenfinelytuned,thepatientisaskedtoabducttheirrighthip against a resistance applied by the therapist for 10 seconds, as shown inFigure13.66.

Figure13.66.Thepatientabductstheirrighthipfor10seconds.

After thecontraction,andduring therelaxationphase, the therapistencouragesmotionofthetoplegtowardthefloor,asthistypeofmovementintroducesrightside bending of the lumbar spine, as shown in Figure 13.67. This movementsubsequentlyhastheabilitytoopentherightL4/5facetjoint,whichisfixedinaclosedposition.

Figure13.67.AfterthecontractionthetherapistintroducesrightsidebendingofthelumbarspinetoopentherightL4/5facetjoint.

If one is suitably qualified, then from the finely tuned position (as above) thetherapist can apply a thrust technique (HVT) in thedirection through the longleverofthefemurtowardthefloor,asshowninFigure13.68.ThisquickmotionwillcausearightsidebendingmotiontoL4/5,andacavitationmightbeelicitedfromthejoint.

Figure13.68.Fromthefinelytunedposition,thetherapistappliesaquickthrusttechniquetoencouragerightsidebendingofthelumbarspine,whichmayelicitacavitationfromtherightL4/5facetjoint.

Diagnosis:L5FRS(L)

Treatment:Softtissuetechnique

Position:Prone

This specific spinal dysfunction relates to the inferior facet joint of the L5vertebrahavingbecomefixedinapositionofflexion,leftrotation,andleftsidebending on the superior facet of S1. This basicallymeans that the right facetjoint of L5/S1 is fixed in an open position, as shown in Figure 13.69. Thesubsequent motion restriction will affect movements on the side opposite thefixation,namelyextension,rightrotation,andrightsidebending.

Figure13.69.L5FRS(L)onS1.

Withthepatientlyingprone,thetherapistconfirmsbythepositionofthethumbsthattheleftTPofL5isshallowandtherightTPisdeep,thusindicatingaleftrotation.Whenthepatientbackwardbends,theleftTPappearingshallowerandthe rightTP becoming deeper confirms the presence of anFRS(L),where therightfacetjointisfixedinanopenposition,asshowninFigure13.70.

Figure13.70.Withthepatientinabackward-bentposition,theleftthumbpalpatesshallowandtherightthumbpalpatesdeep,indicatinganFRS(L).

Thecorrectionof this spinaldysfunction isverysimple in somerespects,as itcanbetreatedfromthebackward-bentposition.Thetherapistappliesbetween5and10lbs(2–4kg)ofdirectpressuredirectlyontotherightL5TP,eitherwithareinforced thumb as shown in Figure 13.71, or with the elbow as shown inFigure13.72.Thetherapist thenwaitsforthetissuestosoften,beforeretestingthepositiontoseeiftherehasbeenanychange.

Figure13.71.Withthepatientinabackward-bentposition,thetherapistappliespressurewithareinforcedthumbdirectlyontotherightL5TP,toencourageaclosureoftherightfacetjoint.

Figure13.72.Withthepatientinabackward-bentposition,thetherapistappliespressurewiththeirelbowdirectlyontotherightL5TP,toencourageaclosureoftherightfacetjoint.

InthecaseofanFRS(R),theoppositeprocedurewouldbeperformed.

_____________________

Ifyouhavetrulyenjoyedreadingthisbookandwishtocontinueonyourjourneytoward understanding the pelvic girdle, along with all the complexities thatnaturallygowith it, thenI recommendinparticular thefollowingbooks togetyou started: Schamberger (2002; 2013); Vleeming, Mooney, and Stoeckart(2007); Lee (2004); and DeStefano (2011). I wish you every success in yourstudiesandpracticeinthisfascinatingarea.

Appendix1:TablesforDysfunctionTesting

The following tables can be used in the therapist’s own clinical setting(permissiontoreproduceisgranted).

HipExtensionFiringPattern

LeftSide 1st 2nd 3rd 4th

Gluteusmaximus○ ○ ○ ○

Hamstrings○ ○ ○ ○

Contralateralerectorspinae○ ○ ○ ○

Ipsilateralerectorspinae○ ○ ○ ○

TableA1.1:Hipextensionfiringpattern—leftside.

