Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
O S T E O PAT H I C M E D I C I N E
1. Introduction
Due to our sedentary lifestyle most joints are no longer used to their
maximum capacity. How often do we sit in postures such as cross-legged
or slumped sitting positions? We maintain middle range postures with the
consequence that soft tissues around many joints then lose their normal
elasticity and become fibrotic.
Classic pathology describes conditions of the lumbar spine in great detail but has neglected the pelvic complex (sacrum and both iliac bones). Attention is only given to the motions of nutation and contra-nutation during
pregnancy and labour.
In case of pathology of the lower back it seems that lower back pain is
nearly always blamed on the disc. While the importance of a disc hernia is
not disputed, it should not be over-exaggerated. Pre-operative anaesthe2
sia is often sufficient to render the patient pain free! There must be other
factors at play.
When mobility testing a joint it should be remembered that between immobility and normal mobility there is a plethora of possibilities. A joint could
have lost just 20% of normal mobility and is therefore, directly or indirectly,
needing treatment.
In osteopathy it is thought that the sacroiliac joint (SI) consists of both
iliosacral (the lower extremity is the lever) and sacroiliac motion (the spine
is the lever). In case of iliosacral motion, the iliac bone moves relative to
the sacrum while sacroiliac motion involves the sacrum moving between
the two iliac bones.
In the sacroiliac joint two long levers (spine and leg) meet, creating significant mechanical stress.
Although there is some overlap, this e-book concerns examination and
treatment of the iliosacral motion with the lower extremity as the lever.
The sacroiliac motion is described in the e-book The Sacroiliac Joint.
For those who are not familiar with the typical osteopathic terminology,
we refer to chapter 8 at the end of this e-book.
2. Biomechanics
2.1. General
The sacroiliac joint is the largest axial joint in the body, with an average
surface area of 17.5 cm2. There is wide variability in the adult SI joint, encompassing size, shape, and surface contour. Large disparities may even
exist within the same individual.
The SI joint is most often characterized as a large, auricular-shaped, diarthrodial synovial joint. In reality, only the anterior 1/3 and the inferior part
of the interface between the sacrum and iliac bones are true synovial
joints, the rest of the junction is comprised of an intricate set of ligamentous connections.
As we age the characteristics of the sacroiliac joint change. The joint's
surfaces are flat or planar in early life and as we start walking the sacroiliac joint surfaces develop distinct angular orientations. Structure follows
function.
They also develop an elevated ridge along the ilial surface and a depression along the sacral surface ridge and corresponding depression,
along with the very strong ligaments, increase the sacroiliac joints' stability
and makes real dislocations very rare (Walker 1986).
The major function of the SI joints is providing stability of the pelvis. More about this function is described in the e-book The Sacroiliac Joint.
There have been different attempts to discern the biomechanics of the
SI joints.
There is consensus about:
The SI joint rotates in the 3 planes.
The movements are small and difficult to measure. Vleeming et al
found that the total range of motion during flexion and extension at the SI
joint rarely exceeded 2 degrees, with 4 degrees being the upper limit during sagittal rotation. During walking this amplitude is larger.
5
There are differences whether there is load on one or two legs and
this supports the differentiation between iliosacral (lever is lower extremity)
and sacroiliac (lever is spine both legs fixed to the ground in standing)
movements. Researchers found that with 1 leg immobile, movements in all
planes ranged from between 2 to 7.8 times more than that measured with
both legs fixed. This means that the iliosacral movements are more ample
than the sacroiliac movements.
Note concerning mobility in the SI joints:
No differences in mobility were found between symptomatic and
asymptomatic joints, leading the authors to conclude that 3-dimensional
motion analysis was not useful for identifying painful SI joints in most patients.
Low back pain however is often caused by mechanical strain of soft tissues and the SI joints play an important role in the pelvic and low lumbar
mechanics. Therefore testing mobility and treating mobility of the SI joints
is important to reduce mechanical strain in the complex pelvic and low lumbar region.
In this e-book the focus is on the mobility of the iliac bone versus the sacrum. In this context the lever of mobility is the lower extremity.
Figure 1 - Anterior and posterior rotation of the iliac bone around the ITA
Figure 4 - Iliac bone in external rotation
Figure 6 - Iliac bone in in-flare
10
11
Figure 10 - Iliac bone in anterior rotation
12
Because of the obliqueness of the orientation of the SI joint surface, there mostly occurs a movement, which is a combination in the three planes.
Figure 13 (left) - The iliac bone rotates anterior, in out-flare, in internal rotation
Figure 14 (right) - The iliac bone rotates posterior, in in-flare, in external rotation
When the iliac bone rotates anterior in out-flare and internal rotation,
the pubic branch on the same side will descend and rotate anteriorly.
When the iliac bone rotates posterior in in-flare and external rotation,
the pubic branch on the same side will ascend and rotate posteriorly.
13
14
Figure 15 - Sacrum in weight bearing (redrawn from Vleeming)
On the cephalic side of S3 (on the iliac bone) there is an ilial ridge. This
prevents S3 to move cranially.
15
After load bearing, the gravity line is anterior to the sacral axis. The gravity line stays posterior to the acetabula causing a general posterior pelvic
tilt and creating a dynamic, balanced tension on the pelvic ligaments. The
posterior pelvic tilt decreases the lumbar lordosis.
As long as the gravity line falls between the ITA and the acetabula, there is a balance in the pelvic in the sagittal plane: the sacrum tilts anteriorly
and the iliac bones counteract in posterior rotation.
Some authors state that this posterior rotation is around the IFA, other
authors state that this occurs around the acetabula.
16
Figure 18 - Oblique view of some forces involved in pelvic stability and the selfbracing mechanism
17
and coccygeus gluteus maximus (ilial part) Hamstrings on the posterior side is necessary.
The iliacus and coccygeus muscles rotate the iliac bone anteriorly, the
gluteus maximus (ilial part) and the hamstrings rotate the iliac bone posteriorly.
