1. LUMBAR

2. Forward Bending

3. Assess thoracolumbar paravertebral fullness during forward bending

4. Backward Bending

5. Lumbar Sidebending Slide hand down lateral aspect of thigh
Compare curve on each side
Smooth?
Abrupt?
Symmetrical?

6. RED REFLEX Distinguishes acute vs chronic SD
Run index and middle finger vertical down lumbar spine on TPs. Extended redness means acute SD

7. Soft Tissue Techniques
Prone- Direct, Kneading
Lateral Recumbent- Direct, Kneading
Prone- Direct Stretching
Lateral Recumbent- Direct, Kneading and Stretching

8. Lumbar Paraspinal Muscles - Soft Tissue: Prone, Direct, Kneading

9. Soft Tissue: Lateral Recumbent-Direct-Kneading

10. Prone—Direct—Kneading and Stretching: 4913.11B

11. Lateral Recumbent—Direct– Kneading and Stretching: 4913.11C

12. Multiple Plane - Type I Mechanics
Diagnosis

13. Multiple Plane - Type I Mechanics
Diagnosis
Rotation palpation
With the patient prone or seated, place your thumbs on a lumbar vertebra’s transverse processes located an inch lateral to the spinous process;
Push anteriorly on the right TP to induce rotation left. Push anteriorly on the left TP to induce rotation right;
Restricted rotation left = rotated RIGHT; restricted rotation right = rotated LEFT

14. Multiple Plane - Type I Mechanics Diagnosis
Sidebending palpation
Thumbs then slide medially to base of spinous process near the intervertebral space inferior to the lesioned body
Apply motion testing in a medial direction
Sidebending named for way it wants to go
Concave side indicates direction of SB
Sagittal plane
Also check for non-neutral dysfunction

15. Treatment – Type I Mechanics
Indirect technique
Balanced ligamentous tension (BLT)
Seated
Supine
Direct technique
Muscle Energy (ME)

16. Multiple Plane - Type I Mechanics
Indirect Treatment (BLT)
**Sitting, indirect, pt coop, resp force D**
Physician sits behind pt
Physician contacts ipsilateral TP of segment below the rotated side (right TP of L4)
Physician contacts contralateral TP on lesioned segment (left TP of L3)
Pt is instructed to drop arm to induce further SB to float segment
Pt is instructed to BB( “lean back”) to float the segment
Pt instructed in respiratory force
Recheck
Example for L3 N SLRR

17. MULTIPLE PLANE-Type 1 Mechanics Indirect Treatment (BLT)
MULTIPLE PLANE-Type 1 Mechanics Indirect Treatment (BLT) **Supine, indirect, pt cooperation, respiratory force G**
Pt is supine and the physician sits on the side of rotation (right)
Physician reaches under pt and places pad of finger on the contralateral TP of dysfunctional segment – when applying anterior pressure will induce rotation into dx (right)
Pt instructed to “arch back” or “flatten back” as needed to balance ligamentous tension in sagittal plane
Apply anterior tension against contralateral TP (induce rotation) and apply traction to area gently creating SB (left)
Pt instructed in respiratory force
Repeat – avg 3 times
Recheck
DX: N SLRR

18. Multiple Plane - Type I Mechanics
Direct Treatment (ME)
**Sitting, direct, ME / HVLA A or B **
N SLRR
Salute rotated side
R hand behind neck
L hand on R elbow OR
Put pt. in position as palpated
place pt. hands to help you undo the setup
Goal: pt. position opposite of diagnosis
After
Before

19. Multiple Plane - Type I Mechanics
Direct Treatment (ME)
**Sitting, direct, ME / HVLA A or B **
Standing behind the seated patient, place your thenar eminence on the posterior TP(s)
Reach across the upper chest with your other hand and arm to control the pts shoulders/trunk (under)
Move trunk into the SB then rotation barriers until you feel movement at the restricted segments. Extend to localize in sagittal plane
Ask pt to straighten the trunk/shoulders for 3-5 sec. against your equal resistance
Allow FULL relaxation ( 3-5 sec) and then slowly move to new restrictive barrier as you push anterior into the posterior TP(s)
Repeat 3-5 times
Recheck