RightSide 1st 2nd 3rd 4th

Gluteusmaximus○ ○ ○ ○

Hamstrings○ ○ ○ ○

Contralateralerectorspinae○ ○ ○ ○

Ipsilateralerectorspinae

Ipsilateralerectorspinae○ ○ ○ ○

TableA1.2:Hipextensionfiringpattern—rightside.

InitialObservation—PatientStanding

Observation Leftside Rightside

Pelviccrest(posterior)

PSIS

Greatertrochanter

Lumbarspine

Glutealfolds

Poplitealfolds

Foot/ankleposition

Pelviccrest(anterior)

ASIS

Pubictubercle

TableA1.3.Observationassessment—standing.

EvaluationofPelvicDysfunction

Test Leftside Rightside

Mens

Standingforwardflexion

Backwardbending

Seatedforwardflexion

Stork(Gillet)—upperpole

Stork(Gillet)—lowerpole

Stork(Gillet)—lowerpole

Hipextension

Sidebending(trunk)

Pelvicrotation

TableA1.4.Specifictestsfortheevaluationofpelvicdysfunction.

PalpatoryAssessment

Prone

Palpationarea Leftside Rightside

Glutealfold

Ischialtuberosity

Sacrotuberousligament

ILA

PSIS

Sacralsulcus—neutral

Sacralsulcus—extension(sphinxtest)

Sacralsulcus—flexion

L5springtest(neg.orpos.)

L5position

Iliaccrest

Greatertrochanter

TableA1.5.Palpationassessment—prone.

Supine

Palpationarea Leftside Rightside

ASIS

ASIS

Iliaccrest

Pubictubercle

Inguinalligament

Medialmalleolus(leglength)

Supinetolongsittingtest

Longsittingtosupinetest

TableA1.6.Palpationassessment—supine.

SummaryofIliosacralDysfunctions

Dysfunction Leftside

Standingflexiontest

Medialmalleolus ASIS PSIS Sacral

sulcusIschialtuberosity

Sacrotuberousligament

Anteriorrotation

Left Left Longleft Inferior Superior Shallowleft

Superior Laxleft

Posteriorrotation

Left Left Shortleft Superior Inferior Deepleft

Inferior Tautleft

Out-flare Left Left Nochange

Lateralleft

Medialleft

Narrowleft

Nochange

Nochange

In-flare Left Left Nochange

Medialleft

Lateralleft

Wideleft

Nochange

Nochange

Upslip Left Left Shortleft Superiorleft

Superiorleft

Nochange

Superior Laxleft

Downslip Left Left Longleft Inferiorleft

Inferiorleft

Nochange

Inferior Tautleft

TableA1.7.Iliosacraldysfunctions—leftside.

Dysfunction Rightside

Standingflexiontest

Medialmalleolus ASIS PSIS Sacral

sulcusIschialtuberosity

Sacrotuberousligament

Anteriorrotation

Right Right Longright Inferior Superior Shallowright

Superior Laxright

rotation right

Posteriorrotation

Right Right Shortright Superior Inferior Deepright

Inferior Tautright

Out-flare Right Right Nochange

Lateralright

Medialright

Narrowright

Nochange

Nochange

In-flare Right Right Nochange

Medialright

Lateralright

Wideright

Nochange

Nochange

Upslip Right Right Shortright Superiorright

Superiorright

Nochange

Superior Laxright

Downslip Right Right Longright Inferiorright

Inferiorright

Nochange

Inferior Tautright

TableA1.8.Iliosacraldysfunctions—rightside.

SummaryofSacralDysfunctions

L-on-Lsacraltorsion(forward/nutation)

R-on-Rsacraltorsion(forward/nutation)

Deepsacralsulcus Right Left

Shallowsacralsulcus Left Right

ILAposterior Left Right

L5rotation Right—ERS(R) Left—ERS(L)

Seatedflexiontest Right Left

Lumbarspring Negative Negative

Sphinx(extension)test Sulcilevel Sulcilevel

Lumbarflexiontest Rightsacralsulcusdeep Leftsacralsulcusdeep

Lumbarlordosis Increased Increased

Medialmalleolus(leglength)

Shortleft Shortright

TableA1.9.Anterior/forwardsacraltorsions(normalphysiologicalmotion).