Figure 19 - Ligamentous stability and muscular balance of the pelvis in the sagittal
plane
18
Figure 20 - Muscular balance of the unilateral iliac bone
To have an optimal functioning pelvic girdle that spreads tension equally over the joints and capsular-ligamentous structures, the correct locking
mechanism (self-bracing) must be in place. Therefore the condition of the
posterior SI capsule and sacrospinous- and tuberous ligaments must be
optimal.
There is also a need for an effective functioning of the muscular system
that maintains the self-bracing mechanism.
Three muscle slings (chains) are supposed to contribute to force
closure of the SI joints:
A longitudinal muscle sling.
A posterior oblique muscle sling.
An anterior oblique muscle sling.
19
20
Figure 21 - Longitudinal muscle sling
21
Figure 22 - Posterior oblique sling
The anterior oblique sling consists of the external and internal oblique
muscles as well as of the transverse abdominis muscle (connection via rectus sheet).
Muscle contraction of this sling also increases the SI stabilization (selfbracing mechanism).
22
Figure 23 - Anterior oblique sling
For example sitting with the legs crossed reduces strongly the tone of
the anterior oblique sling. This is because sitting with crossed legs increases mechanically the SI compression and friction. Reducing this muscle
tone diminishes this compression and friction.
The iliolumbar ligaments
The iliolumbar ligaments also play an important role in the stability of
the SI joint.
Their action compresses the SI joint.
Goudzwaard et al (2003) found that following severing of the iliolumbar ligaments the range of motion of the iliosacral joint was significantly
higher. According to that study the anterior part of the ligament provides
the strongest influence upon this mobility. They suggested that it is highly
likely that surgical severing of this ligament during lumbosacral surgery
could explain post-operative symptoms and instability.
23
Figure 24 - The iliolumbar ligaments compress the SI joints
This means that when L5 goes in flexion, stretch comes upon the iliolumbar ligaments thus compressing the SI joints even more. Loss of mobility in the SI joints can depend on the tension in these ligaments.
In a case of anterolysthesis, of L5, the vertebra glides anteriorly thus
stretching the iliolumbar ligaments and compressing the SI joints.
24
25
26
Figure 27 - Sacrum and ilial mechanics in walking
27
Figure 28 - Sacrum mechanics in walking left and right oblique axis
28
(Brenard & Cassidy 1991, DeCamp 1990, Peeters & Lason 2005)
Lesion means that there is a loss of mobility.
Dysfunction of the SI joints can cause complaints. Dysfunctions can be
due to hypermobility or hypomobility.
29
3.1.1.1. General
Iliosacral lesion (loss of mobility of the iliac bone versus the sacrum)
are mostly fixed in three dimensions. This is due to the three-dimensional
position of the joint surfaces.
However in many cases we can see that there is dominance in the direction of the mobility loss. The different lesions are named after the dominance in mobility loss although also the other dimensions play a secondary role.
The importance of this differentiation of dominance lies in the correction
techniques.
Osteopaths treat the shortened capsuloligamentous structures by stretching them with short or long lever techniques. They also treat the muscular balance in the plane of the dominance.
Planes of dominance:
Ilium anterior and posterior lesions: sagital plane.
Ilium out-flare and in-flare lesions: frontal plane.
Ilium lesions in external and internal rotations: horizontal plane.
When the tendency of the lesion is more posterior, in-flare, external rotation mostly there is an upslip involved (superior translation of the iliac bone).
30
The iliac bone is fixed in anterior rotation versus the sacrum around the
inferior transverse axis (ITA).
Posterior rotation of the iliac bone versus the sacrum is not possible
any more.
31
The iliac bone is fixed in posterior rotation versus the sacrum around
the inferior transverse axis (ITA).
Anterior rotation of the iliac bone relative to the sacrum is not possible
any more.
The iliac bone is fixed in out-flare versus the sacrum around the anteroposterior axis.
In-flare of the iliac bone versus the sacrum is not possible any more.
The iliac bone is fixed in in-flare versus the sacrum around the anteroposterior axis.
Out-flare of the iliac bone versus the sacrum is not possible any more.
34
The iliac bone is fixed in internal rotation versus the sacrum around the
craniocaudal axis.
External rotation of the iliac bone versus the sacrum is not possible any
more.
The iliac bone is fixed in external rotation versus the sacrum around the
craniocaudal axis.
Internal rotation of the iliac bone versus the sacrum is not possible any
more.
36
37
Stepping in a hole while running or coming down the stairs and missing
the last step, can cause a traumatic ilium anterior lesion. The iliac bone
blocks in anterior rotation versus the sacrum.
The reason therefore is that the patients proprioception doesnt expect
the floor to be that deep and the iliac muscle overstretches and brings the
iliac bone into anterior rotation too far.
A caudal translation mostly accompanies the ilium anterior lesion and in
a prone position, the leg is apparently longer.
38
Figure 36 - Apparent long leg
In normal standing the body weight (gravity line) falls anterior of the SI
joint and posterior of the acetabula.
The body load on the sacral promontory tilts the sacrum in an anterior
rotation.
The body load on the acetabula tilts the pelvis posteriorly thus bringing
the iliac bones in posterior rotation versus the sacrum.
When we lean forward, the line of gravity moves anterior to the hips
and the iliac bones will rotate anteriorly on an acetabular axis. This will loosen the sacrospinous- and sacrotuberous ligaments. The force dependant
axis of rotation is lost and the iliac bones will subluxate in a cephalic and
lateral direction relative to the sacrum (anterior rotation of the Iliac bone).
The lesion ilium anterior is created.
When a person stands, the body weight already brings the iliac bones
into posterior rotation.
If a sudden body rotation is added, the iliac bone can block in posterior
rotation.
