http://robshapiropt.com/2013/03/06/what-the-heck-is-a-posterior-sacrum/
ROB SHAPIRO'S BLOG, jERRY ADDENDUM BELOW


 What the heck is a posterior sacrum ?


Great case study this weekend at the Hesch Method seminar in Las Vegas
where I had the opportunity to assist Jerry teach. I’m just hoping what gets
taught in Vegas does not stay in Vegas.
. One of the students presented with what Jerry Hesch calls a
“posterior sacrum”. A posterior sacrum is defined as a dysfunction in which the
entire sacrum is stuck in a posterior glide between the ilia and bilateral
sacral sulci are shallow. When trying to spring the sacrum and ilium all motions
are blocked and both sacrospinous and sacrotuberous ligaments are taut to
palpation. This dysfunction can cause havoc up the kinetic chain up to the
occiput. The mostly likely cause of this non-physiological dysfunction is some
sort of trauma such as landing on the buttocks. A common complaint by the
patient is increased fatigue, headaches and increased urinary frequency. This
weekend one of the students had this seemingly rare dysfunction with these same
complaints. She was used as a case study using the Hesch Method which consisted
of gentle mobilizations which were performed both manually and with the use of
props to enhance soft tissue mobility based on the the principle of viscoelastic
creep. The treatment took a total of about 15 minutes and consisted of 5
different mobilizations to correct the dysfunction and associated mobility
restrictions and the student got off the table and stated how loose and mobile
she felt. She was given a home exercise program to follow and will report back
to us on her progress.


The main purpose of this short article is to
share with you another tool that can help you with those hard to figure out and
often frustrating cases. For more information go http://www.heschinstitute.com
or check out Jerry’s many videos on YouTube (search
JerryHesch)


jERRY WRITES:
I look forward to following up with her soon, the case of posterior
glide sacrum. AQlso, found the first one in a tall slender male, never have
  encouontered it in a male before. Gotta stay awake and pay attention and be
  cautious of belief; never say never. The spontaneous exclamation when the gal
  stood up and walked was "Wow" x3! Putting drama and enthusiasm aside, it is a
very relevant very under-appreciated and under-treated dysfunction. How can we
spread the word, get researcers engaged, case studies...any volunteers to work
together?

Sakamoto
  et al. suggest that the SIJ may be a source of low back pain, as the majority
  of mechanoreceptors (97%) are Type III nociceptors, the other 3% being
  proprioceptors.[i] 
Szadek, et al performed a detailed histological study of the
intra-articular and extra-articular SIJ nociceptors.[ii] 
Murakami et al[iii]performed a remarkably enlightening
injections study effectively countering the belief that injection into the SIJ
is a “gold standard” in terms of diagnosing the SIJ alone as the pain generator.
 Murakami and colleagues performed
intra-articular injections in 25 consecutive patients. The
SIJ injection provided relief in only 9/25 (36%), whereas among the following 25
who received peri-articular (primary ligaments and soft tissues) injection, 100%
achieved pain relief.  They
concluded that when SIJD is a painful local condition, pain generation is not
from the intrinsic portion of the joint in the majority, and terms such as extra-articular or peri-articular SIJ
pain may be more cogent. 
Repeat studies are needed.



Given the
significant overlap of the relevant lumbar and sacral dermatomes, sclerotomes,
and sensory nerves encompassing L2-L3-L4-L5-S1-S2-S3, cautious interpretation is
mandated.  It should be mentioned
that current thinking is to use a cluster of tests, such that a positive SIJ
injection would require positive mechanical tests, congruent with the history
and overall presentation in order to diagnosis mechanical (as opposed to
inflammatory) SIJD.  Injection can
  reduce overall pain along the extrinsicpathways of these nerve
levels, reducing pain that is of primary lumbar segment origin. 
Therefore the term “gold standard” is overstated in being used to
diagnose the SIJ as the primary pain
generator.  It seems reasonable
ideal to also perform lumbar injection and contrast those results with the SIJ
injection.  Anatomically the lumbar
spine is connected to the sacrum via the last lumbar disc, the lumbosacral facet
joints, and proximal soft tissues. 
The lower lumbar segments are connected to the ilia via the iliolumbar
ligaments and other proximal soft tissues.  The SIJ, shares a similar connection
with the bony pelvis and hip.  This
deepens the complexity of isolating the primary pain generator in structures
that have a very similar neural pathway. 
This complexity is certainly humbling to those clinicians who accept the
clinical reality, insightfully written by Alvin Stoddard, DO:[iv] “The differential diagnosis
  between sacroiliac dysfunction and low back pain is
difficult.”