L-on-Rsacraltorsion(backward/counter-nutation)

R-on-Lsacraltorsion(backward/counter-nutation)

(backward/counter-nutation) (backward/counter-nutation)

Deepsacralsulcus Right Left

Shallowsacralsulcus

Left Right

ILAposterior Left Right

L5rotation Right—FRS(R) Left—FRS(L)

Seatedflexiontest Left Right

Lumbarspring Positive Positive

Sphinx(extension)test

Leftsacralsulcusshallow(rightsacralsulcusdeeper)

Rightsacralsulcusshallow(leftsacralsulcusdeeper)

Lumbarflexiontest Sulcilevel Sulcilevel

Lumbarlordosis Decreased Decreased

Medialmalleolus(leglength)

Shortleft Shortright

TableA1.10.Posterior/backwardsacraltorsion(non-physiologicalmotion).

Bilaterallynutatedsacrum(forward)

Bilaterallycounter-nutatedsacrum(backward)

Standingflexiontest Negative Negative

Seatedflexiontest Positivebilateral Positivebilateral

Stork(Gillet)test Positiveonbothsides Positiveonbothsides

Sacralbase Leftandrightanterior Leftandrightposterior

ILA Leftandrightposterior Leftandrightanterior

Lumbarspringtest Negative Positive

Lumbarlordosis Increased Decreased

Medialmalleolus(leglength)

Equal Equal

TableA1.11.Bilaterallynutatedandcounter-nutatedsacrum.

SummaryofSymphysisPubisDysfunctions

SummaryofSymphysisPubisDysfunctions

Superiorpubis Inferiorpubis

Standingforwardflexiontest Left Left

Pubictubercle Superior Inferior

Inguinalligament Tenderonpalpation Tenderonpalpation

TableA1.12.Symphysispubisdysfunctions—leftside.

Superiorpubis Inferiorpubis

Standingforwardflexiontest Right Right

Pubictubercle Superior Inferior

Inguinalligament Tenderonpalpation Tenderonpalpation

TableA1.13.Symphysispubisdysfunctions—rightside.

Appendix2:OuterCoreStabilizationExerciseSheet

The following exercises can be used in the physical therapist’s own clinicalsetting.Foreachexercisethereisablankspaceinwhichapatient’srepetitionsandsetscanberecorded.

Exercise SETS REPS

1.Push

2.Pull

3.Squat—BendtoExtend

Progression1:WithWeight

Progression2:WithWeightandWithoutaCoreBall

4.BendtoExtendwithRotation

5.Single-LegStance

LateralSlingandPosteriorObliqueSling

6.Rotation

PosteriorRotation

ExerciseVariationsCombinedPush–Pull

CombinedPush–PullonOneLeg

PushwithLunge

PullwithLunge

PushonUnstableBase

PullonUnstableBase

BendtoExtendwithRotationonUnstableBase

BendHightoLow(WoodChop)

BendLowtoHigh(ReverseWoodChop

BendLowtoHigh(SingleArm)

ObliqueSling—AnteriorRotationonUnstableBase

ObliqueSling—AnteriorRotationonOneLeg

AnteriorRotationWhileKneeling

PosteriorRotationWhileKneeling

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Index

AAJ.SeeAtlantoaxialjoint(AAJ)Abbreviations,10Abdominalcrunchintransverseplane,49Acetabularlabrum,164.SeealsoHipjointActivestraightlegraise(ASLR),10,203Adductors,132.SeealsoMuscleenergytechnique(MET)assessmentof,133hipabductiontest,133METtreatmentof,133–134

AHC.SeeAnteriorhorncell(AHC)AIIS.SeeAnteriorinferioriliacspine(AIIS)Anteriorhorncell(AHC),10,119Anteriorinferioriliacspine(AIIS),10,13Anteriorinnominatemotion,23Anteriorobliquesling,47,48Anteriorrotation,58Anteriorsuperioriliacspine(ASIS),10,13,200ASIS.SeeAnteriorsuperioriliacspine(ASIS)ASLR.SeeActivestraightlegraise(ASLR)Atlantoaxialjoint(AAJ),10,104

Backpain,34Backwardbending,26.SeealsoPelvisassessmenttest,207–208

Basicreflexarc,120Bendtoextendwithrotation,51,56toextendwithrotationonunstablebase,65hightolow,66lowtohigh,67

