Evaluation and

Treatment of
Sacroiliac Joint
Dysfunction
 Introduction
 Sacroiliac joint (SIJ) dysfunction generally refers to pain in the
sacroiliac joint region that is caused by abnormal motion in the
sacroiliac joint, either too much motion or too little motion
 SIJ pain is common cause of axial low back pain affecting
between (10%-25%) of people.
(Bernard & Kirkildy, 1987; Fortin, et al., 1994, Cohen, 2007).
 SIJ dysfunction are the fourth common cause of LBP and pelvic pain
(Paris & Viti, 2007).
 6-13% source of LBP, pelvis or referred lower extremity pain
(Schwarzer, et al., 1995a, Bogduk, 1995).
 SIJ surface area is greater in males than
females (Ebraheim & Biyani, 2003) increased biomechanical
loading in males (Vleeming et al.,2012).
SACRAL STRUCTURE, LIGAMENTS,
MUSCLES AND NERVES
 THE SACRUM

 The sacrum, is a large triangular bone at the base of the spine that
forms by the fusing of sacral vertebrae S1–S5 , between 18 and 30 years
of age.

 The sacrum is situated at the upper, back part of the pelvic cavity,
between the two wings of the pelvis.

 It forms joints with four other bones. The two projections at the sides of
the sacrum are called the alae (wings), and articulate with the ilium at the
L-shaped sacroiliac joints.

 The upper part of the sacrum connects with the last lumbar vertebra, and
 Major Pelvic
Ligaments
Iliolumbar ligament: from ilia to 5th lumbar
vertebrae
 Sacrospinous & Sacrotuberous Ligaments

Sacrospinous : Sacrum to spine

of the ischium
Sacrotuberous : Runs from
lower sacral tubercles to ischial
tuberosity
Gluteus maximus attachment
Tendon of the biceps femoris
attachment
Both Ligaments are stabilize to
prevent posterior – superior
rotation of the sacral apex
 Sacroiliac Ligament
• Sacroiliac ligament: actually, three parts
[Link] or ventral sacroiliac from 3rd sacral segment to lateral
preauricular sulcus
[Link] sacroiliac massive bond between the upper parts of
the joint
[Link] sacroiliac Partly covers the interosseous, from lateral sacral crest
to PSIS and internal iliac crest.
 Pelvic muscle attachments from
above.
Posterior Muscular
Attachments
Attach to Sacrum
• Erector Spinae
• Iliocostalis
• Longissimus
• Erector Spinae
• Multifidus
Attach to Innominates
• Obliques (internal,
external, transverse)
• Quadratus Lumborum
 MUSCLE FUNCTIONS

Piriformis
Anterior tilt and rotate sacrum to opposite
side Assisted by Ipsilateral gluteus
maximus
Long head of biceps
–Backward tilt and rotate sacrum to same
side
Longissimus and multifidus
–Pull sacral base superiorly and posteriorly thru
dorsal ligaments
 INNERVATIONS

 SIJ innervated by L4-S1. (Solonen ,1957)

 Supply from dorsal rami L5, S1, S2 and S3. (Bradley, 1985)

 Supply by fifth lumbar nerve. (Ikeda,1991)

 Exclusively innervated by S1-S4 dorsal rami. (Grob et al.,1995)

 Dorsal sacral plexus (S1-S3). (Willard et al.,1998)

 SACROILIAC JOINT STRUCTURE

 Diarthrodial joint with two bony surfaces, sacrum and ilium 1-2 mm wide
 Joint surfaces are lined with hyaline cartilage, and the iliac cartilage seems thinner and
more fibrocartilaginous than that of sacrum side.
 Superior third of hyaline iliac cartilage is strongly attached to surrounding stabilizing
ligaments, forming wide margins of fibrocartilage.
 Inferior third of the joint along iliac bone has some histologic characteristics of a
“synovial joint”.
(Puhakka et al., 2004)
 Sacroiliac Joint
Movement
1) Nutation: Anterior nutation or flexion
2) Counter nutation: Posterior nutation or
extension
3) Forward rotation around an oblique axis
4) Backward rotation around an oblique
axis
 Sacroiliac Joint
Movement
Physiologic Non-physiologic