20. Multiple Plane - Type I Mechanics Direct Treatment (ME)
Multiple Plane - Type I Mechanics Direct Treatment (ME) **Supine, direct, ME / HVLA F **
Pt is supine and physician stands on pts side of rotation (right)
Pt is instructed to flex knees and hips and place feet flat on table creating lumbar flexion
Physician grasps the spinous process of dysfunctional segment and pulls segment towards him/her to induce rotation into restrictive barrier (left)
Physician uses other hand to pull pts feet toward him/her creating SB into restrictive barrier (right)
Pt is instructed to “ put feet back on table while physician offers isometric counterforce for 3-5 sec
Allow full relaxation ( 3-5 second) then positions to new barrier
Repeat 3-5 times
Recheck
DX: N SLRR

21. Multiple Plane – Type II Mechanics Treatment Techniques
Direct (ME)
Seated
Indirect (BLT)
Supine

22. Multiple Plane - Type II Mechanics Direct Treatment (ME)
Multiple Plane - Type II Mechanics Direct Treatment (ME) **Sitting, direct, ME B **
Standing behind the seated patient, place your thenar eminence on the posterior TP/ or contacts SP
Reach across the upper chest with your other hand and arm to control the pts shoulders/trunk (over)
Move trunk into the rotation/SB/ sagittal plane barriers until you feel movement at the restricted segments.
Ask pt to straighten the trunk/shoulders for 3-5 sec. against your equal resistance
Allow FULL relaxation ( 3-5 sec) and then slowly move to new restrictive barrier as you push anterior into the posterior TP(s)
Repeat 3-5 times
Recheck

23. Patient salutes rotated side
Operator’s arm over patient’s shoulder

24. Thumb contacts SP
(can also place heel of L hand over L TP).

25. NN
(F) RLSL
contact the left TP with the heel of left hand

26. Operator applies force to localize sidebending

27. Right hand grasps right proximal humerus and guides patient’s lumbar spine into R sidebending,
R rotation, and FB/BB as needed to take all 3 planes to their restrictive barriers.
Patient then turns or bends against D.O. while D.O. maintains isometric counterforce.
Wait!! (3-5 seconds at least)
Sidebend, rotate, BB/FB (tiny increments to new barrier.)
Move to new barrier. Repeat 3x. Recheck.
(HVLA directed ant/sup with heel of left hand at same time with one body movement.)

28. Multiple Plane - Type II Mechanics Indirect Treatment (BLT)
Multiple Plane - Type II Mechanics Indirect Treatment (BLT) **Supine, indirect, pt cooperation, respiratory force E **
Pt supine with his/her hips and knees flexed and feet flat on table, physician on opposite side of rotation
Physician reaches under the pt and grasps SP of involved vertebra to induce rotation into SD to the point of BLT
Physician instructs pt to move your shoulders and feet to side of rotation/side bending – into dx to the point of BLT
Pt instructed to “arch back” or “flatten back”
Pt instructed in respiration
Repeat – avg 3 times
Recheck

29. INNOMINATES

30. Lateralization Standing flexion test Seated flexion test
ASIS Compression - supine

31. Patient now
SUPINE!!!
Level the
Pelvis on the
Exam Table!

32. Supine Diagnosis Put thumbs horizontally under the ASIS’s
Are they level? Is the lateralized side inferior or superior relative to the non-lateralized side?
correct
incorrect

33. Supine Diagnosis - Inflare/Outflare
Visualize a line from each ASIS to umbilicus
Is lateralized side relatively further (outflare) or
closer (inflare) to umbilicus? L R

34. Innominate Inflare/Outflare Somatic Dysfunction
Lateralized ASIS is closer to the umbilicus than the non-lateralized side
i.e., with a left inflare, there is a shorter distance between the umbilicus and left ASIS than the right ASIS
Outflare:
Lateralized ASIS is further away from the umbilicus than the non- lateralized side
i.e., with a left outflare, there is a longer distance between the umbilicus and left ASIS than the right ASIS
Innominate inflare/outflare somatic dysfunction is not involved in inferior transverse axis mechanics
It occurs about a vertical axis

35. INNOMINATE INFLARE
Def: condition where innominate will rotate medially on vertical axis.
Physical Examination
ASIS more medial on involved side. (lateralized side.)
use umbilicus as reference point for anatomical midline.
positive standing flexion test on involved side.
ischial tuberosity farther from midline.
tender over SI or pubic symphysis.
Don’t forget to lateralize your patient!