Bulgingdiscs.SeeHerniateddiscs

Centerofgravity(COG),10,39Cervicalspine,104Coccyx,15.SeealsoInnominateboneCOG.SeeCenterofgravity(COG)

Combinedpush–pull,60ononeleg,61

Combinedsacroiliacandiliosacralmotion,25backwardbending,25forwardbending,25unilateralmotionofsacrum,26

Compressiontest,197Computerizedtomography(CT),10,98Coreballsquat,54musclerelationships,45–49,71–72

Counter-nutation,23Coupledspinalmotions,98.SeealsoSpinalmechanicsCT.SeeComputerizedtomography(CT)

Deeplongitudinalsling(DLS),10,75Degenerativediscdisease(DDD),10,190–191.SeealsoIntervertebraldiscsDermatomepathways,189Dimplesofvenus,218Distractiontest,198DLS.SeeDeeplongitudinalsling(DLS)Dysfunctiontestingtables,269hipextensionfiringpattern,269iliosacraldysfunctions,272initialobservation,269palpatoryassessment,271pelvicdysfunctionevaluation,270sacraldysfunctions,273–274symphysispubisdysfunctions,274

Electromyography(EMG),43EMG.SeeElectromyography(EMG)ERS(extension,rotation,sidebending),10ERSdysfunction,107.SeealsoLawsofspinalmechanicsERS(R),109–111extensionposition,108flexionposition,108neutralposition,107

Exerciseforoutercoremuscles,49variations,60

FABER(flexion,abduction,externalrotation),10test,160,196

Facetjointssyndrome,190.SeealsoLumbarspineFADIRtest.SeeFAIR—testFAIR(flexion,adduction,internalrotation),10test,160

Femoroacetabularimpingement(FAI),10,165–166.SeealsoHipjointFlexingtowardsleft,28Forceclosure,34,35ligaments,36

Forcecouple,37–38Formclosure,34,35Fortinfingertest,194–195Forwardbending,25headposture,40

FRS(flexion,rotation,sidebending),10FRSdysfunction,111.SeealsoLawsofspinalmechanicsextensionposition,112,115flexionposition,113,115FRS(L),111–113FRS(R),114–115neutralposition,112,114

Fryette’slaws,99,102.SeealsoSpinalmechanicsFunctionalLLD,84Functionalscoliosiscompensation,88

Gaenslentest,198Gaitcycleandpelvis,79gaitcycle,74heel-strike,74iliumroation,76myofasciallink,75–77pelvisandSIJmotion,77–79posteriorobliqueslingwhilerunning,77sacralrotationandlumbarcounter-rotation,77,78

Gillettest.SeeStorktestGlutealmuscles,168Gluteusmaximus(Gmax),10,35,176.SeealsoGluteusmedius(Gmed)assessmentof,178casestudy,182–183

functionof,177–178,183gaitcycle,181–182hipextensionfiringpatterntest,179–181holisticapproach,183normalmuscleactivationsequence,178posteriorobliquesling,177prognosis,184thoracolumbarfascia,182treatment,184

Gluteusmedius(Gmed),10,169.SeealsoGluteusmaximus(Gmax)anteriorfibersstrengthtest,173assessmentof,170–172casestudy,175functionof,170hipabductionfiringpatterntest,172–173posteriorfibersstrengthtest,174

Gluteusminimus(Gmin),10Gmax.SeeGluteusmaximus(Gmax)Gmin.SeeGluteusminimus(Gmin)Golgitendonorgan(GTO),10,119Groupneutraldysfunction,rotationleft(NR(L)),116.SeealsoLawsofspinalmechanicsGroupneutraldysfunction,rotationright(NR(R)),116.SeealsoLawsofspinalmechanicsGTO.SeeGolgitendonorgan(GTO)

Hamstrings,135.SeealsoMuscleenergytechnique(MET)assessmentof,136assessmentoflateral,139assessmentofmedial,138hipflexiontest,136METtreatmentof,136–139

Heel-strike,74Herniateddiscs,188.SeealsoIntervertebraldiscsHigh-velocitythrust(HVT),10Hipabductionfiringpatterntest,166test,133