Left sacral torsion on left oblique Left sacral torsion on right

axis oblique axis
Right sacral torsion on right oblique
axis Right sacral torsion on left
 Bilateral anterior sacral nutation oblique axis
 Bilateral posterior sacral nutation  Left unilateral anterior
Anterior sacral nutation with nutation
exhalation  Right unilateral anterior
Posterior sacral nutation with nutation
inhalation
 Left unilateral posterior
nutation
 Right unilateral posterior
nutation
 Reciprocal
Movement at
Lumbosacral
Flexion of L5-S1 Junction
– Sacral base moves posteriorly into extension
(counternutates)
Extension of L5-S1
– Sacral base moves anteriorly into flexion(nutates)
Right rotation and left side bending of L5
– Sacral base rotates to left and side bends right
 Impairment
s
 Excessive articular compression
– Fusion (AS)
– Capsular fibrosis
– Over activation of global Myofascial
system
– Joint fixation (underlying instability)
 Insufficient articular compression
– Ligamentous laxity
– Underactivity of local Myofascial
system
 Somatic
Function Dysfunction
– Stability and motion of SI joints result of shape of joint surfaces (form
closure) and altering of ligamentous tension in response to changes
of muscle tone (force closure) (Isaacs & Bookhout)
Dysfunction
– Imbalance of tension and tone between muscles and ligaments which
locks SI joint and prevents normal function (Isaacs & Bookhout)
ARTT
– Asymmetry of position, restricted motion, tissue texture, tenderness
 Sacroiliac Somatic
Dysfunctions
• Forward sacral torsion
• Backward sacral torsion
• Bilateral sacral anterior nutation
• Bilateral sacral posterior nutation
• Unilateral sacral anterior nutation
• Unilateral sacral posterior nutation
 Symptom
s
• Stiffness and pain with
walking
• Pain opposite side with
walking
• Pain same side with
walking
• Unilateral pain below L5
• Pain with sit to stand
• Coccydynia (torsions)
• Groin pain
SIJ Pain Patterns
 A B C D
Myotomal pain referral regions from muscle trigger points:

(A) Quadratus lumborom.

(B) Piriformis.
(C) Iliopsoas.
(D) Rotatores and Multifidis muscles.

(Kuchera,2007, Journal of American Osteopathic Association, ES31, Suppl6, 107, 11)

 A B C
Sclerotomal pain referral regions from ligaments:
(A) Iliolumbar ligament
(B) sacrospinous and sacrotuberous ligaments.
(C) posterior sacroiliac ligament.

(Kuchera,2007, Journal of American Osteopathic Association, ES31, Suppl6,107,11)

 Examination
 Positional tests
 Motion tests
 Passive mobility
tests
 Pain provocation
tests
 Palpation
EXAMINATION SEQUENCE

1. Observation
2. Temperature
3. Skin topography and texture
4. Fascia
5. Muscle
6. Tendon
7. Ligament
8. Erythema friction rub
 Visual observation of
patient
Prior to touching the patient, the examiner should visualize the area to be examined
for evidence of trauma, infection, anomalies, Gross asymmetries, skin
lésions,and/or anatomic variations.
 Temperature

Temperature is evaluated by using the volar aspect of the wrist or

the dorsal hypothenar eminence of the hand.
 Skin Structure and Texture

 A very light touch will be used.