40
Figure 39 - Traumatic ilium posterior lesion
42
Figure 43 - Anterolysthesis L5
43
44
Sacral lesions as discussed in the e-book The Sacroiliac Joint are lesions versus both iliac bones and versus L5. These lesions occur around different axis.
Although the sacroiliac part of the lesion is dominant, also the iliosacral
part will show lesions.
These secondary iliosacral lesions normally disappear when the sacroiliac lesions are corrected.
45
These type of lesions are called ascending chains. This means that
the primary lesion is in the foot and the consequence in the pelvic region.
Ascending chains, starting in the foot and causing a posterior rotated iliac bone can find their origin in three types of lesions, both mostly caused
by an inversion trauma.
46
Type I:
The patient makes an inversion trauma through which the subtalar
joint (between calcaneus and talus bone) blocks in a postero-external lesion. The talus blocks in a postero-external direction versus the calcaneus.
The lateral ligaments are overstretched and keep the fibula in a caudal position.
This caudal traction on the fibula also keeps the head of the fibula in a
caudal position and the attachment of the biceps femoris muscle can
cause a stretch on the biceps femoris muscle which keeps the iliac bone in
a posterior rotated position by pulling on the ischial tuberosity.
47
Figure 48 - Ascending chain
48
Type II:
The patient jumps in the air with the foot in inversion.
He comes down to the floor with the foot still in inversion.
This trauma causes an impaction lesion of the tibiatalar joint with external rotation of the talus within the fork tibia-fibula.
The impaction lesion with external rotation of the talus keeps the fibula
mechanically in an inferior position.
The malleoli are spread by the impaction of the talus as it ascends.
49
Type III:
The patient does an inversion trauma and blocks the cuboid bone in
external rotation. This type of lesion is rather seldom.
The rotated cuboid bone overstretches the peronei muscles.
The overstretched peronei muscles keep the fibula in a caudal position.
The same type of ascending chain occurs with an ilium posterior lesion.
50
3.2.1. General
The sacroiliac joint is a source of pain in the lower back and buttocks in
approximately 15% of the population (Dreyfuss 2004). Rarely pain above
L5 is reported.
The innervation of the sacroiliac joint is not clear.
Different experts claim different segments:
Dorsal joint:
Dorsal rami L4-S3.
L3 and S4.
Ventral joint:
L2-S2.
L4-S2.
L5-S2.
Each time ventral rami.
Pain sensitivity of the SI joints is much lower than the lumbar facet
joints but higher than the anterior portion of the lumbar discs.
Although it is widely acknowledged that dysfunctional SI joints may
cause low back pain, the prevalence of this condition has not been well studied.
The causes of sacroiliac pain can be divided into intra-articular and extraarticular sources. Arthritis and infection are two examples of intra-articu51
lar causes of SI joint pain. Extra-articular sources are the more common of
the two and include enthesopathy, fractures, ligamentous injury, and myofascial pain. Clinical studies have demonstrated significant pain relief after
both intraarticular and periarticular SI joint injections.
The osteopath starts his or her investigation with an anamnesis or case
history.
In the case history, the osteopath tries to identify the nature of the
pain:
Aching pain can be ligamentous, especially when occurring in the morning and associated with stiffness. Also when it occurs after a longer period of immobilisation (sitting or standing).
Sharp pain on specific movements can be caused by muscle strain or
inflammation.
Fatigue can be caused by bad posture and poor muscular balance.
Sharp pain when coughing often directs towards inflammation.
Irradiating pain indicates a neurogenic factor, can be radicular or pseudo radicular.
Numbness or muscle weakness indicates severe radicular inflammation, often with hernia compression on the nerve root.
Vague, sometimes irradiating pain in the legs during exercise can indicate an ischemic neuralgia.
Are there visceral signs associated with the pelvic pain?
Nocturnal pain often indicates cancer.
The type of patient (child, adult, elderly, pregnant, peri-menopausal
woman) can give information to the osteopath.
The onset of pelvic pain is important. Was there a trauma? Was the onset sudden or progressively worsening?
Where there recent infections?
52
53
Figure 51 - Pathways SI joint neural structures
54
As a consequence of an anterior rotated iliac lesion, the gluteus maximus muscle may be disrupted between the ilial and sacral part at the level
of the muscle origin.
The muscular fibres separate on a line from the conjoint origin towards
the great trochanter.
This may even produce a trochanteric bursitis and pain down the iliotibial tract towards the lateral aspect of the knee.
This should not be confused with pain originating from the piriformis
muscle. Differentiation is done by palpation (the piriformis muscle lies more caudal).
The ilial and sacral portion of the gluteus maximus muscle have different functions. In standing on one leg during walking, the gluteus maximus
muscle pulls the iliac bone towards posterior. The sacral portion however
is stretched because of the anterior rotation of S1 on the same side. This
sacral portion then contracts isolytically while the ilial portion contracts isometrically.
With muscular separation of the gluteus maximus muscle, the line
between the ilial and sacral portion of the muscle is painful.
After osteopathic treatment, where the aim is to restore normal function
of the whole pelvis, rest is absolutely necessary to let the separation heal.
55
Figure 52 - Separation line gluteus maximus m.
Caused by an anterior rotated iliac lesion, on the anterior side separation of the small sacral part of the origin of the ilacus muscle may occur.
This is called enthesopathy.
Pain on hip flexion is then noticed.
Anterior synovial leakage may also cause this hip flexion pain.
Note on enthesopathy:
Enthesopathy is a condition that affects the entheses (e.g. inflammation of the entheses). The entheses are sites of tendinous or ligamentous
attachment to the bone. Enthesopathy may be due to an inflammatory condition or to a constant or abrupt pull on muscle or ligamentous attachment.
Most obvious in the case history is a sudden sharp and local pain after
an extreme movement.
56
59
An anterior rotated iliac bone can cause stretch of the biceps femoris
muscle since the extension of the muscle is the sacrotuberous ligament
that stretches cranially.
Tendonitis of the muscle may occur at the level of the tuber or at the level of the fibular head.