Hipextension.SeealsoPelvisassessmentfiringpatterntest,179test,213

Hipflexiontest,136Hipjoint,154

acetabularlabraltear,164anatomy,154casestudy,165FABERtest,160FAIRtest,160femoroacetabularimpingement,165–166passiveROMforexternalrotation,157passiveROMforflexion,158passiveROMforinternalrotation,158pathologicalendfeel,156pathology,163pelvic,hip,andlumbarmotionguidelines,155quadranttest,159screening,156Thomastest,161,162

HVT.SeeHigh-velocitythrust(HVT)Hydraulicamplifier,46

IdiopathicLLD,85ILA.SeeInferiorlateralangle(ILA)Iliaccrest,13Iliopsoas,125.SeealsoMuscleenergytechnique(MET)assessmentof,126METtreatmentof,127–128modifiedThomastest,126

Iliosacraldysfunction,206,229–230.SeealsoPelvicgirdledysfunctions;Pelvisassessmentanteriorly/posteriorlyrotatedinnominate,230–232innominateout-flare/in-flare,234–235leftanteriorlyrotatedinnominate,248–249leftiliosacralin-flare,254leftposteriorlyrotatedinnominate,250leftsuperiorshear,253rightanteriorlyrotatedinnominate,247–250rightiliosacralout-flare,253rightposteriorlyrotatedinnominate,251rightsuperiorshear,252superior/inferiorshear,232–234treatmentprotocolfor,247

Iliosacralmotion,22,23–24Iliotibialband(ITB),10,77,124,140.SeealsoMuscleenergytechnique(MET)assessmentof,141

METtreatmentof,142–143Ober’stest,141–142

Inferiorlateralangle(ILA),10,27,216Inferiortransversesacralaxis,27Innominatebone,12,13.SeealsoPelvicgirdlecoccyx,15ilium,13ischium,14pubis,14sacrum,14–15

Intervertebraldiscs,188.SeealsoLumbarspinedegenerativediscdisease,190–191discherniation,188intervertebralforamen,188

Intervertebralforamen,188.SeealsoIntervertebraldiscsIschium,14.SeealsoInnominatebone

Lateralsling,47andanteriorobliquesling,57andposteriorobliquesling,58

Lawsofspinalmechanics,98cervicalspine,104ERSdysfunction,107–111FRSdysfunction,111–115lumbarspine,104NR(L),116NR(R),116spinalenginetheory,100–101spinalmechanics,98–99,102–103thoracicspine,104vertebraposition,104–106viewingperspective,103

Leftobliquesacralaxis,27Left-on-left(L-on-L),10Left-on-right(L-on-R),10,30sacraltorsion,30

Leglengthdiscrepancy(LLD),10,82.SeealsoStandingbalancetestASIS,82assessment,85externalrotationwithSTJpronation,91externalrotationwithSTJsupination,92

footandankleposition,86footinover-pronation,90functionalLLD,84functionalscoliosiscompensation,88andgaitcycle,89andglutealmuscles,93idiopathicLLD,85internalrotationwithSTJpronation,92leftlegcompensations,93leftlong-legsyndromevs.rightshort-legsyndrome,85LLDcompensations,89–90over-pronationsyndrome,90–93andpelvis,86–87positionsofmedialmalleoli,83,84structuralLLD,84supinetolongsittingtest,83andtrunkandhead,88typesof,84

Leglengthmeasurement,82fromASIStoumbilicus,83bypalpation,82sacralmotion,28sacraltorsion,28fromumbilicustomedialmalleolus,83

L-on-L.SeeLeft-on-left(L-on-L)L-on-R.SeeLeft-on-right(L-on-R)Lumbarflexiontest,221.SeealsoPelvisassessmentLumbarsidebendingtest,214.SeealsoPelvisassessmentLumbarspine,104,186anatomy,187ascauseofpelvisdysfunctions,191–192dysfunctiontreatmentprotocol,263–267facetjoints,190intervertebraldiscs,188–189