Gentle palpation with the palmar surface of the tips of the fingers will
provide the necessary pressure.
The pressure will permit the finger pads to glide gently over the skin
without drag (friction).
Skin Structure and texture are evaluated for increased
or decreased humidity, oiliness, thickening, roughness.
 Fascia
 Apply the enough pressure to
move the skin the hand to
with
evaluate the fascia.
 The examiner moves the hand very
gently in left, right, clockwise, and
anti clockwise directions to elicit
motion and tension quality barriers of
ease and bind .
 Minimal changes in pressure to
evaluate the different levels of fascia
are helpful.
 Muscles

• Muscle is deeper tissue; therefore, the next degree of palpatory

pressure is applied.
• The examiner adds slightly more pressure to evaluate the muscle's
consistency and determines there is resistance to pressure.
LIGAMENTS
• Ligaments must be considered when restriction of joint
motion, hypermobility (joint laxity), pain.

Tenderness
L5-S1 –
yellow
Lumbar –
black SI
joint - blue
 Erythema Friction Rub
• The final step is to perform the erythema friction rub, in which the pads of the examiner second and
third digits are placed just paraspinal and then in two to three quick strokes drawn down the spine
cephalad to caudal.
• Pallor or reddening is evaluated per spinal segment for vasomotor changes that may be secondary to
dysfunction.
• This is not typically done on the extremities, as the purpose of this test is to identify central spinal
areas of autonomic change related to segmental dysfunction
 Diagnose the Sacrum
• Sitting Flexion Test (SFT)
• Sacral Sulcus (SS)
• Inferior Lateral Angle (ILA)
• Spring Test (ST)
 Seated Flexion Test
• The patient is seated on a stool or treatment table with both feet flat on
the floor a shoulder-width apart.

• The examiner stands or kneel down behind the patient with the eyes at the
level of the patient's PSISs.

• The examiner’s thumbs are placed on the inferior aspect of the patient's
PSISs and a firm pressure is directed on the PSISs, not skin or fascial
drag, to follow bony landmark motion . Hand placement on PSIS.

• The patient is instructed to forward-bend as far as possible within a pain-

free range.

Forward bending.
 Cont…
• The test is positive on the side where the thumb (PSIS) moves more at the end
range of motion.

Positive seated flexion test

 Sacral Sulcus
• Palpable groove just Depth
medial to PSIS.
• Space between sacral spines and lateral sacral
crest.
• Place thumbs in inferior border of PSIS.
• Move ½ to 1” up and medial to PSIS.
• Push thumb tips on sacral base.
• Pads of thumbs are on ilium and tips on sacral
base.
Measure the depth of each sacral
sulcus relative to opposite
sulcus? Record even, deep,
or shallow, comparing one
side to the other.
Both sides may be shallow
or deep as well.
 Spring Test
 Also known as sacral compression test, downwards pressure test , sacral thrust test
 Spring Test + ev = Extension dysfunction

Technique:
 With the patient prone, the examiner
applies an anteriorly directed pressure
over the sacrum. One hand is placed
directly on the sacrum and is being
reinforced by the other hand.
 Purpose is to apply an anterior shear
force to both sacroiliac joints since the ilia
are fixed by the examination bench.
 The test is positive if pain is reproduced in
the sacroiliac region

Laslett et al (2005)
PROVOCATIO
N TESTS
 FABERS test
 The patient is positioned in supine, hip flexed and
abducted with the lateral ankle resting on the
contralateral thigh proximal to the knee.
 While stabilizing the opposite side of the pelvis at the
ASIS, an external rotation, abduction and posterior force
is then lightly applied to the ipsilateral knee until the end
range of motion is achieved.
 A further few small-amplitude oscillations can be applied
to check for pain provocation at the end range of motion.
 A positive test is one that reproduces the patient's pain or
limits their range of movement
 Sacroiliac stress test

