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.