Laslett
  has described some diagnostic success with a small cluster of manual pain
  provocation tests, as they correlate well with positive SIJ
injections.[v] Cautious interpretation is warranted
because these tests do also stress the lumbar spine and the hip, and due to the
above stated limitations of the “gold-standard” diagnostic injection.  The ability to specifically isolate the
  majority of the force application to the SIJ and not the hip or lumbar spine
has yet to be thoroughly researched. 
It seems as though these studies and their impact on the profession
provide a sense of permission-granting to treat the SIJ with manual
procedures.  Yet many more clients
have faulty posture and faulty motion coupling in the lumbopelvic-hip region,
such that a biomechanical model, rather than only a pain-provocation model may
be more appropriate for this population. 
I submit that both models have relevance in differing populations. Hands-on clinicians may be frustrated
with limited ability to confidently reproduce or rule out SIJ pain.  However,
a biomechanical perspective does encourage treatment in order to enhance posture
and mobility of the pelvis, hip, SIJ, and proximal structures.  Reduction
  in pain may be facilitated by enhancing function via the restoration of optimal
  posture, movement, and muscle tone and length, etc. 
This encapsulates my philosophy regarding movement testing versus pain
provocation with manual tests.  In
support of movement testing, next we will discuss a fluoroscopy
study.








[i] Sakamoto N,
Yamashita T, Takebayashi T, et al. (2001). An Electrophysiologic Study of
  Mechanoreceptors in the Sacroiliac Joint and Adjacent Tissues. Spine,
26(20):68-71.




[ii] Szadek KM, Hoogland
PV, Zuurmond WW, et al. (2009). Nociceptive nerve fibers in the sacroiliac joint
in humans. Reg Anesth Pain Me.,
33(1):36-43.




[iii]Murakami E, Tanaka
Y, Aizwa T, et al. (2007). “Effect of periarticular and intraarticular lidocaine
injections for sacroiliac joint pain: prospective comparative study”. J
Orthoped Science,12: 274-280.




[iv]Stoddard A. (1980).
Manual of Osteopathic Technique.
London,United Kingdom: Hutchinson Publ.
1.




[v] Laslett M. (2008).
Evidence-based diagnosis and treatment of the painful sacroiliac joint.J
Man Manip Ther.


 

This was just submitted to CSM 2014 Women's Health for a paper presentation.

Pelvic joint mobilization for false positive late pregnancy
instability             
 
A 29 year old female in the 32nd week of pregnancy had progressive
pelvic pain and perceived instability feeling that her pelvis was coming apart
in the front. She maintained hip adduction with all positional changes. Gait was
antalgic, with a narrow base of support and shortened stride length. Pelvic
instability in pregnancy is a well-established concept due to the enhancing size
of the fetus, with a background of hormonal priming; particularly relaxin and
  estrogen. Evaluation was performed in a very cautious and limited manner with
  the expectation that significant pelvic instability would be encountered.
  Instead, micromotion testing revealed a surprising, significant hypomobility in
  multiple directions. Within a single intervention her posture and mobility were
  much improved, along with significant pain reduction. She reported significant
  improvement in bladder control and went on to have an easy natural delivery. In
  this case the subjective sense of instability was most likely a reflection of
  the visceral and neural tension and compression in response to the
  3-dimensional non-physiological positioning of the pelvic articulations with
  induced spasm. This case of true hypomobility presenting as subjective
“instability” underscores the utility of joint micromotion testing, AKA
springing with awareness. Hypomobility and hypermobility are relevant peripartum
  constructs.

I  posted a proposal to teach a 2-day and 2 papers for CSM 2014 Women's Health Here
is one abstract.

Pelvic  joint mobilization for false positive late pregnancy instability

 A 29 year old female in the 32nd week of pregnancy had progressive pelvic pain and
perceived instability feeling that her pelvis was coming apart in the front. She
maintained hip adduction with all positional changes. Gait was antalgic, with a
narrow base of support and shortened stride length. Pelvic instability in
pregnancy is a well-established concept due to the enhancing size of the fetus,
with a background of hormonal priming; particularly relaxin and estrogen.
Evaluation was performed in a very cautious and limited manner with the
expectation that significant pelvic instability would be encountered. Instead,
micromotion testing revealed a surprising, significant hypomobility in multiple
directions. Within a single intervention her posture and mobility were much
improved, along with significant pain reduction. She reported significant
improvement in bladder control and went on to have an easy natural delivery. In
this case the subjective sense of instability was most likely a reflection of
the visceral and neural tension and compression in response to the 3-dimensional
non-physiological positioning of the pelvic articulations with induced spasm.
This case of true hypomobility presenting as subjective “instability”
underscores the utility of joint micromotion testing, AKA springing with
awareness. Hypomobility and hypermobility are relevant peripartum
constructs.

