00:00
We're going to review the main sacral somatic
dysfunction categories.
00:05
We've already talked about physiologic
sacral dysfunction
where it follows an oblique axis and
it's what you normally do
that gets restricted or action is stopped.
The sacral torsion
is when you have an oblique axis,
a physiologic problem.
00:22
But then if you look at L5, it occurs to
the opposite side of rotation.
00:26
That's going to be a torsion. Some people
separate out sacral rotations
as another form of oblique
obstruction of motion
saying that it's on an oblique
axis of the sacrum
where you have the rotation to the same side
where you have the lesion.
00:43
When you talk about non-physiologic
sacral dysfunction,
that's the unilateral dysfunctions and
the bilateral dysfunctions.
00:51
The unilateral dysfunctions are those
sacral abnormalities on one side.
00:56
It's non-physiologic. It's not
how the body works.
00:59
It's a deep sacral sulcus and a deep ILA
or an anterior sacral sulcus
and a shallow ILA. That's going to be
a unilateral dysfunction.
01:09
A bilateral dysfunction is when both
sides have some pathology.
01:13
Again, those are the non-physiologic
sacral somatic dysfunctions.
01:18
When we talk about the main sacral
somatic dysfunctions,
let me review sacral torsions again. People
go into a sacral oblique axis
when they're walking. That's physiologic.
That's going to happen
normally with your daily activity. If it
gets stuck, if it's not moving,
if the sacral base ends up moving forward
and then blocking motion
on a left-sided axis without rotation along
that axis, that's a physiologic change.
01:52
That's a left on left abnormality or
right on right abnormality.
01:56
If you end up with it switched
with a left on right,
a left axis that won't
rotate right,
then you've got yourself a
non-physiologic sacral base.
02:06
That's when the sacral base goes
posterior or backward.
02:11
We often differentiate this
from sacral rotations
which is when L5 is also
not moving well.
02:17
You have the sacrum rotating
in the same direction
as the sacral oblique axis
and that's a sacral torsion.
02:27
The other types are the non-physiologic
sacral somatic dysfunctions.
02:31
You can have a unilateral dysfunction
which is again non-physiologic.
02:35
It is a sacral shear where on one side
you have both sides not moving
and it's not anything that would happen
with normal functioning.
02:44
Bilateral dysfunction is when both sides
of the sacrum are not moving
and your spring test is not showing
a spring or motion that's working.
02:53
That's bilateral extension which
is again non-physiologic.
02:58
When you're talking about the axes,
it's important to know
if something is on an oblique axis and
rotating on either right or left,
or whether it's a unilateral
sacral dysfunction.
03:09
Again, unilateral is non-physiologic
or where that occurs
along one of the three transverse
axes we talked about,
the superior, middle, or inferior
transverse axis of the sacrum.
03:21
When you have a torsion and it's
rotating on an oblique axis,
and let's say it's the left and
you get some motion
with the sacrum on the
left sacral axis,
so the superior pole and the
inferior lateral angle move,
that's a left sacral torsion.
It's physiologic.
03:43
And it happens normally but
it does get to the point
where if the lumbar spine
is going to restrict motion,
you're going to have yourself
somatic dysfunction.
03:52
On the right side, if you have
a right-sided torsion
and you have the right
sacral sulcus is deep,
you can still have motion as long
as it's along the sacral axis.
04:03
It's still a physiologic sacral
somatic dysfunction.
04:09
Unilateral sacral somatic dysfunctions
would be a unilateral sacral flexion
where you don't have
motion on one side.
04:16
Unilateral sacral extension,
also non-physiologic
where you have a
positive spring test,
meaning you're not
able to get motion
when you're trying to
spring the sacrum.
04:30
That's a sacral
dysfunction.
04:33
You can have one side not
moving or you can have
both inferior lateral
angles not moving.
04:42
A shallow sulcus and an
anterior ILA
will be one type of
unilateral sacral sulcus.
04:48
And a unilateral sacral
flexion is named
for the side of the positive
seated flexion test.
04:55
Again, the seated flexion test,
you sit him on a chair
you take the pelvis out of the motion,
and whichever side moves
is the positive side. Again,
these are non-physiologic.
05:07
Unilateral sacral dysfunctions,
we name it
again from the side that's not moving.
If you have a deep sulcus
and a posterior ILA on the right
and the right seated flexion
test is positive, that is a right-sided
unilateral sacral dysfunction.
05:26
If the deep sulcus and posterior
ILA are on the right
and the seated flexion test
is positive on the left,
the diagnosis is a left-sided
unilateral sacral dysfunction.