 The patient lies supine. The examiner applies a

vertically orientated, posteriorly directed force to
both the anterior superior iliac spines (ASIS)
 A test is positive if it reproduces the patient's
symptoms.
 This indicates SIJ dysfunction or a sprain of the
anterior sacroiliac ligaments
Cook and Hegedus (2013)
 Laguerre test
Procedure:
• Patient in supine, examiner flexes, abducts & laterally
rotates the patients affected leg . Applies gentle pressure
at the end range of motion.
Interpretation:
Positive Laguerre’s Test
• Ipsilateral sacroiliac pain:
Sacroiliac joint pathology (ligamentous
sprain, instability, sacroiliitis)
• Hip pain: Hip joint pathology (arthritis,
ligament sprain, rule out hip fracture and
infection)
 Gillet test
 The examiner palpates the inferior aspect of the PSIS of the
tested side with one hand and the S2 spinous process with the
other.
 The patient flexes the hip at 90 degrees.
 The examinershould feel the PSIS move inferiorly
and laterally relative to the sacrum.
 A positive test is when this motion is absent.
 The examiner should then compare this to the opposite
side.
 An alternate method for this test is to palpate both PSIS's
at the same time and compare the end position.

Meijne w et al.,2012
 Yeoman's test
 The patient is prone with the knee flexed 90°.

 The examiner raises the flexed leg off the examining table, hyperextending the hip.

 This test places stress on the posterior structures and anterior sacroiliac ligaments. Pain
suggests a positive test
 Respiratory motion
test
• With the patient prone, the examiner hand rest gently on the sacrum with fingertip at
the sacral base and palm at coccyx
• Ask the patient to take the deep breath and follow the sacrum into anatomical
extension with inhalation and anatomical flexion with exhalation.
• Restriction of sacral extension indicates flexion ease
• Restriction of sacral flexion indicates extension ease
 MANAGEMEN
T
• Soft Tissue Techniques
• Myofascial Release Techniques
• Counterstrain Techniques
• Muscle Energy Techniques
• High-Velocity, Low-Amplitude Techniques
• Facilitated Positional Release Techniques
 Soft Tissue
Soft tissue techniqueTechniques
is defined by the Education Council on Osteopathic
Principles (ECOP) as,
"a direct technique, which usually involves lateral stretching, linear
stretching, deep pressure, traction, and/or separation of muscle origin and
insertion while monitoring tissue response and motion changes by palpation;
also called Myofascial technique"
 Prone Pressure
[Link] patient is prone, with the head turned toward the physician.

2. The physician stands at the side of the table opposite the side to be treated

[Link] physician places the thumb and thinner eminence of one hand on the
medial aspect of the patient's lumbar paravertebral musculature overlying the
transverse processes on the side opposite the physician
[Link] physician places the thinner eminence of the other hand on the abducted
thumb of the bottom hand.
[Link] the elbows straight and using body weight, the physician exerts a
gentle force ventrally to engage the soft tissues and laterally perpendicular to the
lumbar paravertebral musculature.
[Link] force is held for several seconds and is slowly released.

[Link] 5 and 6 can be repeated several times in a gentle, rhythmic, and

kneading fashion.

[Link] physician's hands are repositioned to contact different levels of the

lumbar spine, and steps 5 to 7 are performed to stretch various portions of
the lumbar paravertebral musculature.

[Link] technique may also be performed using deep, sustained pressure.