It has been busy. Last week submitted 3 abstracts for AAOMPT and this week 2 abstracts and a proposal to do a 2-day session plus 2 papers for combined section next year. Those programs are so finicky and not intuitive as they say so I cycle around a few times trying to do the simple! Will go teach in Cleveland this weekend and Las Vegas the following. Lori Layton will help with lab in Cleveland and Rob Shapiro in Las Vegas. Look forward to the challenge and grateful for the support.

THIS IS AN INTERESTING PAPER, WORTHY OF CONVERSATION.

Am J Sports Med. 2012
May;40(5):1113-8. Epub 2012 Mar 5.
 The effect of dynamic
femoroacetabular impingement on pubic symphysis motion: a cadaveric
study.
 Birmingham PM, Kelly BT,
Jacobs R, McGrady L, Wang M.
 Source
 Department of Orthopaedic
Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
patrickbirmingham@gmail.com
 Abstract
 BACKGROUND:
 A link between
femoroacetabular impingement and athletic pubalgia has been reported clinically.
One proposed origin of athletic pubalgia is secondary to repetitive loading of
the pubic symphysis, leading to instability and parasymphyseal tendon and
ligament injury. Hypothesis/
 PURPOSE:
 The purpose of this study
was to investigate the effect of simulated femoral-based femoroacetabular
impingement on rotational motion at the pubic symphysis. The authors hypothesize
that the presence of a cam lesion leads to increased relative symphyseal
motion.
 STUDY  DESIGN:
 Controlled laboratory
study.
 METHODS:
 Twelve hips from 6
fresh-frozen human cadaveric pelvises were used to simulate cam-type
femoroacetabular impingement. The hips were held in a custom jig and maximally
internally rotated at 90° of flexion and neutral adduction. Three-dimensional
motion of the pubic symphysis was measured by a motion-tracking system for 2
states: native and simulated cam. Load-displacement plots were generated between
the internal rotational torque applied to the hip and the responding motion in 3
anatomic planes of the pubic symphysis.
 RESULTS:
 As the hip was internally
rotated, the motion at the pubic symphysis increased proportionally with the
degrees of the rotation as well as the applied torque measured at the distal
femur for both states. The primary rotation of the symphysis was in the
transverse plane and on average accounted for more than 60% of the total
rotation. This primary motion caused the anterior aspect of the symphyseal joint
to open or widen, whereas the posterior aspect narrowed. At the torque level of
18.0 N·m, the mean transverse rotation in degrees was 0.89° ± 0.35° for the
native state and 1.20° ± 0.41° for cam state. The difference between cam and the
native groups was statistically significant (P <
.03).
 CONCLUSION:
 Dynamic femoroacetabular
impingement as caused by the presence of a cam lesion causes increased
rotational motion at the pubic
symphysis.
 CLINICAL  RELEVANCE:
 Repetitive loading of the
symphysis by cam impingement is thought to lead to increased symphyseal motion,
which is one possible precursor to athletic
pubalgia.
 PMID: 22392561 [PubMed -
indexed for MEDLIN


 

There is one other study that I am aware of re pelvic bone deformation. An interesting consideration re the felt experience of springing with awareness.

Mean range of 3D deformation of the innominate bone (3.39 ±2.92
mm) is comparable to the range of symphysis motion (3.20 ± 2.58 mm; p >
  0.05). Largest deformation within the innominate was present in the transverse
  plane (1.41 ± 3.1 mm). Significant differences (p < 0.01) occured in the
  mobility of the pubic symphysis between male and female specimens. No
  significant gender differences were present in the deformation of the
  innominate bone.
 
Pool-Goudzwaard A, Gnat R, Spoor K. Deformation of the innominate
bone and mobility of the pubic symphysis during asymmetric moment application to
the pelvis. Man Ther. 2012 Feb;17(1):66-70. Epub 2011 Oct
20.