Magneticresonanceimaging(MRI),10,98Mensactivestraightlegraisetest,203–205.SeealsoPelvisassessmentMET.SeeMuscleenergytechnique(MET)Middletransversesacralaxis(MTA),10,27ModifiedThomastest,126,130,162Movement-basedexercise,49,71–72

anteriorrotation,58bendhightolow,66bendlowtohigh,67bendtoextendwithrotation,51,56bendtoextendwithrotationonunstablebase,65combinedpush–pull,60combinedpush–pullononeleg,61coreballsquat,54exercisevariations,60lateralslingandanteriorobliquesling,57lateralslingandposteriorobliquesling,58obliquesling—anteriorrotationononeleg,69obliquesling—anteriorrotationonunstablebase,68posteriorrotation,59primarymovementpattern,51progressiveexercise,50pull,51,53pullonunstablebase,64pullwithlunge,62,63push,51,52pushonunstablebase,63pushwithlunge,62repetition,50rotation,51,58–59rotationwhilekneeling,70set,50singlearmbendlowtohigh,67single-legstance,51,57–58squat—bendtoextend,51,54

MRI.SeeMagneticresonanceimaging(MRI)MTA.SeeMiddletransversesacralaxis(MTA)Multifidus,46Muscleactivitybeforeandafterstretching,43Muscledysfunctionfactors,48–49Muscleenergytechnique(MET),10,44,118acuteandchronicconditions,122adductors,132–134basicreflexarc,120benefitsof,118hamstrings,135–139iliopsoas,125–128

iliotibialband,140–143increasingjointmobility,119methodofapplication,122musclepreparationforstretching,119musclestrengthening,119andpelvismuscles,124physiologicaleffectsof,119–120PIRexample,122–123piriformis,144–148PIRvs.RI,122pointofbind,122procedure,121quadratuslumborum,149–151rectusfemoris,129–131RIexample,124tensorfasciaelatae,140–143tonerestoration,118–119

Muscleimbalanceeffects,44Musculoskeletaldeterioration,44

Neutralmechanics,102–103.SeealsoSpinalmechanicsNon-neutralmechanics,103NR(neutral,rotation),10Nutation,22–23

OAJ.SeeOccipitoatlantaljoint(OAJ)Ober’stest,141–142Obliquesling—anteriorrotationononeleg,69onunstablebase,68

Occipitoatlantaljoint(OAJ),10,88,104Osteo-articular-ligamentoussystem,35Osteophytes,189Outercorestabilizationexercisesheet,275–278Over-pronationsyndrome,90–93

Painsource,39spasmcycle,39,40

Palpatoryassessment,216.SeealsoPelvisassessmentPatrick’stest.SeeFABER—test

Pelvicforcecouple,37Pelvicgirdle,12.SeealsoSacroiliacjoints(SIJsorSIjoint)iliofemoraljoint,12iliosacralmotion,23–24innominatebone,12,13–15motiontypes,22nutation,22–23sacroiliacmotion,22symphysispubismotion,24–25

Pelvicgirdledysfunctions,229.SeealsoPelvisassessmentiliosacraldysfunction,229–235sacroiliacdysfunction,235–238symphysispubisdysfunction,238–240

Pelvicgirdlepain(PGP),10,203Pelvicrotationtest,215–216.SeealsoPelvisassessmentPelvis.SeealsoSacralaxis;Sacroiliacmotionmotion,22stability,37

Pelvisassessment,200.SeealsoPelvicgirdledysfunctionsanterior/forwardfixedsacraldysfunction,221anteriorview,202–203

ASIS,225backwardbendingtest,207–208false-positiveresult,207glutealfoldandischialtuberosity,216greatertrochanter,224hipextensiontest,213

ILAofsacrum,217iliaccrest,217,224,225lumbarflexiontest,221lumbarsidebendingtest,214lumbarspine,222–224medialmalleolus,226mensactivestraightlegraisetest,203–205out-flare/in-flare,228–229palpatoryassessment,216pelvicbalancetest,200pelvicrotationtest,215–216posterior/backwardfixedsacraltorsion,220posteriorview,201–202procedure,200

PSIS,217pubictubercleandinguinalligament,225sacralrotation,218–219sacralsulcus,218sacrotuberousligament,217seatedforwardflexiontest,208–210sphinxtest,220–221springtest,222standingforwardflexiontest,205–207storktest,210–212supinetolongsittingtest,226–227trueLLD,228upslip,228

Pelvistreatment,242foriliosacraldysfunctions,247–253forlumbarspinedysfunctions,263–267forsacroiliacdysfunctions,254–262strategy,242–243forsymphysispubisdysfunctions,243–246