It may also subluxate the fibular head in a cranial and posterior direction. This stress may continue caudally and cause symptoms in the peroneal muscles.
This pull on the peronei muscles will rotate the cuboid bone internally
thus creating a collapse downwards of the joint between cuboid and navicular, thus creating a flatfoot.
60
When there is a change in the relationship between the SI joint and the
acetabula, an apparent leg length difference can occur. Heel lifts are no solution here.
61
The long dorsal sacroiliac ligament lies between the PSIS (postero superior iliac spine) and sacrum (lateral S3, S4) and the ischial tuberosity.
It has strong anatomical connections with the erector spinae, the thoracolumbar fascia, the gluteus maximus muscle, the sacrotuberous ligament
and the SI capsule.
Pain can be found just below the PSIS.
Functionally the ligament works opposite to the sacrotuberous ligament.
Anterior rotation of the sacrum decreases the tension on the long dorsal
sacroiliac ligament. This is in contrast to the tension that increases on the
sacrotuberous ligament.
Posterior rotation of the sacrum leads to the opposite, more tension in
the long dorsal sacroiliac ligament.
Traction on the biceps femoris muscle hardly provokes tension in the
long dorsal sacroiliac ligament but strong tension in the sacrotuberous ligament.
62
Figure 58 - Long dorsal sacroiliac ligament
After vaginal delivery it regularly happens that not only the pubic symphysis opens too far but also that the anterior part of the SI joint opens
and overstretches (or tears) the anterior capsule.
Extreme abduction with the hip in sports injuries can also cause this SI
joint opening on one side.
63
This condition can be seen in elderly people and presents with severe
difficulty in walking and groin pain.
The condition is seldom seen but is always associated with severe osteoarthritis.
This condition is a contraindication for manipulation. Only surgery will
help.
64
3.2.2.13. Osteoarthritis
Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After 55 years of age, it occurs more frequently in females.
Primary osteoarthritis is mostly related to aging. With aging, the water
content of the cartilage decreases, and the protein makeup of cartilage degenerates.
The cartilage begins to degenerate by forming tiny crevasses.
In advanced cases, there is a total loss of cartilage cushion between
the bones of the joints.
Repetitive use of the worn joints over the years can irritate and inflame
the cartilage, causing joint pain and swelling.
Loss of the cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility.
65
3.2.2.14. Sacroiliitis
(OShea et al 2010)
Sacroiliitis describes inflammation in the sacroiliac joint.
Sacroiliitis is often found as a part of inflammatory conditions of the spine. As a group, these conditions are called spondyloarthropathy and they
include conditions such as ankylosing spondylitis, psoriatic arthritis and reactive arthritis amongst others.
Sacroiliitis may also be a component of other types of arthritis, such as
ulcerative colitis, Crohns disease or osteoarthritis.
Sacroiliitis may also be caused by sacroiliac dysfunction.
The most common symptoms of sacroiliitis are fever, low back pain, hip
pain, buttock pain, stiffness in hips and back, especially after prolonged sitting or in the morning.
68
Figure 64 - Reactive bilateral arthritis
69
Symptoms:
Intermittent low back pain, usually most severe in the morning or after
a period of inactivity.
Stiffness and limited motion of the sacroiliac joints and the lumbar spine.
Pain and limited expansion of the chest due to involvement of the costovertebral joints.
Peripheral arthritis involving shoulders, hips and knees.
Mild fatigue, fever, anorexia, or weight loss.
Occasional iritis.
Aortic regurgitation and cardiomegaly are possible.
Bechterews disease often starts with a complaint related to the SI joints
(most bilaterally). These joints will progressively ankylose (fuse) after a longer period of arthritis.
The further evolution is the calcification of the intervertebral capsules,
resulting in a bamboo spine.
70
Figure 66 - SI ankylosis
71
4. Examination
72
The osteopath puts both hands on the medial side of the ASIS and provokes in a lateral direction. This way the posterior side of the SI joint is under compression.
The test is first done with light pressure and continued by provocative
pressure.
The osteopath puts both hands on the lateral side of the ASIS and provokes in a medial direction. This way the anterior side of the SI joint is under compression.
The test is first done with light pressure and continued by provocative
pressure.
74
The leg of the patient is bent, the foot against the medial side of the
knee and the leg supported against the thigh of the osteopath. This way
the femur is put in the direction of the SI joint.
The osteopath fixes the opposite Iliac bone and compresses along the
femur in the direction of the SI joint.
The test is first done with light pressure and continued by provocative
pressure.
Some body weight must be used in this compression test.
75
The foot of the SI joint is the caudal part of the joint where the most
compressive forces occur.
The patient is in sidelying with the superior leg bended, the knee on the
table and the pelvis oblique on the table to bring the articular surface of
the SI joint parallel to the table.
The osteopath stands on the backside of the patient and contacts with
his pisiform the PIIS without compressing the muscles excessively.
The other hand supports this position.
The osteopath gives compression in the foot of the SI joint, perpendicular to the table.
The test is first done with light pressure and continued by provocative
pressure.
Some body weight must be used in this compression test.
This test is very reliable but care must be taken as the local soft tissue
can also cause pain.
76
77
78
79
Video 8 - Lateral view of the SFT
80
Video 9 - Dorsal view of the SitFT
81
82
Video 12 - Rucklauf test lateral view
83
84
Video 14 - In-flare test lateral view
85
86
Video 16 - Out-flare test lateral view
87
Shortening test (ST): hip motion: extension - abduction - internal rotation: the internal rotation is maintained.
The ilium rotates posteriorly causing the leg to apparently shorten.
This test is used to identify an anterior fixation.
88
Video 18 - Shortening test ST
89
90
91
92
The pain from the provocation should not be confused with pain that is
due to entrapment of the dorsal ramus L1 or L2 nerve roots (Figure 69).