[Link] tension is reevaluated to assess the effectiveness of the

technique.
 Prone Traction
[Link] patient is prone with the head turned toward the physician.
(If the table has a face hole, keep the head in neutral.)
[Link] physician stands at the side of the table at the level of the
patient's pelvis.
[Link] heel of the physician's cephalad hand is placed over the
base of the patient's sacrum with the fingers pointing toward the
coccyx
4. The physician does one or both of the following:
a) The physician's caudad hand is placed over the lumbar
spinous processes with the fingers pointing cephalad,
contacting the paravertebral soft tissues with the thinner and
hypothenar eminences
b) The hand may be placed to one side of the spine, contacting
the paravertebral soft tissues on the far side of the lumbar
spine with the thinner eminence or the near side with the
hypothenar eminence.
 Cont…
[Link] physician exerts a gentle force with both hands ventrally
to engage the soft tissues and to create a separation and
distraction effect in the direction the fingers of each hand are
pointing . Do not push directly down on the spinous processes.
[Link] technique may be applied in a gentle, rhythmic, and
kneading fashion using deep, sustained pressure.
[Link] physician's caudad hand is repositioned at other levels of
the lumbar spine and steps 4 to 6 are repeated.
[Link] tension is reevaluated to assess the effectiveness of the
technique.
 Bilateral Thumb Pressure, Prone
1. Patient and therapist/physician position same as before technique
2. The physician's thumbs are placed on both sides of the spine,
contacting the paravertebral muscles overlying the transverse
processes of LS with the fingers fanned out laterally
3. The physician's thumbs exert a gentle force ventrally to engage the
soft tissues cephalad, and laterally until the barrier or limit of tissue
motion is reached .
4. This stretch is held for several seconds, is slowly released, and is then
repeated in a gentle, rhythmic, and kneading fashion.
5. The physician's thumbs are repositioned over the transverse processes
of each lumbar segment (L4, L3, L2, then L1) and steps 4 and S are
repeated to stretch the various portions of the lumbar paravertebral
musculature.
6. This technique may also be performed using deep, sustained pressure.
7. Tissue tension is reevaluated to assess the effectiveness of the
technique.
 Prone Pressure with Counter leverage
 The physician places the thumb and thinner eminences of the cephalad hand on the
medial aspect of the paravertebral muscles overlying the lumbar transverse
processes on the side opposite the physician.
 The physician's caudad hand contacts the patient's anterior superior iliac spine on
the side to be treated and gently lifts toward the ceiling
 To engage the soft tissues, the physician's cephalad hand exerts a gentle force
ventrally and laterally, perpendicular to the lumbar paravertebral musculature
 This force is held for several seconds and is slowly released.
 Steps 4 to 6 are repeated several times in a slow, rhythmic, and kneading
fashion.
 The physician's cephalad hand is then repositioned to contact different levels of the
lumbar spine and steps 4 to 6 are performed to stretch various portions of the
lumbar paravertebral musculature.
 This technique may also be performed using deep, sustained pressure.
 Tissue tension is reevaluated to assess the effectiveness of the technique.
 Lateral Recumbent
 The patient lies in the Position
lateral recumbent position with the treatment
side up.
 The physician stands at the side of the table, facing the front of the
patient.

 The patient's knees and hips are flexed, and the physician's thigh is
placed against the patient's infrapatellar region.

 The physician reaches over the patient's back and places the pads of
the fingers on the medial aspect of the patient's paravertebral
muscles overlying the lumbar transverse processes

 To engage the soft tissues, the physician exerts a gentle force

ventrally and laterally to create a perpendicular stretch of the
lumbar paravertebral musculature
 While the physician's thigh against the patient's knees may simply
be used for bracing, it may also be flexed to provide a combined
bowstring and longitudinal traction force on the paravertebral
musculature. This technique may be applied in a gentle rhythmic
and kneading fashion or with deep, sustained pressure

 This technique may be modified by bracing the anterior superior

iliac spine with the caudad hand while drawing the paravertebral
muscles ventrally with the cephalad hand

 The physician's hands are repositioned to contact different levels of

the lumbar spine and steps 4 to 6 are performed to stretch various
portions of the lumbar paravertebral musculature.

 Tissue tension is reevaluated to assess the effectiveness of the

technique
 Supine
Extension
 The patient is supine. (The patient's hips and knees may be flexed for
comfort.)The physician is seated at the side to be treated.