PGP.SeePelvicgirdlepain(PGP)Phasicmuscles,40,41,42,43PHC.SeePosteriorhorncell(PHC)PIIS.SeePosteriorinferioriliacspine(PIIS)PIR.SeePost-isometricrelaxation(PIR)Piriformis,144.SeealsoMuscleenergytechnique(MET)hippositionassessment,145METtreatmentof,146–148passiveassessmentof,145–146

PLS.SeePosteriorlongitudinalsling(PLS)Posteriorhorncell(PHC),10,119Posteriorinferioriliacspine(PIIS),10Posteriorinnominatemotion,24Posteriorlongitudinalsling(PLS),10,47,75Posteriorobliquemyofascialsling,35sling,47,48slingwhilerunning,77

Posteriorrotation,59Posteriorsacroiliacligament,37Posteriorsuperioriliacspine(PSIS),10,13,200Post-isometricrelaxation(PIR),10,119,150

Posture,39.SeealsoStaticstabilitycoremusclerelationships,45–49,71–72forwardheadposture,40muscleactivitybeforeandafterstretching,43muscleimbalanceeffects,44musculoskeletaldeterioration,44painsource,39painspasmcycle,39,40phasicmuscles,40,41,42,43posturalmuscles,40,41,42,43

Primarymovementpattern,51Progressiveexercise,50Prolapseddiscs.SeeHerniateddiscsPSIS.SeePosteriorsuperioriliacspine(PSIS)Pubis,14.SeealsoInnominatebonePull,51,53withlunge,62,63onunstablebase,64

Push,51,52withlunge,62onunstablebase,63

QL.SeeQuadratuslumborum(QL)Quadranttest,159Quadratuslumborum(QL),10,124,149.SeealsoMuscleenergytechnique(MET)assessmentof,150METtreatmentof,150–151PIRmethod,150reciprocalinhibitionmethod,151

Rangeofmotion(ROM),10,25Reciprocalinhibition(RI),10,94,119,181method,151

Rectusfemoris,129.SeealsoMuscleenergytechnique(MET)assessmentof,130

METtreatmentof,130–131modifiedThomastest,130

Repetition,50RI.SeeReciprocalinhibition(RI)Rightobliquesacralaxis,27Right-on-left(R-on-L),10,31

sacraltorsion,31Right-on-right(R-on-R),10sacraltorsion,29

ROM.SeeRangeofmotion(ROM)R-on-L.SeeRight-on-left(R-on-L)R-on-R.SeeRight-on-right(R-on-R)Rotation,51,58–59whilekneeling,70

Sacralaxis,27.SeealsoSacrumanteriorinnominatemotion,23backwardbending,26bilateralmotion,25flexingtowardsleft,28forwardbending,25inferiorlateralangle,27inferiortransversesacralaxis,27leftobliquesacralaxis,27L-on-Lsacraltorsion,28middletransversesacralaxis,27posteriorinnominatemotion,24rightobliquesacralaxis,27R-on-Rsacraltorsion,29sacralobliqueaxis,27superiortransversesacralaxis,27symphysispubismotion,22,24verticalsacralaxis,27

Sacralnutation,22andcounter-nutation,36

Sacralobliqueaxis,27Sacralrotationandlumbarcounter-rotation,77,78Sacraltorsions,32Sacroiliacdysfunction,235.SeealsoPelvicgirdledysfunctionsanterior/forwardsacraltorsions,235bilateralanteriorsacrum,261bilaterallynutated/counter-nutatedsacrum,236,238bilateralposteriorsacrum,262fixation,237–238L-on-Lanteriorsacraltorsion,254–256L-on-Rposteriorsacraltorsion,258–259posterior/backwardsacraltorsion,236

R-on-Lposteriorsacraltorsion,259–260R-on-Ranteriorsacraltorsion,256–257treatmentprotocolfor,254–262

Sacroiliacjoints(SIJsorSIjoint),10,12,16,34.SeealsoPelvicgirdleanatomy,17–18forceclosuremechanismin,100functionof,20iliolumbarligament,20interosseousligament,19ligamentsof,18–20longdorsalligament,19sacrospinousligament,19sacrotuberousligament,19

Sacroiliacjointscreening,194compressiontest,197distractiontest,198FABERtest,196Fortinfingertest,194–195Gaenslentest,198SIJprovocative/screeningtests,196thighthrusttest,197