36. INNOMINATE INFLARE TREATMENT
1. Pt. supine and D.O. on dysfunctional side.
2. Hip & knee partially flexed, foot on table close to buttocks.
3. Stabilize opposite ASIS.
4. Move knee laterally abducting thigh to innominate’s restrictive barrier.
5. “Move knee toward middle of table.”
6. Wait 3-5 seconds & abduct thigh to new restrictive barrier.
7. Repeat until best motion. (usually 3 times.)
8. Recheck.

38. INNOMINATE OUTFLARE TREATMENT
1. Pt. supine and D.O. on dysfunctional side.
2. Knee & hip partially flexed.
3. Grasp patella with one hand and hook fingers of the other hand over medial margin of involved PSIS.
4. Move knee medially adducting thigh to restrictive barrier.
5. “Move knee outward.”
6. Wait 3-5 seconds and adduct thigh to new restrictive barrier.
7. Repeat until best motion. ( ave. 3 times.)
8. Recheck.

40. Pubic Symphysis Diagnosis
Place your fingers on the superior aspect of the pubic symphysis to diagnose sup./inf.
Place your fingers on the anterior aspect of the pubic symphysis to diagnose ant./post. L L

41. Compression of the Pubic Symphysis
Tissue texture changes in the pubic region
The superior margin of the pubic symphysis is level unless associated with a pubic shear
Superior and inferior glides are restricted
Posterior springing of the pubes is bilaterally restricted
ASIS springing test may be positive bilaterally
Tenderness to palpation over the pubic symphysis. May have symptoms of frequency and burning on urination even without infection
Note: Pubic decompression is helpful in preparing innominates for other techniques.

42. PUBIC DECOMPRESSION- MUSCLE ENERGY
1. Pt. supine on table, knees and thighs flexed.
2. Feet flat on table inches apart.
3. Grasp both knees. “Try to pull your knees apart.” (abductor muscles pull laterally on innominate compressing the symphysis further to prepare it to relax.)
4. Repeat.
5. Heel of one hand in knee, posterior distal humerus in other knee.
6. Knees 10 to 12 inches apart. “Try to pull your knees together.”
7. Repeat . (av. 3 times)

45. SUPERIOR PUBIC SHEAR
1. Pt. supine and D.O. on dysfunctional side between table & leg.
2. Stabilize opposite ASIS.
3. Have pt. move laterally until ischial tuberosity at edge of table.
4. Abduct knee to gap symphysis.
5. Extend thigh. (rotates innominate anteriorly and carries symphysis inferiorly.)
6. “ Lift knee toward ceiling.” Wait 3-5 seconds.
7. Extend thigh to new barrier.
8. Repeat until best motion. (av. 3 times.)
9. Recheck.
Trauma or tight rectus abdominus

46. Just like a tight iliospoas or posterior innominate, but this time include gapping.

47. TREATMENT: INFERIOR PUBIC SHEAR
1. Pt. supine and D.O. on side of dysfunction.
2. Flex lower extremity at knee and hip an abduct thigh to gap pubic symphysis.
3. Place knee against chest, cup cephalad hand against ASIS, grasp ischial tuberosity with other hand. (rotates innominate posteriorly to carry pubic symphysis superiorly.)
4. “Push knee toward end of table against my chest.”
5. Move innominate to new restrictive barrier.
6. Repeat until best motion. (approx. 3 times.)
7. Recheck.
Trauma or tight adductors

48. Treatment just like anterior innominate, but with gapping

49. L Supine Diagnosis Place thumbs under medial malleoli
Apply slight inferior traction
Is the lateralized side inferior or superior relative to the non-lateralized side?
Malleoli are mixed landmarks, but can alert the operator to stresses placed on pelvis, leg, and ankle, or to functional/anatomical short leg
Can be used to help confirm diagnosis L
correct
incorrect

50. Prone Diagnosis Preparation
Patient is prone!
Align Pelvis:
Operator bends patient’s knees, then returns legs to table
Alternatively, operator can lift patient’s hips, then recenter them over table

51. Prone Diagnosis Place thumbs horizontally under the PSIS’s
Are they level? Is the lateralized side inferior or superior relative to the non-lateralized side?
There is a “dimple” under the PSIS: place thumbs horizontally
Correct
Incorrect

52. Ischial Tuberosity: Can use palms of hand to dx.
Superior/Inferior on the side of lateralization!

53. Movement of the Innominates
Innominates rotate around the inferior transverse axis of the sacrum
Located at inferior limb of sacroiliac joint
S: pubic symphysis
H: acetabulum
X: inferior transverse axis

