PULL OUTS FROM THE SACRAL TORSION CHAPTER

These are parts of the text that were highlighted and placed in a box throughout the chapter to promote interest in the content. Not all of these made it to the final printed text, but are included nonetheless.

From Hesch J. Sacral torsion about an oblique axis: a new approach to an old problem. Dynamic Body. Dalton E., ed. 2011:190-231.

With torsion, one sacral quadrant will be prominent. In the presence of a sacral torsion the sacrum will be most asymmetrical at only one side of the sacral base or apex. In the most common torsion, the left lower sacral quadrant is prominent.

A frequently reported sacral movement dysfunction is named sacral torsion about an oblique axis, which is also known as sacral torsion, or simply as torsion. Torsions do meet the above definition of SIJD, and are the focus of this chapter.

Torsions frequently coexist with low back pain, making them difficult to isolate as the underlying issue.

This chapter will present an alternate model of sacral torsion theory.

If sacral torsion theory is to be integrated into a larger segment of clinical practice, then a reasonably less complex model is long overdue.

Torsions can be understood with small changes in nomenclature and in the method of screening.

The new nomenclature seems to be much easier to visualize and understand, and treatment is implied in the descriptive term.

The following terminology is suggested as the most ideal improvement over the traditional.  Note that the treatment technique is implied in the description.  Specifically, the prominent and blocked quadrant is the one where the mobilizing force is applied.

1. Posterior Left Lower Sacral Quadrant with Blocked P-A Spring, instead of Left on Left Sacral Torsion, or Left Rotation on Left Upper Oblique Axis.
2. Posterior Left Upper Sacral Quadrant with Blocked P-A Spring, instead of Left on Right Sacral Torsion, or Left Rotation on Right Upper Oblique Axis.
3. Posterior Right Upper Sacral Quadrant with Blocked P-A Spring, instead of Right on Left Sacral Torsion, or Right Rotation on Left Upper Oblique Axis.

4.     Posterior Right Lower Sacral Quadrant with Blocked P-A Spring, instead of Right on Right Sacral Torsion, or Right Rotation on Right Upper Oblique Axis.

The bony pelvis and the SIJ are not one-and-the- same, and their distinctions should not be blurred.

The creative clinician needs to bridge the two topics of so-called SIJD and pathomechanics of the pelvis.

Treatment is unnecessarily complex

The treatment technique for torsion can be rather complex.  The following is a typical treatment sequence for a left on left sacral torsion, using muscle energy technique:[i]

1. Patient in left lateral Sims position, close to edge of table, right arm over side of table, left arm behind and on table.

2. Operator faces patient, palpates lumbosacral junction.

3. Operator flexes patient’s legs (knees and feet together) until motion felt at sacral side of LS junction.

4. Patient’s legs maintained in this position against operator’s abdomen, hip or thigh.

5. Operator’s right hand now moved to patient’s right shoulder. As patient exhales, instructed to reach to floor with right hand. Operator maintains pressure on right shoulder. Repeat until L5 is rotated to left.

6. Operator’s left hand moves to patient’s feet, which are placed off edge of table, and pressed downward.

7. Patient instructed to push feet to ceiling as operator maintains pressure on patient’s feet and monitors L5 junction.

8. When patient relaxes, slack is taken up by operator with left hand.

9. Repeat 7 two or three times. (Right sacral base should be felt to move posteriorly).

10. Retest! Note: a variation allows the operator to sit on the table with the left hand monitoring the sacral base while the right hand resists elevation of patient’s legs toward ceiling.

I find the above positioning to be a challenge for both patient and practitioner.

I developed a model of torsion evaluation and treatment that made sense to me, and one which I could readily apply on a daily basis.

In addition to better teaching tools, students need more time to acquire manual skills.

Although torsions have been described as being a normal motion that occurs during the gait

cycle that concept has been discouraged by some clinicians, who essentially dismiss the overall concept of SIJD.

It may be that the sacrum does not move in toprsion during the gait cycle.