These nerves cross the iliac crest approximately 7 cm from the middle line
and run through a osteofibrous opening where entrapment is possible.
Maigne et al (1991) first discovered these entrapment locations.
93
Figure 69 - Palpation in case of nerve entrapment
94
5. Techniques
Disclaimer
The techniques in this e-book are exclusively meant for academically
trained osteopaths who know their capacities and limits and who know
when a patient should be refered to another qualified health professional.
The authors are not responsible for the wrong use of the techniques
described and explained in this e-book.
95
5.1. Mobilisations
(Kutchera 1996, 2001, Maitland 2001)
5.1.1. General
The aim of a mobilisation is:
Correction of the false axis in the joint by stretching retractions in the
capsule and surrounding ligaments. This is done with enough specificity
so that it is appropriate even in a joint that is hypermobile in other directions. In this way the biomechanical quality of the joint can be repaired and
the overstretched soft tissues can relax.
Via rhythmical mobilisations and use of long lever techniques a drainage of all soft tissues around the joint will occur. Local to the false axis (shortened structures) a congestion of all tissue will still occur.
The mobilisation is done in a pain free and rhythmical manner. The
aim is to normalise any hyperactivity of the sympathetic system in the surrounding tissues. Pain will increase this sympathetic activity further.
Via rhythmical compression/traction the synovial production is stimulated which is a desirable reaction when treating arthrotic joints. This is also
the reason why mobilisations of an arthritic joint are not suggested.
Range of motion increase is not necessarily the primary aim of mobilisation. It can even be relatively contraindicated so as not to cause instability (especially of concern in arthrotic joints).
The mobilisation must be pain free so as to avoid further increasing
sympathetic activity further which is contradictory to the aim.
The mobilisation must occur on the end of range so that a light tension
is maintained in the tissues being treated.
96
97
The patient is supine with the legs straight on the table. The osteopath
sits facing the patient on the side to be mobilised.
The knee and hip are flexed and the knee is held with the hand.
While adducting the hip, the osteopath places the fingers of the other
hand posterior to the sacroiliac joint with the fingertips in the sacroiliac
joint space against the sacrum, the palmar surface of the fingers contact
the PSIS.
While the osteopath fixes the sacrum ventrally with the fingertips, the
leg is mobilised in a combined flexion-external rotation-abduction circumduction. The osteopath mobilises using his bodyweight.
The palmar surface of the fingers palpates the ilium (PSIS), to ensure
that it is being mobilised in a posterior/medial direction.
98
The osteopath hooks onto the PSIS with the fingertips and mobilises
the hip in a combined extension-internal rotation-adduction circumduction
while simultaneously pulling the ilium laterally via the PSIS.
The osteopath mobilises with his bodyweight.
Remark: after this mobilisation the leg is put back to rest on the table:
In the case of a posterior ilial mobilisation in abduction/external rotation.
In the case of an anterior mobilisation in adduction/internal rotation.
99
While the other hand fixes the sacrum towards anterior rotation, the leg
is mobilised into external rotation / circumduction.
100
The osteopath stands next to the pelvis on the side to be mobilised and
uses his knee to fix the lateral side of the knee so that the hip remains in
adduction during the mobilisation.
The caudal hand takes the ankle and flexes the knee to 9O.
While the other hand fixes the sacrum in posterior rotation, the leg is
mobilised into internal rotation / circumduction.
101
102
103
Video 27 - Anterior mobilisation
104
The osteopath must feel the low lumbar spine flatten, if not the technique is not stretching the iliolumbar ligament.
106
107
5.2.1. General
A manipulation or HVLAT (High Velocity Low Amplitude Thrust) is a
short, specific and rapid thrust applied to an articulation.
The aim of a manipulation is variable depending upon the lesion and
joint being treated.
The aim of a manipulation is:
Repositioning of a joint subluxation.
Alleviation of muscular spasm in short musculature.
Stretching of a capsulo-ligamentous retraction (correction of false axis
shortened structures).
Manipulations are in some situations a necessity, most notably in cases
of an articular blockade or subluxation. This is often difficult to differentiate
from a restriction (mobility loss with elastic end feel).
Manipulations are, in some cases, a more efficient treatment for restriction. Where elastic end feel is present mobilisations can be used but, if no
contra indications exist, then manipulation is also an option.
Before the age of 20 years, real articular blockades seldom occur.
The OAA region is an exception because no discs are present but articular blockades occur. Even in small children subluxations can be found
here.
108
Contraindications
Before an osteopath decides to use a manipulative technique it must be
sure that no contraindications are present.
Contraindications fall into several categories:
Medication
The osteopath will not manipulate if the patient takes anticoagulants or corticosteroids.
Trauma
The osteopath will not manipulate directly after trauma, without radiological testing showing no osseous lesions.
The osteopath will not manipulate too soon after an operation.
Lever use
If the patient has pain or neurological symptoms during the positioning of the body and levers for the technique, the osteopath will not
manipulate.
Osteoporosis
The osteopath will not manipulate in cases of obvious osteoporosis such as Sudeck atrophy.
Children
Real articular blockades do not occur in children, so manipulation
is not necessary. A real blockade is not only a facet fixation but implicates certain damage to the disc, which allows displacement of the
nucleus pulposus. It is very rare that the disc is damaged in children.
The OAA is an exception. Because no discs are present, subluxations
can occur. Cervical manipulations on children are to be avoided. The reason for this is that the vulnerable structures cant be blocked in that way
that this cant be solved with other, softer techniques such as gentle mobilisations and side of ease side of barrier techniques.
109
Pregnancy
Manipulation of lesions during pregnancy is not an absolute contra indication but does deserve extra vigilance. Hypermobility is not
infrequent so any manipulative technique must be carried out very
specifically.
Elderly
In older patients, arthrosis is a frequent reality and changes the
joint surface congruency. Manipulation is not absolutely contra indicated but extra care must be taken. Manipulation is needed only in
cases of subluxation.