54. Sacral Axes Multiple axes of motion: Transverse (3) Vertical A/P
Superior S1
Middle S2
Inferior S3 (innomates rotate on this axis!!!)
Vertical
A/P
Oblique (2)
Left
Right
Innominate axis
Innominate axis
Innominates rotate about the inferior transverse axis = “Iliosacral Motion”
Know what each axis relates to for the written test and maybe verbal questions on the practical
Transverse
Superior – respiration axis, in posterior, out anterior
Middle – Rotation about this axis for sacral base anterior/posterior

55. Pubic Symphysis Somatic Dysfunctions
Pubic Symphysis Superior/Inferior Shear
Can be a SD by itself (rare)
May often follow innominate SD (innominate ant/post rotation, up/down slipped innom).
Can follow sacral shear
Common in obstetrical patients due to relaxin
Pubic Symphysis Anterior/Posterior Shear
Relatively rare, usually caused by trauma
Compression of the Pubic Symphysis
Everything looks even, just tenderness, restricted motion

56. Innominate Diagnoses:
Left Anterior Rotation
Findings
Left ASIS relatively inferior
Left PSIS relatively superior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis

57. ANTERIOR INNOMINATE ROTATION SUPINE MUSCLE ENERGY
Ex: Right Anterior Innominate:
1. Pt. supine & D.O. on side of dysfunction.
2. Flex lower extremity on side of dysfunction at knee and hip. (no abduction as in pubic shears and innominate flares).
3. Put shoulder against pt’s leg & cup ASIS with cephalad hand & ischial tuberosity with caudad hand.
4. Hold tension at all points until innominate rotates posteriorly to restrictive barrier.
5. “Push knee against my chest.” (Use ½ your strength)
6. Sense that force is localized at SI joint.
7. Wait 3-5 seconds.
8. Flex hip and rotate innominate posteriorly to new restrictive barrier.
9. Repeat until best motion. (usu. 3 times). Recheck.

59. ANTERIOR INNOMINATE PRONE DIRECT MUSCLE ENERGY
EX: Left Anterior Innominate.
1. Pt. prone and D.O. on side of dysfunction.
2. Extremity hangs freely off table.
3. Flex pt’s hip and knee. Grasp lower leg to do this.
4. Place pt’s foot flat against your thigh.
5. Other hand on posterior surface of sacrum.
6. Grasp knee & further flex hip & knee.
7. Lift pt’s knee & “squat” to raise foot superiorly. (rotates innominate posteriorly.)
8. “Push foot against my knee.” (Maintain isometric counterforce.)
9. After tissues relax, flex hip to rotate innominate posteriorly to new barrier.
10. Repeat until best motion. (usu. 3 times). Recheck.

61. Innominate Diagnoses:
Left Posterior Rotation
Findings
Left ASIS relatively superior
Left PSIS relatively inferior
S: pubic symphysis
H: acetabulum
X: inferior transverse axis

62. INNOMINATE POSTERIOR SUPINE MUSCLE ENERGY
EX: Left Posterior Innominate
1. Pt. supine & D.O. on side of somatic dysfunction.
2. Pt. on edge of table allowing ischial tuberosity to be off edge.
3. Leg hangs freely.
4. Cephalad hand reaches across & stabilizes opposite ASIS.
5. Tension applied to ant. thigh rotating innominate anterior to new restrictive barrier.
(D.O. leg on outside of pt’s leg).
6. “Pull your knee up to the ceiling.”
7. Sense that contractile force is localized to SI joint.
8. Extend extremity to new restrictive barrier.
9. Repeat until best motion obtained. ( usu.. 3 times.)
10. Recheck.
Same as tight iliopsoas treatment from Block II;

64. POSTERIOR INNOMINATE: PRONE- MUSCLE ENERGY
1. Pt. supine & D.O. on side opposite dysfunction.
2. Cephalad hand- hypothenar eminence on iliac crest & PSIS.
3. Caudad hand- grasp distal femur just above knee.
4. Extend hip to move innominate anteriorly to the restrictive barrier.
5. “Pull your knee down toward the table.”
6. Sense that force is localized at SI joint.
7. Extend extremity to new restrictive barrier.
8. Repeat until best motion. (usu. 3 times.)
9. Recheck.