The bony pelvis does move on the femoral heads in standing, and asymmetry of the pelvic landmarks does not validate that the SIJ is the cause of that asymmetry.  That belief has been negated and reinterpretation is timely.

A very relevant and perhaps obscure fact is that none of these “objective radiological studies” measured the presence or absence of concomitant motion in the symphysis pubis, which by design; always occurs with SIJ motion.

Perhaps the joint does in fact function with compression and recoil throughout much of the articular surfaces during normal motions of the body, whereas end-range positions with large passive forces are required to induce true joint fixation.

SIJD in the female is a valid paradigm due to gender-specific anatomy and physiology, including

hormonal influences, pregnancy and birth mechanics, which of course can be enhanced by passive trauma or repetitive strain in the adult female.  Therefore, clinicians should become very skilled in treating this population.

Health practitioners sometimes tend to medicalize SIJD diagnoses, when oftentimes, rational early intervention can provide significant and lasting benefit.

In this example, a functional activity screening would not have been as informative as hands-on passive joint movement testing, typically referred to as spring/micro-motion testing.  As shown in this example, hands-on screening, including passive spring/micro-motion (joint motion) testing was necessary, in spite of prevailing clinical dogma.

SIJ mobilization or manipulation can certainly have a clinical effect, yet the treatment may have less specificity than is purported, and affect the surrounding soft tissues rather than reposition the joint.

The asymmetry of sacral sulcus depth needs to be addressed within several contexts, and ILA asymmetry alone is a poor indicator of mechanical SIJD.

The fluoroscopy video seems to clearly convey that motion transfers through the SIJ, and it is functionally relevant and of normative anatomy, physiology, and biomechanics.

The fact that muscle length has a significant influence on ligament tone in several regions of the body, including the pelvis, is a very under-appreciated clinical fact.

Initially this method can seem challenging, but is easily learned with a little practice while slowly reading the sequence with your hands on an anatomical model, or a volunteer.

Treatment will consist of applying approximately 20# of force.  This will be maintained for two minutes, and the sacrum will typically release within that time frame, such that repeat testing will indicate normal mobility.

Thus, it is easy to encounter weak muscle groups that are reflexively inhibited, although not intrinsically weak.  With this treatment paradigm, removing the inhibition is the first order of care.  To do otherwise unnecessarily protracts care.

“Dogma dulls the wits… it is better to let the joints (and somatic structures) speak for themselves, rather than dictate to the joint how it is to behave based on various theories.”

Gregory Grieve

We are screening for treatable motion that is blocked, not allowing forces to travel through the SIJ, as opposed to the illusion that we can discern motion loss in the SIJ.

I find the traditional springing portion of the sacral evaluation difficult to use, as it only gives me half of the movement information – the forward portion.

Noteworthy is the observation that pathomechanics and treatment of the pelvis and pelvic joints is not always a natural extension of normal mechanics, and thus there is a knowledge gap in the education of biomechanically-based health care practitioners.

Springing is part of a basic skill set that should be accessible to manualy-oriented clinicians.



 

Another abstract on location for SI belts. In reviewing multiple images of diastasis, it is interesting to note that the separation at the symphysis can be severe such as greater than 1" (2.54 cm), yet the increased width at the sacroiliac joints is much less, only a few millimeters. It seems reasonable that for subtle forms of SIJ hypermobility that do not show on MRI, that the same low application of the support is appropriate. The high application is certainly contraindicated for most post-partum because it actually replicates the lower pubic joint distractive forces. Specific research needed on a large scale for the subtler SIJD cases of which many are not actually hypermobile, in spite of symptoms. 
J Bone Joint Surg Br. 2011 Nov;93(11):1524-8.
Accurate placement of a pelvic binder improves reduction of unstable fractures of the pelvic ring.
Bonner TJ, Eardley WG, Newell N, Masouros S, Matthews JJ, Gibb I, Clasper JC.
Source
Royal Centre for Defence Medicine, Academic Department of Military Surgery and Trauma, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, UK. [email protected]
Abstract
The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis. Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C). We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01). Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

Regarding Sacroiliac Article ADVANCE October 29, 2012.
 