When treating arthrotic joints it is not the aim to drastically improve the range of motion. This will only lead to joint instability. In cases
of arthotic joints it is necessary to leave the general mobility loss alone because this is seen as a normal protective mechanism of the body. The aim is to not allow false axis to develop and to maximise circulatory factors.
Cardiac patients
Manipulations that can create a potential neurovegetative influence upon the heart are contraindicated. These patients are not the
ideal patients for a total osteopathic treatment because osteopathy
works so effectively on the circulatory system. Cardiac patients have
a faulty motor in their circulatory system and an improvement in
this circulation may well create overload for the heart.
Other authors propose that it is indicated to optimise the neurovegetative influences to the heart via manipulations, MET and mobilisations of the thoracic and cervical region, but the author has no such
specific experience and so can only suggest that any such treatment
is done in a clinically controlled environment.
110
Cancer patients
It is also strongly suggested to avoid manipulation of cancer patients. Osseous metastasis is always possible.
These patients are not the ideal patients for a total osteopathic treatment because osteopathy works so effectively on the circulatory
system, which can allow rapid spread of any metastasis. Post-operative treatment of complaint is possible if allowed by the consulting
specialist. This must be considered case by case.
Psychiatric patients
Much care must be taken with these patients as manipulation can
release unexpected emotional reactions and with this patient group
this is not desired as the appropriate reaction for the osteopath is not
always evident.
Prosthesis
Prosthetic articulations are not manipulated.
111
The spine and thorax are placed in light flexion and rotation by gently
pulling on the underlying arm until rotation and, most importantly, flexion is
palpated at the sacroiliac joint.
The spine should remain in the same position on the table. The spine is
then very lightly flexed further so that additional rotation can be added.
The superior leverage is complete up to the sacroiliac joint.
The patient then straightens the underlying leg so that the hip and knee
are no longer flexed.
The osteopath holds the upper leg in flexion.
The osteopath s superior hand and forearm fix the patients thorax while the thumb of this same hand fixes the lateral surfaces of the spinous processes S1, L5, L4.
The osteopath uses his thorax to support the fixation of the superior leverage with a light pressure towards the sacrum.
The osteopath contacts the upper ilium with his elbow, just under the
dorsal surface of the iliac crest.
The patients pelvis is then rolled towards the osteopath and after several mobilisations of the sacroiliac joint to anterior rotation and without creating any tension; the ilium is corrected anteriorly by way of a thrust towards
the table/anterior rotation from the osteopaths bodyweight, via the elbow.
The joint plane should be respected and visualised so that the corrective thrust is given in the correct direction.
The thrust is only employed once the patient is relaxed and while the
patient exhales.
112
Video 31 - Anterior manipulation
113
114
Video 32 - Posterior manipulation
115
116
117
118
Isometric techniques
A 3 second contraction against resistance at the muscles end of
range (max. length) is done, without allowing motion.
A 3 second rest phase follows. If this is not done muscular fatigue
will occur.
Then a gentle, 3 seconds stretch of the muscle is done.
This procedure is repeated 3 times.
Other variants of the same principle are suggested in other texts
(longer contractions, more repetitions etc.), in the authors experience the procedure described above is adequate to stretch a muscle.
The technique has the effect of not only mechanically stretching the
muscle (this can also be done passively) but also decreasing the tone.
Isolytic techniques
A contraction against strong resistance so that the muscle is simultaneously contracted and stretched. This powerful technique is not
for every patient and provides a very strong muscular stretch.
Remarks: if a muscle is painful when palpated it cannot be assumed
that the muscle is retracted and needs to be stretched!
A painful palpation can indicate:
Spasm (strong pain, due to hypertonia, with palpation and shortened):
the related segment is the beginning point of the treatment.
Hypertonia (strong pain with palpation and when stretched): the related joints are to be mechanically treated so that the cause of it being overstretched is removed and the muscle can repair. The related segment is also treated.
Congestion of the muscle (pain and swollen due to poor venous drainage): of primary concern is the opening of all drainage channels and use
of repetitive contractions/relaxation.
119
120
Video 35 - Posterior lesion of the ilium
122
The patient is instructed to abduct the hip against the static resistance
from the osteopath, whereby the mobility gain creates a new end of range
in the sacroiliac joint.
This is repeated 3 to 4 times.
The patient is instructed to adduct the hip against the static resistance
from the osteopath, whereby the mobility gain creates a new end of range
in the sacroiliac joint.
This is repeated 3 to 4 times.
The patient is instructed to extend the hip against the static resistance
from the osteopath, whereby the mobility gain creates a new end of range
in the sacroiliac joint.
This is repeated 3 to 4 times.
Only this phase is demonstrated, as it is the most important of the
three.
123
124
125
5.4.1. General
Strain and Counterstrain is a type of "positional release" discovered in
the early 1960s by Dr. Lawrence Jones, D.O. It is a treatment that alleviates muscle and connective tissue tightness by the use of very specific treatment positions held for 90 seconds. During the procedure, the involved tissue is "slackened" causing a relaxation of the "spasm" which, in turn, allows local areas of inflammation, trapped within the painful tissue to dissipate. Following this "release" there is an immediate reduction of pain and
tension in the involved tissue. This relaxation helps restore normal joint mobility and is also beneficial to other structures in the region that may have
been compressed.
This gentle and painless technique has no contra-indications and can
be used in almost any condition and on patients of any age.
126
127
128
129
130
131
132
133
134
Video 48 - Adductors
135
6. All videos
136
On this page you will find all multimedia of this e-book. Click on the
link to view a specific video.
crospinous ligament
Video 31 - Anterior manipulation
Video 32 - Posterior manipulation
Video 33 - Anterior manipulation
Video 34 - Decoaptation of the pubic
symphysis
Video 35 - Posterior lesion of the ilium
Video 36 - Anterior lesion of the ilium
Video 37 - Anterior lesion of the ilium
Video 38 - External rotation lesion
Video 39 - Internal rotation lesion
Video 40 - Anterior lesion of the ilium
Video 41 - First position
Video 42 - Second position
137
7. Bibliography
138
1.