 The physician's hands (palms up) reach under the patient's lumbar spine,
with the pads of the physician's fingers on the patient's lumbar
paravertebral musculature between the spinous and transverse processes
on the side closest the physician

 To engage the soft tissues, the physician exerts a gentle ventral and
lateral force perpendicular to the thoracic paravertebral musculature. This
is facilitated by downward pressure through the elbows on the table,
creating a fulcrum to produce a ventral lever action at the wrists and
hands.
 Cont….
 The fingers are simultaneously drawn toward physician,
the
producing a lateral stretch perpendicular to the thoracic
paravertebral musculature.
 This stretch is held for several seconds and is slowly released.
 Steps 4 to 6 are repeated several times in a gentle, rhythmic, and kneading
fashion.
 The physician's hands are repositioned to contact the different levels of the
lumbar spine and steps 4 to 6 are performed to stretch various portions of
the lumbar paravertebral musculature.
 This technique may also be performed using deep,
sustained pressure.
 Tissue tension is reevaluated to assess the effectiveness of the
technique.
 MFR Techniques
 Ward describes Myofascial release technique as,
"designed to stretch and reflexly release patterned soft tissue and joint
related restrictions“
Myofascial Release is a safe and very effective hands-on technique that
involves applying gentle sustained pressure into the Myofascial
connective tissue restrictions to eliminate pain and restore motion. (John F.
Barnes)
 Bilateral Sacroiliac Joint with Forearm
Pressure, Supine
1. The patient lies supine and the physician sits at the side of
the patient at the level of the mid femur to knee.

[Link] physician asks the patient to bend the proximal knee so the
physician's cephalad hand can internally rotate the hip until the
pelvis comes off the table.

[Link] physician's other hand is placed palm up under the sacrum

[Link] returning the hip to neutral, the physician places the other
forearm and hand over the anterior superior iliac spines (ASIS)
of the patient's pelvis
[Link] physician leans down on the elbow of the arm that is
contacting the sacrum, keeping the sacral hand relaxed and with
the forearm monitors for ease-bind asymmetry in left and right
rotation and left and right torsion.

[Link] determining the presence of an ease-bind asymmetry, the

physician will either indirectly or directly meet the ease-bind
barrier, respectively.

7. The force is applied in a very gentle to moderate manner.

[Link] is held for 20 to 60 seconds or until a release is palpated

 Bilateral Sacroiliac
Joint with Forearm
Pressure, Prone
 The patient lies prone. The physician stands beside the patient.
 The physician places one hand over the inferior lumbar segment (e.g.,
L4-LS) and the other over the superior lumbar segment (e.g., LI-L2)
 The physician monitors inferior and superior glide, left and right rotation,
and clockwise and counterclockwise motion availability for ease-bind
asymmetry
 After determining the presence of an ease-bind asymmetry, the physician
will either indirectly or directly meet the ease-bind barrier, respectively.
 The force is applied in a very gentle to moderate manner. This is held for
20 to 60 seconds or until a release is palpated.
 Counterstrain Techniques
 Counterstrain technique was proposed by Lawrence H. Jones, DO, FAAO ( 1912-
1996).
 Jones initially believed that a patient could be placed in a position of comfort so as
to alleviate the symptoms. After noticing a dramatic clinical response, he studied
the nature of musculoskeletal dysfunctions and determined that tender points could
be elicited by prodding with the fingertip.
 The Educational Council on Osteopathic Principles (ECOP) has defined this technique
as,
"a system of diagnosis and treatment that considers the dysfunction to be a
continuing, inappropriate strain reflex, which is inhibited by applying a position of mild
strain in the direction exactly opposite to that of the reflex; this is accompanied by
specific directed positioning about the point of tenderness to achieve the desired
therapeutic response."
Posterior Lumbar Tender
Points
 PL1 to PL5
 Tender Point location: The tender point lies at the inferolateral
aspect of the spinous process or laterally on the transverse process of
the dysfunctional segment.
 Treatment Position:
[Link] patient lies prone and the physician, standing opposite the tender
point, grasps the patient's lower thigh or tibial tuberosity on the side of
the tender point.
[Link] physician extends the patient's thigh and hip until the dysfunctional
segment is engaged.
[Link] physician adducts the patient's leg and slightly externally rotates it
until the lower of the two segments involved in the dysfunction is
engaged fully
[Link] physician fine-tunes through small arcs of motion (hip flexion and
extension, external and internal rotation, and adduction and abduction).
 PL5, Lower Pole
Tender Point Location: The tender point lies at
PL5 lower pole 2 cm below the PSIS .
Treatment Position
 The patient lies prone, and the physician sits at
the side of the table on the side of the
tender point.
 The patient's lower extremity on the side of
the tender point hangs off the side of the
table with hip and knee flexed to 90 degrees.
 The physician internally rotates the patient's
hip and thigh, and the patient's knee is
adducted slightly under the table .
 The physician fine-tunes through small arcs of
motion (hip flexion and extension, internal and
external rotation, and knee adduction and
abduction).
 Muscle Energy Technique (MET)