66. Innominate Diagnoses:
Left Upslipped Innominate
Findings
Left ASIS relatively superior
Left PSIS relatively superior
Nonphysiologic.
No axis!
Symphysis and Ischial tuberosity could also be superior in more severe cases.
S: pubic symphysis
H: acetabulum
X: inferior transverse axis

67. Supine, Direct, HVLA Sacral shear and upslipped innominate
Block inferior ILA with pt hand, wallet, towel, or wedge
Grasp leg above ankle and abduct until SI joint is gapped
Internally rotate leg to point of SI gapping
Apply traction and then perform a swift tug
May also use ME (localize or tx)
right sacral shear

68. Downslipped Innominate (Respiratory Cooperation)
Dx - (+) StFT on affected side with all ASIS, PSIS, and pubic rami inferior
aka, Inferior Pelvic Shear
Tx – With patient lying on unaffected side and knees bent, apply an upward & lateral force on the ischial tuberosity & the ilium.
Have patient take several deep breaths while you resist, & then advance cephalad as able & repeat.
Recheck your findings.
(Another treatment option is to have
the patient hop on the affected leg
several times and then recheck)

70. SACRUM

71. Sacral Base Anterior
Name: Sacral Base Anterior, Bilateral Sacral Flexion
Lateralization: Does NOT matter.
Spring test: Negative
Landmarks:
Sacral Base: Bilaterally (B/L) Anterior
Sacral Sulcus: B/L Deep
ILA: B/L Posterior
STL: B/L Tight
Motion:
Sacral Base: B/L +
ILA: B/L –
Ant Ant+
Deep Deep
Post - Post-

72. Muscle Energy for Sacral Base Anterior #2
patient is supine and doctor stands to the side at about hip level
the patient is instructed to bring his/her knees to the chest
the doctor contacts the sacral base bilaterally, with his/her chest against the patient’s knees
the patient is instructed to push the knees toward the doctor against the doctor’s resistance
hold for approx 3-5 secs/relax for 3 secs
Flex patient to new barrier
repeat as necessary
recheck

73. Direct Respiratory Force for Sacral Base Anterior
Patient is prone with doctor at side of table
Doctor places heel of hand on the ILAs, applying downward pressure
Patient inhales, holding his/her breath in inhalation for as long as possible
During inhalation apply a continuous anterior force on ILAs exaggerating sacral extension
Resist sacral flexion during exhalation (hold in sacral extension)
Repeat as necessary
Recheck
Nicholas p. 268

75. Sacral Base Posterior
Name: Sacral Base Posterior, Bilateral Sacral EXTENSION
Lateralization: Does NOT matter.
Spring test: Positive
Landmarks:
Sacral Base: Bilaterally (B/L) Posterior
Sacral Sulcus: B/L Shallow
ILA: B/L Anterior
STL: B/L Loose
Motion:
Sacral Base: B/L –
ILA: B/L +
Post Post -
Shallow Shallow
Ant Ant +

76. Bilateral Sacral Extension
Patient prone, physician on dominate eye side.
Place the thenar eminence of the treating hand over the sacral base .
Abduct both legs until motion is felt by the palpating hand (~ 20), & then internally rotate the legs.
Instruct pt to exhale fully & hold it.
Exert a downward pressure over the sacral base while pt. inhales, resisting sacral extension.
The pressure is maintained for 3 – 5 seconds while gapping the SI joints bilaterally.
This may be accomplished by bending the patient’s knees 90  & gently internally rotating the patient’s abducted legs.
Repeat above 2-3 times & recheck.

77. Direct Respiratory Force for Sacral Base Posterior
Patient is prone, doctor at side of table
Doctor places fingers on the sacral base, applying equal downward pressure to both sides
Patient rests on his/her elbows – sphinx position
Patient exhales completely and holds while doctor encourages anterior motion of the sacrum
Repeat as necessary
Recheck
Nicholas P. 269

78. Vertical Axis Diagnosis: less common
Name: Left Sacral Margin Posterior
Lateralization: Matters NOT. Always call on Posterior side.
For Left Sacral Margin Posterior:
Landmarks:
Sacral Base: L Posterior
Sacral Sulcus: L Shallow
ILA: L Posterior
STL: L Tight
Motion:
Sacral Base: L –
ILA: L –
P –
Shallow
P -
How could we treat this?

