Sacral rotation

Dysfunctions of motion created by the sacrum moving on the ilium are commonly unilateral anterior or posterior sacral dysfunctions, a unilateral shear of the sacrum along the articulation or oblique rotational sacral dysfunctions. If the fifth lumbar vertebra is not involved in the oblique rotation, the dysfunction is described as a sacral rotation dysfunction. if the fifth lumbar vertebra rotates in a direction opposite that of the sacrum, it is described as a sacral torsion. 

During these motions, the lumbar spine rotates to the right and flexes laterally to the left, compensating for the right sacral flexion created by pelvic rotation toward the left with right pelvic tilt The relationship of the rotated right L5 to the left-on-left sacral rotation completes the picture... 

Posterior Iliac Somatic Dysfunction/ Unilateral Sacral Shear/Forward Sacral Rotations and Torsions... 

Anterior Iliac Somatic Dysfunction/ Backward Sacral Rotation or Torsion... 

Anterior Sacral Flexion/Unilateral Sacral Shear/Sacral Rotations orTorsions... 

The characteristic of dysplastic high grade slips is not the anterior translation of L5, but really rotation of L5 around the sacral dome, with the lum-bo-sacral kyphosis, and associated perturbation of sagittal alignment. The gravity line still falls through the lumbo-sacral junction and close to the posterior centre of the femoral heads. Little adaptation has to be done to keep the sagittal balance, and the problem is purely localised at the lumbosacral junction. 

This left-on-left sacral torsional pattern. It is not pathological or dysfunctional because it is temporary and instantaneous and the adaptive motion of the lumbar region is for the side-bending and rotation to occur in opposite directions. 

Unilateral erector spinae contraction will cause lateral flexion to the side of contraction, scoliosis with convexity to the opposite side, and extension of the spine. The patient walks with a stiff back, with no lumbar rotation or flexion. The spinal areas involved are usually at the fourth or flfth lumbar and first sacral segments. An acute anterior sacrum dysfunction on the same side may also be present. If findings include a raised iliac crest height, lumbar scoliotic convexity, and sciatic pain distribution, all on the same side, the prognosis for a speedy recovery is often good. If the pain is on the other side, the cause may be a prolapsed disk or some other serious pathologic condition, and both physician and patient may be in for a difficult time. 

A short leg has numerous effects on the body. Usually, the sacral base lilts toward the side of the short leg. The iliac crest is generally low on the short leg side. Occasionally, the innominate on the shorter side will rotate forward or the opposite side posteriorly as a means of compensating for the leg length discrepancy. The lumbar spine develops a convexity toward the side of the short leg, and once the problem has existed for sufficient time, a compensatory curve will develop in the thoracic spine. The shoulder will be low on one side, depending on whether a secondary thoracic curve is present the scapula will be low on the same side as the shoulder. The cervical angle will be more acute as the head tilts toward the midline to keep the eyes level. 

The action of flexion, along with internal or external rotation, changes the orientation of the ilium relative to the sacrum if there is no restriction. The subsequent extension of the leg maintains this change in relationship. If the Iliosacral joint is restricted, hip flexion induces posterior rotation of the ilium, which causes posterior movement of the sacral base. Little or no change occurs at the joint, as indicated by the small total excursion of the medial malleolus. 

The tests for pelvic dysfunctions have fair specificity and variable sensitivity. The presence of a sacral dysfunction can obscure or exaggerate the findings for pelvic dysfunction. The standing flexion test can be falsely positive if there is an overwhelmingly positive seated flexion test and sacroiliac dysfunction. The depth of the sacral sulcus is not specific to pelvic dysfunction because a deep sulcus can also indicate a forward sacral torsion with the axis opposite to the deep sulcus, a unilateral sacral shear, as well as a posteriorly rotated ilium on the same side. A shallow sulcus can also indicate sacral dysfunction in addition to an anterior rotated ilium on that side. 

FIG. 60-11 Sacral torsion. (A) Left rotation of sacrum on left oblique axis. (B) Right rotation of sacrum on ieft oblique axis. (C) Saaum on left oblique axis. (D) Right rotation of sacmm on right oblique axis. 

The lateral rotator muscles of the hip include the piriformis and the obturator internus. The piriformis muscle has its medial attachment to the lateral border of the sacrum and is often involved in sacral dysfunctions. 

On examination, the left buttocks was lender to palpation and there were tender points at the mid-pole of the sacrum on the lateral border and one deep to the gluteus maximus, where a lense piriformis could be palpated. There was a unilateral sacral flexion (sacral shear) present on the left. No lumbar somatic dysfunctions were present. There was mild tenderness at the sciatic notch of the ischium. Deep tendon reflexes were normal and muscle strength of the ihigh was normal. There was some pain on internal rotation and adduction of the left hip. 

Findings observed on osteopathic examination were compression of the occipital condyles bilaterally (the left side greater than right], left parietal bone externally rotated, right medial pterygoid muscle spasm, and an anterior sacral base. No bossing ofthe frontal and parietal bones was noted and there was no overlapping of sutures present. 

The chief finding in this patient was a posteriorly rotated ilium with a unilateral sacral shear. This was fairly simple to address and the patient felt that she returned to her previous level of functioning in this regard. The patient did accept treatment for the edema as well. The edematous legs also had an ashen appearance and the skin was flaky. 

Sacral rocking may be used to release sacral restrictions, both before delivery and during early delivery (Fig. 116-8). After delivery, the woman s legs are removed from the stirrups and her hips are put through adduction and internal rotation while still flexed, followed by extension (Figs. 116-9 and 116-10). This reduces the po-... 

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