 Source
 Department of Neuroscience, Faculty of Medicine and Health
  Sciences, Erasmus MC University, Rotterdam, The Netherlands.
  a.goudzwaard@erasmusmc.nl

 Abstract
 BACKGROUND:
 Angular motions of human joints are frequently accompanied by
bony deformations. In the case of the pelvis it is unknown how much deformation
within the innominate and movement within pelvic joints will occur during an
asymmetrical loading. Deeper insight into this topic could help to increase the
understanding of the biomechanics of the pelvis during e.g. locomotion and
improve interpretation of clinical tests in which manual force is asymmetrically
applied to the pelvic bones.
 OBJECTIVE:
 To test the occurrence of deformation within the innominate and
movement within the pubic symphysis during asymmetric moment application to the
pelvis.
 METHODS:
 In 15 embalmed specimens an incremental moment was applied to one
innominate bone in the sagittal plane with respect to the fixated contralateral
innominate. The three-dimensional (3D) deformation within the fixated
innominate, as well as displacement of the pubic symphysis, were described
during each increment of the moment. Maximal amount of deformation within the
fixated innominate was compared with displacement in the pubic symphysis and
tested for significant difference for all subjects and separately by
gender.
 RESULTS:
 Mean range of 3D deformation of the innominate bone (3.39 ±2.92
mm) is comparable to the range of symphysis motion (3.20 ± 2.58 mm; p >
  0.05). Largest deformation within the innominate was present in the transverse
  plane (1.41 ± 3.1 mm). Significant differences (p < 0.01) occured in the
  mobility of the pubic symphysis between male and female specimens. No
  significant gender differences were present in the deformation of the
  innominate bone.
 CONCLUSIONS:
 During asymmetrical loading both movement within the pubic
  symphysis as well as deformation within the innominate occur simultaneously.
  Deformation of the innominate is the largest in the transverse
plane.

One of my mentors Phillip Greenman, DO passed away on February 7, 2013. Below
is a quote from the sacral torsion chapter I wrote acknowledging his influence
on my work. He has influenced many. 


"I wish to express a debt of gratitude to the osteopathic profession, and in
particular to Philip Greenman, DO, who greatly influenced my development as a
hands-on clinician.  I hope my reinterpretation honors your vision and your
body of work." 



Philip E. Greenman, D.O. Philip E. Greenman, D.O., passed away on
February 5, 2013 in Tucson, AZ due to complications of pneumonia. Dr. Greenman
was born on February 25, 1928 in Deposit, NY, the only son of Joseph and Thelma
Greenman, and was a 1952 graduate of the Philadelphia College of Osteopathic
Medicine. He was in private practice in Buffalo, New York for almost twenty
years before accepting a position at Michigan State University in East Lansing,
MI in 1972, where he served as Professor and Associate Dean of the College of
Osteopathic Medicine before retiring to Tucson in 2004. Dr. Greenman authored a
noted medical textbook and was internationally known for his work and research
in the field of manual medicine. He is survived and fondly remembered by his
wife of 63 years, Patricia Bingham Greenman, his sons John and Jeffrey,
daughters-in-law Laura and Janet, and grandchildren Elizabeth, Alexander, Emily,
Matthew and Andrew. A memorial service will take place at Grace/St. Paul's
Episcopal Church in Tucson at a later date. Memorial gifts would be welcomed for
the Philip E. Greenman Endowed Residency (AS040) by sending a check payable to
"Michigan State University" to MSU College of Osteopathic Medicine, 965 Fee
Road, Room A310, East Lansing, MI 48824.

THEORY REPORT

REAPPRAISAL OF SOME FUNDAMENTAL MANUAL THERAPY CONCEPTS

Hesch J,  Hesch Institute,  Henderson, NV
Corresponding author: HeschInstitute@yahoo.com
 
Every profession benefits from periodic appraisal of their foundational concepts. It is encouraging to note fundamental reappraisals of basic tenets such as recent works on evaluating concave-convex rule, and potential belief such as grade V manipulation being superior to grades I-IV mobilization. Other foundational beliefs and scales may be timely for reappraisal. Qualifiers may enhance the traditional joint movement scale. For example Grade I, II hypomobility can include a fixed, immutable hypo and hypermobility such as in the former; from genetics, age, disease, scar tissue, and for the latter etc. Treatable hypomobility may also be due to proximal or distal reflex or biomechanical faults, muscle guarding, etc. Similar rationale may apply to grades IV and V hypermobility. The mobilization scale could include a separate grade for constant force maintained at end of available range for an extended period of time, AKA viscoelastic creep. Non-synovial joints with dense connective tissue such as the SIJ, symphysis pubis, or joints such as the subtalar with an interosseous ligament, or joints with long-lasting restriction may benefit from creep mobilization. Another concept is that of end feel. A recent case presented  with a bone on bone end feel of both hips with ten degrees of internal rotation.  Initially reluctant, the author ultimately treated it with a gain to 45 degrees within two sessions. A separate topic for exploration would be the limits imposed by language and by categorization, and the value of clarifying  terminologies within manual therapy, medicine and the overall clinician-client  interaction.