Dear  Editor,
I have a few comments that were motivated by the article on SI Joint Pain titled Finding the Perfect Fit: Therapist learns through personal experience how to identify SI joint pain. The author insightfully reports that SIJ symptoms can be overlooked in clients with total hip and total knee replacements, who experience asymmetry of weight bearing. I agree that there is a common faulty pelvic pattern in this population consisting of left or right pelvic side-glide fixation. While this may have served them well in decreasing weight-bearing on the painful side pre-op, it idealy would be addressed in post op rehab. This pattern is sometimes obvious visually, other times it is subtle and can only be found with passive testing. Unfortunately, at times this specific pattern is perhaps neglected, such that long after rehab, patients are observed with the
pelvis shifted to one side, still requiring an assistive device. This pattern can be readily corrected or significantly improved with prolonged passive pelvic glide over a fulcrum.

The author insightfully encourages referral to pelvic floor specialists such as for peri-partum SIJ conditions and advocates addressing the trunk, hip and pelvic musculature for strengthening and restoration of normative movement.

I respectfully disagree with the author’s statement that lax ligaments will always be lax. While sometimes true, the pelvic ligaments have extensive muscular attachments, directly, or indirectly via fascial expansions as is detailed in the literature, including the 2012 book titled Fascia (Elsevier). Muscle function can be inhibited via the Type III and IV mechanoreceptors when a ligament has excessive tension, compression or chemical irritation. Ligaments can respond to alterations in muscle length/tension. Fortunately, the long dorsal SI, sacrotuberous and sacrospinous ligaments are readily accessible for palpation and discerning changes in tone in response to intervention. It is important to discern if the laxity is mutable. 

There is a pervasive belief that malalignment of the pelvis is caused by malalignment within the SIJ. Quite often it is simply due to the unique biomechanics of the entire pelvis moving asymmetrically, in which the SIJ’s are loaded and function as a stable clutch. Soft tissue overlying the lumbopelvic region deforms asymmetrically and gets over-interpreted. Sturesson et al have done detailed studies that undergird this statement, and others have addressed the semantic and clinical problems of sacroiliac “joint” dysfunction. A detailed exploration of these concepts can be found in a very recent book chapter title Sacral Torsion: A New Approach To an Old Problem, in the book Dynamic Body. The topic of SIJ dysfunction is controversial, yet the paradigm is slowly changes as research continues to provide guidance.

 Thank you very  much.

 Jerry Hesch, MHS,  PT
 Hesch  Institute
 Henderson, NV
USA

 
REFERENCES
 
Cook C, Massa L, Harm-Ernandes I, et al. (2007). Inter-rater reliability and diagnostic accuracy of pelvic girdle pain classification. J Manip Physiol Ther., 30:252-8.
 
Egund N, Olsson TH, Schmid H, et al. (1978).  Movements in the sacroiliac joints demonstrated with roentgen stereophotogrammetry. Acta Radiol Diagnosis, 19:833-846.
 
Goode A, Hegedus EJ, Sizer P, et al. (2008). Three Dimensional Movements of the Sacroiliac Joints: A Systematic Review of the Literature and Assessment of Clinical Utility. J Man Manip Ther., 16(1):25-38.
 
Hesch  J. (1996). Evaluating sacroiliac joint play with spring tests

Hesch J. (1997). Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. London, United Kingdom: Churchill Livingstone, 535-552.
 
Hesch J, Aisenbrey J, Guarino J. (June 25, 1990). The Pitfalls Associated With Traditional Evaluation of Sacroiliac Dysfunction and Their Proposed Solution. Presented at Annual Conference of the American Physical Therapy Association, Anaheim, Ca.
 
Huijbregts P. (May/June 2004). Sacroiliac joint dysfunction: evidence-based diagnosis. Feature Article of the Orthopedic Division Canadian Physical Therapy Association,
18-44.
 
