President Hesch Institute - Las Vegas Manual Therapy
Regarding the costocorporal and costotransverse joints one of the most painful rib fixations is a medially compressed rib. It can be released slowly and gently with an anterior glide sustained for 30 seconds and then adding a lateral vector along the angle of the rib. Best is to actually add a slight lateral vector. The rib can of course do the opposite, rather common at upper to upper-mid from posture, habit, work, sitting, etc.
The next most painful would be inferior fixation, though they can be fixated superiorly, tested just lateral to the transverse process. This is not a bucket handle dysfunction, they are tested laterally and are subtle if tested proximally.
Lastly, the thoracic segments, if mobilized or manipulated typically correct a side-bending restriction and a rotation can remain, only discovered with medial spring test at spinous process on each side. If restricted stack side bending above and below and gentle rotation. If spinous process rotated to the right and does not spring right to left, thenside bending and rotation is to the right because the front of the vertebrae is rotated left moving spinous process to the right.
Again, I favor gentle forces and contact the right side of spinous process and the segment above and below and lean in and maintain the force for 2 minutes.
I do teach courses on very gentle mobilization throughout the body.
Hope this is helpful, can clarify, shoot video etc.
PULL OUTS FROM THE SACRAL TORSION CHAPTER by Jerry Hesch
From Hesch J. Sacral torsion about an oblique axis: a new approach to an old problem. Dynamic Body. Dalton E., ed. 2011:190-231.
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.
Springing used as a passive accessory motion test (and grading system) is part of a basic skill set that should be accessible to manually-oriented clinicians.
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.
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.
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.
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.
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 torsion 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, includinghormonal 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 manually-oriented clinicians.
Palpation and Spring Test Practice
Introduction to Hesch Lumbopelvic Workbook
Hesch Institute Web Site
From a recent blog
Jerry, During your full body screens, do you have a tool that shows you exactly where dysfunction is occurring?
No, nothing shows me "exactly where dysfunction is occurring", it is a process. Yesterday had a challenging case and I learned something anew. Her ankle was in fact unstable in spite of a negative drawer test for anterior talofibular ligament. Her anatomy apparently unique in that only when I tested it in mild inversion did the instability become glaring obvious. So paying attention and following the process is part of the journey. My best tool I believe is that of paying attention, using mind, hands and heart (metaphor) and the stored history of past success and failure. I am not the expert. I consider the client and their body to be the expert, even if either or both at the moment might be incapable of communicating the precise "dysfunction diagnosis". Listening is girded to humility.
N….., I believe that the question posed by Debbie implies that there is a '"dysfunction" which initially is occulted. Debbie?
I just posted a YouTube video demonstrating the limits of a traditional AP pelvic film in discerning vertical asymmetry. Repeat films with stork stance can show alteration, whereas a single static film may simply show long standing asymmetry. I believe itwas Walheim in 1984 who suggested the above.
Dr. Jerry Hesch, DPT, MHS, PT
Married with 4 grown kids. Earned my Doctorate at A.T. Still University in Tempe, AZ, MHS at the University of Indianapolis and my BS PT at University of New Mexico. I enjoy working with my hands and particularly making glass objet d'art.