Main Sacral Somatic Dysfunctions Categories

by Tyler Cymet, DO, FACOFP

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    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.

    About the Lecture

    The lecture Main Sacral Somatic Dysfunctions Categories by Tyler Cymet, DO, FACOFP is from the course Osteopathic Diagnosis of the Sacral Region.

    Included Quiz Questions

    1. Anterior
    2. Posterior
    3. Oblique to the left
    4. Oblique to the right
    5. Stationary
    1. Posterior
    2. Anterior
    3. Oblique to the left
    4. Oblique to the right
    5. Stationary
    1. Unilateral flexion
    2. Unilateral extension
    3. Bilateral flexion
    4. Bilateral extension
    5. Stationary motion
    1. Oblique axis
    2. Transverse axis
    3. Anterior posterior axis
    4. Vertical axis
    5. Sagittal axis
    1. Side of L5 sidebending
    2. Opposite side of L5 sidebending
    3. Side of L5 rotation
    4. Opposite side of L5 rotation
    5. Side of positive seated flexion test

    Author of lecture Main Sacral Somatic Dysfunctions Categories

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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