Huijbregts P. (2008). Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther., 16(3):153–154.
 
Janiak DD. (2001). Review of sacral somatic dysfunction. AAO,  18-23.
 
Jordan Theodore R. (2006). Conceptual and treatment models in osteopathy II. Sacroiliac mechanics revisited. AAOJ, 11-17.
 
Levangie PK, Norkin CC. (2005). The hip complex. In: Joint Structure & Function: A
Comprehensive Analysis. Philadelphia, PA:F.A. Davis, 368-372.
 
Neumann D. (2002). Axial skeleton: osteology and arthrology. In: Kinesiology of the
Musculoskeletal System. St Louis, MO. Mosby Inc., 303-305.

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.
 
Sturesson B, Selvik G, Uden A. (1989). Movements of the sacroiliac joints: a roentgen
stereophotogrammetric analysis. Spine, 14:162-165.
 
Sturesson B, Uden A, Vleeming A. (2000). A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine, 1;25(3):364-8.

Tullberg T, Blomberg S, Branth B, et al. (1998).  Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine, 15;23(10):1124-8; Discussion 1129.Wyke B.D. (1972). Articular neurology: a review. Physiother.,
58:94.
 
Walker JM. (1992). The SacroiliacJoint: A Critical Review. Phys Ther., 72(12):913.


 

Note, The original post from Michele Doyle's FB, you can go there for the full discussion or add to this, I really do not know what is proper etiquette, attribution, etc!


Michelle:
I've often wondered about the connection of TMJ and pelvic pain and dysfunction, and got this answer from Dr. Sheila Laws. 

"I've been told that the TMJ is the 'pelvis of the skull', and since the head "rules" the body, so does the TMJ rule the body's pelvis. In other words, as the TMJ goes, so goes the pelvis. I've seen it hundreds of times." Thank you, Sheila K. Laws!

So is this some kind of wild compensatory pattern or what?


Jerry Hesch reply:
The degree to which one structure affects another is an individual phenomenon, based on that person's presentation. This ignores the all people are the same and leans towards the "all are similar", at least for now. I very frequently encounter clients who have altered upper cervical (occipito-atlantal and atlas-axis) fixations that are unilateral or bilateral. The eyes achieve horizontal, (another theory being cerebral blood flow) yet there are asymmetries in tone that impact the TMJ. The distal inciting event is the subtalar joint more so than talocrural, a restriction that is incongruent with that person's body template. Same for supinatory pattern of multiple joints (Hesch Type II Cuboid Syndrome) or any pattern in lower extremity, hip, pelvis.

Aligning the lower body with the body template reflexively, on the table releases the distal upper cervical/TMJ phenomenon. So it can also be a bottom up phenomenon. When we encounter the lower body phenomneon and the upper body pattern is not there, it is then detective work; as Jeff implicated another diaphragm area, the cervicothoracic/1st rib area, sometimes slightly lower, that can be a fun detective work. This does not negate that treating the TMJ or upper body first may change things below. The key is to discern which one is primary that gives the most bang for the buck. If today I treat the TMJ and or upper cevical and the tight hip rotators (every one of them forget there ever was a piriformis.....(too much isolated focus on that one :)  ), I have to then
test the rest of the body to discern that which did not reflexively release.

If I fall and strike my mandible, all bets are off, that of course is a fresh isolated TMJ injury so presently an unknown what the rest of the body says or needs. Lastly before my next 120z of slept in coffee, if there are rules of coupled motion in the jaw for mobilization, they are arbitrary and again; test the individual. That is the best I can do. All above letter singular or group biased based on my world view, experience, limited education and experience, extensive experience and education, limited caffinated consumption, sleep deprivation, and apoplectic computer key pounding. g' morning! MIss y'all.
Thank you for inviting me in the discussion. Also the key for me in knowing it is NOT
top down is that it is so rigid, so unalterable that I know it is reflexively engaged.