Atlihan D., Tekdemir I., Ates Y. & Elhan A. (2000) Anatomy of the
anterior sacroiliac joint with reference to lumbosacral nerves. Clin. Orthop.
376: 236-241.
2.
Basadonna P.T., Gasparini D. & Rucco V. (1996) Iliolumbar ligament insertions. In vivo anatomic study. Spine. Oct 15; 21(20): 2313
2316.
3.
Benzon H.T., Katz J.A., Benzon H.A. & Iqbal M.S. (2003) Piriformis syndrome: anatomic considerations, a new injection technique, and a
review of the literature. Anesthesiology. 98:1442-1448.
4.
Bernard T.N. & Cassidy J.D. (1991) The sacroiliac syndrome. Pathophysiology, diagnosis and management. In: Frymoyer JW, Ed. The
adult spine: principles and practice. New York: Raven, pp. 21072130.
5.
Bernard T.N. & Kirkaldy-Willis W.H. (1987) Recognizing specific
characteristics of nonspecific low back pain. Clin Orthop; 217: 266280.
6.
Bowen V. & Cassidy J.D. (1981) Macroscopic & microscopic anatomy of the sacroiliac joint from embryonic life until the eighth decade. Spine: 6(6), 620-628.
7.
Brenard T.N. Jr. & Cassidy J.D. (1991) The Sacroiliac Joint Syndrome. Pathophysiology, Diagnosis, and Management Raven Press Ltd.
NY. (Ed.).
8.
Brolinson P.G., Kozar A.J. & Cibor G. (2003) Sacroiliac joint dysfunction in athletes. Curr Sports Med Rep. Feb; 2(1): 47-56.
9.
Carragee E. & Hannibal M. (2004) Diagnostic evaluation of low
back pain. Orthopedic Clinics of North America; 35 (1).
10. Cohen S.P. (2005) Sacroiliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anestesia & Analgesia. Vol.
105 n. 5, pp. 1440-1453.
139
11. Chow D.H., Luk K.D., Leong J.C. & Woo C.W. (1989) Torsional
stability of the lumbosacral junction. Significance of the iliolumbar ligament. Spine. Jun; 14(6): 611615.
12. DeCamp O.N. (1990) Diagnosis and Correction of Innominate Subluxations, Todays Chiro. July 19(4): 50-52.
13. DiGiovanna E.L., Schiowitz S. & Dowling D.J. (2005) An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins.
14. DonTigny R.L. (1985) Function and Pathomechanics of the Sacroiliac Joint: A Review. Phys. Ther. 1985; 65: 35-44.
15. DonTigny R. (1993) Mechanics and Treatment of the Sacroiliac
Joint, The Journal of Manual and Manipulative Therapy. Vol.1, No. 1, pp.
3-12.
16. DonTigny R.L. (1994) Function of the Lumbosacroiliac complex as
a self-compensating force couple with a variable, force-depending transverse axis: A theoretical analysis. The Journal of Manual dz Manipulative Therapy 2: 87-93.
17. DonTigny R.L. (2005) Critical analysis of the functional dynamics
of the sacroiliac joints as they pertain to normal gait. J of Orthopaedic Medicine (UK) 27:3-10.
18. DonTigny R.L. (2007) A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology. The implications for
lumbopelvic function and dysfunction. In Vleeming A, Mooney V, and
Stoeckart R (Eds): Movement, Stability & Lumbopelvic Pain: Integration of
Research and Therapy. Churchill Livingstone, 2nd edition, Chapter 18, pp
265-278.
19. Dreyfuss P., Dreyer S.J., Cole A. & Mayo K. (2004) Sacroiliac
Joint Pain. J. Am. Acad. Orthop. Surg. July/August vol. 12 no. 4
pp.255-265.
140
20. Dreyfuss P., Park K. & Bogduk N. (2000) L5 dorsal ramus and
S14 lateral branch blocks protect the sacroiliac joint from an experimental
pain stimulus? A randomized, double-blinded controlled trial. Presented at
the International Spinal Injection Society 8th Annual Scientific Meeting,
San Francisco, CA, September 810.
21. Durrani Z. et Winnia A.P. (1991) Piriformis muscle syndrome: and
underdiagnosed cause of sciatica. Journal of Pain Symptoms Management. 6: 374-379.
22.
23. Egund N., Olsson T.H., Schmid H. & Selvik G. (1978) Movements
in the sacroiliac joints demonstrated with roentgen stereophotogrammetric
analysis. Acta Radiol Diagn; 19: 833845.
24. Fishman L.M., Dombi G.W., Michaelsen C., Ringel S., Rozbruch
J. & Rosner B. (2002) Piriformis syndrome: diagnosis, treatment, and outcomea 10-year study [review]. Arch Phys Med Rehabil.;83:295-301.
25. Fortin J.D. (1995) Sacroiliac joint injections and arthrography with
imaging correlation. In Leonard T. Physiatric procedures in clinical practice. Harley & Belfus, Philidelphia.
26. Fortin J.D., Kissling R.O., O'Connor B.L. & Vilensky J.A. (1999)
Sacroiliac joint innervation and pain. Am J Orthop; 28: 6890.
27. Foster M.R. (1998) Primary and secondary forms of the piriformis
syndrome. Presented at; Eastern Orthopaedic Association Annual Meeting; October 17, San Juan, Puerto Rico.
28.
825.
29. Friedman H., Gilliar W. et Glassman J. (2000) Counterstrain Approaches in Osteopathic Manipulative Medicine S F I M M S Pr.(Ed.).
141
142
40. Hughes R.J., Harish S., Saifuddin A. & O'Donnell P. (2006) Large
Synovial Cyst Arising from the Sacroiliac Joint. American Journal of Roentgenology, Volume 187.