80. Findings for Unilateral Sacral Flexion (Sacral Shear)
The sacral base on the side of the significantly inferior ILA will generally be anterior: FLEXED
The ILA will be significantly inferior (& posterior!)
{Sacrotuberous ligament will be pliable and under less tension than the contralateral side.}
Anterior
Posterior
Markedly
Inferior
Right unilateral sacral flexion

81. Motion Testing for Unilateral Sacral Flexion (Sacral Shear)
There will be no motion at the inferior ILA - it is locked down
The base on the same side is likely to have adequate motion
There is generally good motion at any of the other locations but the motion is not likely to “add up” or
+/-
+/- A -
P/I
(we can’t use our paper model for this one!)
(No Axis.)

82. Supine, Direct, HVLA Unilateral Sacral Flexion (Sacral shear) and Upslipped Innominate
Block inferior ILA with pt hand, wallet, towel, or wedge
Grasp leg above ankle and abduct until SI joint is gapped
Internally rotate leg to point of SI gapping
Apply traction and then perform a swift tug (can use ME as in upslipped esp in geriatric pt.)
right sacral shear
Previously taught

84. Prone, Direct, Springing Sacral shear and upslipped innominate
May stand or sit as shown, on same side as shear
Find amount of abduction that gaps joint and internally rotate leg (see pdf and video)
Thenar eminence on inferior ILA, other hand on top of it
Pt breathes in; at height of inhalation - spring sacrum in an anterior/ superior direction
left sacral shear
This may be a muscle energy technique if you ask the patient to use their
abductors to pull the leg on the affected side towards midline. Usual ME technique -
Or have them hold to the point of air hunger with an inspiratory hold.

86. Unilateral Sacral Extensions
Findings:
Rare
L Base P
L sulcus shallow
L ILA ant/markedly superior
STL loose
Spring: may be positive (no spring!)
Motion:
Sacral Base: L R +/-
ILA: L +/ R +/- S A P-
+/-
ASIS compression test + on L in this example.
+/-
A/S
+/-
P/I

87. Unilateral Sacral Extension
Patient prone, physician on dysfunctional side.
Place the thenar eminence of the treating hand over the sacral base of the dysfunctional side of the sacrum.
Abduct ipsilateral leg until motion is felt by the palpating hand (~ 20), & then internally rotate the leg.
Instruct pt to exhale fully & hold it.
Exert a downward pressure over the sacral base while pt. inhales, resisting sacral extension.
The pressure is maintained for 3 – 5 seconds while gapping the SI joint on the side of the dysfunction.
This may be accomplished by bending the patient’s knee 90  & gently internally rotating the patient’s abducted leg.
Repeat above 2-3 times & recheck.

88. Left Neutral Sacral Oblique Axis Somatic Dysfunction
Name: L on LOA, RL on LOA, L Forward Torsion
Seated Flexion: Positive on R (rec use for confirmation)
Landmarks: if calling on L side as lateralized
Sacral Sulcus: L Shallow
Sacral Base: L Posterior
ILA: L Post./ Inf.
STL: L Tight
Motion Testing:
Spring: - (It springs!)
Sphinx: - (improves with extension)
L5: NSLRR
Sacral Base L - R +
ILA: L +/- R +/-
L5: SLRR
A +
P+/-
Neutral - Right Oblique Axis Findings:
Name: R on ROA, RR on ROA, R forward torsion
Lateralization: Right
Landmarks:
Sacral sulcus: L deep
Sacral base: L anterior
ILA: R Post/Inf.
STL: R tight
Motion Testing:
Spring: -
L5: SRRL
Sacral Base: L +
ILA: R +/-
Left Right
Midline

89. Neutral Sacral Rotation on the Same Oblique Axis: Ex: L on LOA Prone, Physiologic response: Operator springing, ME, or Resp. force, or combine activating forces.
Patient L lateral recumbent and physician facing patient
Side of oblique axis toward table
With knees bent, flex hips to greater than 90 degrees with knees off table
Physician seated, support patient’s knees with thigh
While monitoring lumbosacral junction (or sacral base), instruct patient to hug table (We LOVE neutrals!) until motion localized at lumbosacral junction
Flex to > 90°

90. Neutral Sacral Rotation: L on LOA (Rotated Left on a Left Oblique Axis) Prone, Physiologic response: Operator springing, ME, or Resp. force
With forces localized at lumbosacral junction, grasp spinous process of L5 and pull away from table. You may also simply monitor the R sacral base to be sure it is moving posteriorly.
Apply activating force to the patient’s feet toward floor to localize sidebending while monitoring sacral base opposite of axis
LVMA springing
ME – repeat three times
Resp. force
Can utilize a combination of the above forces.
Repeat activating force until adequate motion felt at sacral base
Recheck
Lumbar spine is flexed, Rotate left, sidbent left, he rotates right at the sacrum