 Muscle energy technique (MET) is a form of Osteopathic manipulative treatment

developed by Fred L .Mitchell , Sr. , DO (1909-1974).
 It is defined by the Education Council on Osteopathic Principles (ECOP) as,

"a system of diagnosis and treatment in which the patient voluntarily moves the
body as specifically directed by the physician; this directed patient action is from a
precisely controlled position, against a defined resistance by the physician"
 Correction of Forward
Sacral Torsion
• Lie axis side down
• Rotate trunk to right with right
arm off table
• Flex knees and hips to localize
forces at L/S junction
• Resist bottom heel lifting
toward ceiling
 Correction of Backward
Sacral Torsion
• Lie axis side down
• Extend lower leg to induce some sacral
flexion
• Flex upper hip so leg off table
• Extend trunk to L/S junction
• Rotate trunk left to L/S junction
• Resist lifting upper leg toward ceiling
 Correction of bilateral anterior
nutated sacrum

• Patient seated
• Feet apart and legs internally rotated
• Patient flexes forward
• ATC hands on sacral apex and thoracic
spine
• Maintain pressure on sacral apex (ILA’s)
and resist trunk extension with full
inhalation
 Correction of Bilateral
Posterior Nutated
Sacrum
• Patient seated
• Feet together and legs externally rotated
• Arms crossed
• One hands on sacral base and another across
anterior chest
• Maintain pressure on sacral base and resist
trunk flexion with full exhalation or have
patient arch back by pushing abdomen to
knees
 Correction of Unilateral
Anterior Sacral
• Patient prone Nutation
• Abduct (15°) and internally rotate left leg
• Right hand on left ILA
• Apply and maintain anterior and superior
pressure on left ILA as patient inhales and
holds breath
• Maintains pressure as patient exhales

Left Unilateral Anterior Nutation

 Right Unilateral
Correction of Unilateral Posterior Posterior Sacral Nutation
Sacral Nutation
• Patient prone
• Abduct (15°) and externally rotate right leg
• Trunk extended via prone on elbow
position
• ATC’s right hand on right sacral base
• Apply and maintain anterior and inferior
pressure with right hand as patient exhales
• ATC’s left hand applies posterior pressure
to right ASIS
• After exhalation, patient pulls ASIS toward
table
• Return to prone lying position while
maintaining pressure
 Referances
• Cohen, S.P. (2005). Sacroiliac Joint Pain: A Comprehensive Review of
Anatomy, Diagnosis, and Treatment. Anesthesia & Analgesia, 101,
1440-53.
• Atlas of osteopathic technique, Alexander S. Nicholas, DO,FAAO,
Evan
S. Nicholas, DO.
• Issacs ER, Bookhout MR. Bourdillon’s Spinal Manipulation (6th Ed.).
Butterworth-Heinemann:Boston, 2002
• Foundations of osteopathic medicine(3rd Ed.),Anthony Chila.