05:37
The site of the suspected
unilateral dysfunction
should be the same side
that tested positive
in the seated flexion test. That's
an important concept.
05:48
For unilateral sacral
flexion, the spring test
or the Sphinx test
may be negative.
05:54
You can have the
sacrum springing.
05:57
You can have motion. And it
will become more symmetric
in extended position which
is a Sphinx test.
06:04
You have them sit on their
arms or extend themselves
up on the couch. The
deep sacral sulcus
will be on the same side
as the posterior ILA.
06:15
If the posterior ILA
is deep on the left,
the sacral sulcus will
be deep on the left.
06:22
The posterior and
inferior inferior lateral angle
will be on the same side
as the deep sulcus.
06:30
L5 rotation doesn't matter
in this situation.
06:33
The seated flexion
test will be positive
on the side of the dysfunction.
On side of the deep sulcus
and on the side of the posterior
ILA should be the side
that you have the positive
seated flexion test
in a unilateral sacral flexion.
There's no axis
of rotation because
it's unilateral.
06:52
The unilateral sacral
extension test,
your spring test, or your sphinx
test will be positive.
06:58
You will have a
shallow sulcus
on the same side as
the inferior ILA.
07:04
The anterior superior ILA will
be on the same side
as the shallow sulcus.
L5 rotation doesn't matter
and the seated flexion
test will be positive.
07:15
The side that's positive will
determine how we name it.
07:18
If it's positive on the side
of the shallow sulcus
on the anterior ILA,
then that's the side
that you're going to name
the dysfunction.
07:27
Again, there's no
axis of rotation.
07:30
Here's a simple case. You have
a 35-year old female
who presents to your office
with low back pain
which started about
six months ago.
07:37
She sits for most of the
day at her new job.
07:39
The pain is described as achy and
left-sided greater than right side.
07:44
Additionally, she notes
increased dysmenorrhea,
pain with her menses.
On physical exam,
it's neurologically intact. She
has a negative spring test
and a positive seated flexion
test on the left
with a deep sulcus on the left. The
posterior and inferior ILA
on the left and L5, flex, side
bent left, rotated left.
08:06
What do we say if the deep
sulcus and the posterior ILA
are ipsilateral and they're on the
left, then we know the sacrum
as a whole is unilaterally
flexed or extended.
08:15
In order to determine if it's to be
named as unilateral flexion
or unilateral extension,
we need to know
which side tests positive for
the seated flexion test.
08:25
That's how we're
going to name it.
08:28
Same case, if the seated flexion
test is positive on the left,
we name it for the static
findings on the left.
08:36
If the seated flexion test is
positive on the right,
we name it for the static
findings on the right.
08:43
Three basic rules,
rule number one:
the side of the L5 side bending
is the sacral oblique axis.
08:51
Rule number two: the side
of L5 rotation
is going to be opposite
to the sacral rotation.
08:59
Rule number three: if the seated
flexion test is positive,
it's going to be positive on the side
opposite of the oblique axis.
09:08
We're going to use L5 to
diagnose our sacral torsions.
09:12
Physiologic or forward sacral
torsions will coincide
with a type 1 dysfunction in
neutral mechanics at L5.
09:21
If you're given an L5 diagnosis
of side bent left, rotated right,
you can figure out the sacral
diagnosis using the L5 rules.
09:33
The sacral axis left, the same
size as L5 side bending.
09:36
Sacral rotation left, opposite
of L5 rotation.
09:40
And a positive seated flexion
test on the right
which is opposite
to the left axis.
09:46
The diagnosis is left on left,
forward sacral torsion.
09:51
Using L5 to diagnose
the sacral torsion:
If you have a type 2
dysfunction, non-neutral
and your L5 are correlated with
non-physiologic dysfunction
of the sacrum, let's say
you're given an L5
that's diagnosed with L5 as flexed,
rotated right, side bent right,
you want to figure out the sacral
diagnosings using the L5 rules.
10:13
Well, the sacral diagnosis is right,
same as the L5 side bending.
10:16
The sacral rotation is left,
opposite of the L5 rotation.
10:21
And you have a positive seated flexion test
on the left, the opposite axis.
10:26
Your diagnosis is a left
on right backward
sacral torsion or
non-physiologic.
10:34
In summary, if the
sacrum is torsioned,
the seated flexion test is positive
opposite the axis of rotation.
10:44
It should rotate the
opposite way of L5
on an oblique axis. The
side bending direction of L5
will engage the sacrum's axis
of rotation ipsilaterally.