41. Ikeda R. (1991) Innervation of the sacroiliac joint: macroscopic
and histological studies. J Nippon Med Sch; 58: 587596.
42. Jacob H. & Kissling R. (1995) The mobility of the sacroiliac joints
in healthy volunteers between 20 and 50 years of age. Clin Biomech;10:
352361.
43.
(Ed.).
Patients With and Without Low Back Pain. Physical Therapy, November 1,
79(11): 1043 - 1057.
52. Luukkainen R., Wennerstrand P.V. & Kautiainen H.H. (2002) Efficacy of periarticular corticosteroid treatment of the sacroiliac joint in nonspondyloarthropathic patients with chronic low back pain in the region of
the sacroiliac joint. Clin Exp Rheumatol; 20: 5254.
53. Maigne J.Y., Aivaliklis A. & Pfefer F. (1996) Results of sacroiliac
joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine; 21: 18891892.
54. Maitland J. (2001) Spinal Manipulation Made Simple: A Manual of
Soft Tissue Techniques. North Atlantic Books. (Ed.).
55. Maugars Y., Mathis C., Berthelot J.M., Charlier C. & Prost A.
(1996) Assessment of the efficacy of sacroiliac corticosteroid injections in
spondyloarthropathies: a double-blind study. Br J Rheumatol; 35: 767
770.
56. Mitchell F.L. (1965) Structural pelvic Function. Acadamy of Applied Osteopathy Yearbook1965 Vol.2. P.178.
57. Murata Y., Takahashi K. & Yamagata M. (2000) Sensory innervation of the sacroiliac joint in rats. Spine. 16:20152029.
58. O'Shea F.D., Boyle E., Salonen D.C., Ammendolia C., Peterson
C. & Hsu W., Inman R.D. (2010) Inflammatory and degenerative sacroiliac
joint disease in a primary back pain cohort. Arthritis Care res. April 62(4):
447-454.
59. Pace J.B. & Nagle D. (1976) Piriformis syndrome. West J Med;
124: 435-439.
60. Papadopoulos E.C. & Khan S.N. (2004) Piriformis syndrome and
low back pain: a new classification and review of the literature. Orthop Clin
North Am; 35: 65-71.
144
61. Panjabi, M. M. & White, A. A. (2001) Biomechanics in the Musculoskeletal System. Churcill Livingston. (Ed.).
62. Paris, S. V. (1997) Introduction to Spinal Evaluation and Manipulation. University of St. Augustine for Health Sciences, St, Augustine. (Ed.).
63. Peeters L. & Lason G. (2005) Integratie en toegepaste principes
in de Osteopathie Osteo 2000. (Ed.).
64. Ramirez M.A., Haman J. & Worth L. (1989) Low back pain: Diagnosis by six newly discovered sacral tender points and treatment with
counterstrain. The Journal of The American Osteopathic Association
(JAOA).
65. Read M.T. (2002) The piriformis syndromemyth or reality? Br
J Sports Med.; 36: 76.
66. Sady R., Schmidt A. P. & van der Wurff P. (2003) Sacroiliac dysfunction Acta ortop. bras. Vol. 11 no. 2. So Paulo Apr./june.
67. Sakamoto N., Yamashita T. & Takebayashi T. (2001) An electrophysiologic study of mechanoreceptors in the sacroiliac joint and adjacent tissues. Spine; 26: E468471.
68. Schwarzer A.C., Aprill C.N. & Bogduk N. The sacroiliac joint in
chronic low back pain. Spine; 20: 3137.
69. Sobotta J. (2001) Atlas of Human Anatomy Sobotta - 13th English
edition December 15. Lippincott, Williams & Wilkins (Ed.).
70. Steven P. (2005) Sacroiliac Joint Pain: A Comprehensive Review
of Anatomy, Diagnosis, and Treatment. Anesth. Analg. 101: 1440-1453.
71. Sturesson B., Selvik G. & Uden A. (1989) Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine; 14:
162165.
72. TePoorten B.A. (1969) The piriformis muscle. J. Am. Osteopath.
Assoc. 69: 150-160.
145
146
83. Weiselfish-Giammatteo S. & Giammatteo T. (2003) Integrative Manual Therapy for Biomechanics: Application of Muscle Energy and
'Beyond' Technique.
84. Wells P.W. (1986) The Examination of the Pelvic Joints. Grieve
GP: Modern Manual Therapy of the Vertebral Column. Churchill Livingstone. Edinburgh, P. 591.
85. Zelle B.A., Gruen G.S., Brown S. & George S. (2005) Sacroiliac
joint dysfunction: evaluation and management. Clin. J. Pain. Sep-Oct;
21(5): 446-455.
147
8. Osteopathic Terminology
148
149
150
The left and right translations occur along the transverse axis. The ventral and dorsal translations occur along the anteroposterior axis. The motions of compression and traction occur along the craniocaudal axis. When
describing a vertebral motion or lesional motion, the description is always
relative to the inferior (underlying) vertebra.
151
152
S
sidebending or lateroflexion
SBS
spheno basilar symphysis
SIJ
Sacroiliac Joint
SLR
straight leg raise test
SR motion
vertebral motion involving a contralateral rotation and sidebending where the sidebending precedes the rotation
SFT
standing flexion test
SitFT
sitting flexion test
STA
superior transverse axis
T
thoracic vertebra
TS
thoracic spine
154
155
Acknowledgment
We are grateful to those colleagues who knowingly or unknowingly assisted in the development of this e-Book.
We also acknowledge that the constant questioning by students has significantly contributed to the development of the material in this e-book.
Our greatest debt of gratitude goes to those family members and good
friends whose tireless support made the writing of the e-book possible.
This e-book is a product of Osteo 2000 bvba.
If you are interested in publishing an e-book or if you have questions or
suggestions, please contact us.
clvii