Sacroiliacjointstability,34,35.SeealsoForcecoupleforceclosure,34,35forceclosureligaments,36formclosure,34,35Gmax,35osteo-articular-ligamentoussystem,35pelvisstability,37posteriorobliquemyofascialsling,35posteriorsacroiliacligament,37sacralnutationandcounter-nutation,36self-lockingmechanism,34shearin,35tensioninsacrotuberousligament,37

Sacroiliacmotion,22andiliosacralmotion,25unilateralmotion,26

Sacrotuberousligamenttension,37Sacrum,14–15.SeealsoInnominatebone;sacralaxisL-on-Lsacralmotion,28L-on-Rsacraltorsion,30neutralpositionof,28

non-physiologicalmotion,30,31,32physiologicalmotion,32R-on-Lsacraltorsion,31sacraltorsions,32andSIJmotion,77–79

SCM.SeeSternocleidomastoid(SCM)Scoliosis,102.SeealsoSpinalmechanicsSeatedforwardflexiontest,208–210.SeealsoPelvisassessmentSet,50SIjoint.SeeSacroiliacjoints(SIJsorSIjoint)SIJs.SeeSacroiliacjoints(SIJsorSIjoint)Singlearmbendlowtohigh,67Single-legstance,51,57–58Slippeddiscs.SeeHerniateddiscsSomaticspinaldysfunctions,102.SeealsoSpinalmechanicsSphinxtest,220–221.SeealsoPelvisassessmentSpinalenginetheory,100.SeealsoLawsofspinalmechanicsclosedkineticchain,100forceclosuremechanism,100posteriorlongitudinalsling,100posteriorobliquesling,101

Spinalmechanics,102.SeealsoLawsofspinalmechanicsFryette’slaws,102law,103neutralmechanics,102–103non-neutralmechanics,103scoliosis,102somaticspinaldysfunctions,102typeIdysfunction,102typeIIdysfunctions,103

Spinalmovementswithinvertebralcolumn,98

Spine,100SPJ.SeeSymphysispubisjoint(SPJ)Spondylosis,191Squat—bendtoextend,51,54Standingbalancetest,94compensatoryTrendelenburggait,95positionofPSIS,95positivetestforweakrightGmed,94shiftofpelvis,95

stabilityononeleg,95Trendelenburggait,94

Standingforwardflexiontest,205–207.SeealsoPelvisassessmentStaticstability,45abdominalcrunchintransverseplane,49anteriorobliquesling,47,48hydraulicamplifier,46lateralsling,47multifidus,46muscledysfunctionfactors,48–49outercoremuscleexercise,49posteriorlongitudinalsling,47posteriorobliquesling,47,48transversusabdominis,45–46

Sternocleidomastoid(SCM),10,88,183STJ.SeeSubtalarjoint(STJ)Storktest,210–212.SeealsoPelvisassessmentStructuralLLD,84Subtalarjoint(STJ),10,172Superiortransversesacralaxis,27Supinetolongsittingtest,83,226–227.SeealsoPelvisassessmentSymphysispubisdysfunction(SPD),10,24,238.SeealsoPelvicgirdledysfunctionscasestudy,239forwardflexiontests,239–240treatmentfor,243–246

Symphysispubisjoint(SPJ),10,12,16,22,24

Temporomandibularjoint(TMJ),10,88Tensorfasciaelatae(TFL),10,124,140.SeealsoMuscleenergytechnique(MET)assessmentof,141METtreatmentof,142–143Ober’stest,141–142

Thighthrusttest,197Thomastest,161Thoracicspine,104Thoracolumbarfascia,182.SeealsoGluteusmedius(Gmed)TMJ.SeeTemporomandibularjoint(TMJ)Tonicmuscles.SeePosture—posturalmusclesTP.SeeTransverseprocess(TP)Transverseprocess(TP),10,187Transversusabdominis(TVA),10,37,45–46

TVA.SeeTransversusabdominis(TVA)TypeIIspinaldysfunctions,103.SeealsoSpinalmechanicsTypeIspinaldysfunction,102.SeealsoSpinalmechanics

Unilateralmotionofsacrum,26

Vertebraposition,104–106.SeealsoLawsofspinalmechanicsVerticalsacralaxis,27

Zygapophysealjoints.SeeFacetjoints