91. Neutral Sacral Rotation: Rotated Left on a Left Oblique Axis: L on LOA Sitting, Direct, articulatory, Pt. coop.
Patient seated and physician behind patient
Use thumb to monitor for motion at sacral base on side of diagnosed oblique axis
Opposite hand grasps shoulder to guide patient into R sidebending toward opposite side of diagnosed oblique axis and L rotation (L5 NSRRL)
Induces a R on ROA
Instruct patient to “Arch your back” and then “Slump forward”
Continue extension and flexion cycle of LS junction while adjusting sidebending and rotation until sacrum releases with motion at thumb
Good for pregnancy. Here we change the axis, not induce physiologic effect. Now if we have Left on LOA,, we create R on ROA

92. Right Neutral Sacral Oblique Axis Somatic Dysfunction
P+/- A+
L5: SRRL
Name: R on ROA, RR on ROA, R Forward Torsion
Seated Flexion: Positive on L (confirmatory)
Landmarks:
Sacral Sulcus: R Shallow
Sacral Base: R Posterior
ILA: R Post./ Inf.
STL: R Tight
Motion Testing:
Spring: -
Sphinx: -
L5: NSRRL
Sacral Base L + R -
ILA: L +/- R +/-
To treat this dysfunction, set up everything the opposite of slides or 91.
Left Right
Midline

93. Left Non-Neutral Sacral Oblique Axis Somatic Dysfunction
Name: R on LOA, RR on LOA, L Backward Torsion
Lateralization: Right (use for confirmatory)
Landmarks: calling Left lateralization in this example
Sacral Sulcus: L Deep
Sacral Base: L Anterior
ILA: L Ant./Sup.
STL: L Loose
Motion Testing:
Spring: + (It does not spring!)
Sphinx: + (findings worsen with extension)
L5: confirmatory FRLSL
Sacral Base L - R +/-
ILA: L + R +/-
L5: RLSL
P+/-
A+
Left Right
Midline

94. Sacral Rotation on the Opposite Oblique Axis (Ex: R on LOA) Tx: Lateral Recumbent, Direct Physiologic Response, Respiratory force, Springing, ME Kimberly Manual A, P
Patient lateral recumbent and physician facing patient
Side of oblique axis toward table
With knees bent, flex hips to less than 90 degrees with knees off table
Draw shoulder on table forward so patient’s torso faces upward to induce rotation to lumbosacral junction
Reverses rotation
Physician seated, support patient’s knees with thigh
Non-neutrals hate the table
Patient is now Sleft, rotate right, created neutral, now have left on LOA. Listen to slide

95. Sacral Rotation on the Opposite Oblique Axis (Ex: R on LOA) Tx: Lateral Recumbent, Direct Physiologic Response, Respiratory force, Springing, ME Kimberly Manual A, P
With patient’s knees balanced on thigh, apply activating force on feet toward floor
Sidebending maintains axis
Repeat activating force until adequate motion felt at sacral base
LVMA springing ME
Respiratory force
Reassess

96. Sacral Rotation of the Opposite Oblique Axis ( Ex: R on LOA) Tx: Sitting, Physiologic Response, ME Kimberly Manual: B, P
Patient seated and physician behind patient
Use thumb to monitor for motion at sacral base on opposite side of diagnosed oblique axis
Opposite hand grasps shoulder on opposite side of oblique axis
Guide patient into extension, rotation away from axis, and sidebending toward axis
Instruct patient to gently try to bend to the side away from the axis while physician provides counterforce
Patient then relaxes and physician moves to new barrier
Reassess

97. Right Non-Neutral Sacral Oblique Axis Somatic Dysfunction
Name: L on ROA, RL on ROA, R Backward Torsion
Lateralization: Left (use for confirmatory)
Landmarks: if patient lateralized Right
Sacral Sulcus: R Deep
Sacral Base: R Anterior
ILA: R Ant./ Sup.
STL: R Loose
Motion Testing:
Spring: +
Sphinx +
L5: FRRSR
Sacral Base L +/- R -
ILA: L +/- R +
L5: RRSR
P+/-
For this, reverse all the setups from slide or 96.
A+
Left Right
Midline