lumbosacral coupling assessment

[mulberry]

I believe that pain is a product of dysfunctional athrokinematic coupling. In particular the lumbo sacral coupling biomechanics is able to objectively demonstrate dyfunctional patterns that should be used to determine appropriate treatment.

To do this the patient is positioned in prone. The therapist starts with stabilising the sacrum over S2/3 and performs hip flexion.

Limitation of hip flexion will determine the side to continue assessment.

Take up the slack, reaching the barrier of hip flexion a spring test is performed over the ishial tuberosity. (a hard end feel is abnormal a springy end feel is normal).

The next step is to apply sustained pressure over the ishial tuberosity while performing hip IR / ER. The osteokinematics of the ishial tuberosity should inflare with hip ER and outflare with hip IR . limitation into direction determines treatment.

Then sustained pressure is applied over the ipsilateral ILA adjacent to the sacral hiatus. hip IR /ER is performed and the osteokinematics of the sacral ILA should cause derotation of the ipsilateral ILA with hip ER and ILA prominence with hip IR.

The sacral base is assessed with sustained pressure over the ipsilateral region while hip ER / IR is performed. the osteokinematics of the ipsilateral sacral base should increase in prominence with hip ER and derotate with hip IR.

Finally the lumbar segments are assessed with sustained pressure over the facet joints of each level while performing hip ER and IR. The osteokinemeatics of lumbar coupling are derotation with hip ER and prominence with hip IR.

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[alophysio]

Hi Mulberry,

Interesting post.

I think i agree with you...not everything is clear to me - e.g. are you still prone. How do you do hip F when prone - over the side of the bed or is it isometric? What is a limitation to hip F? What happens if Both SIJ or both hips are dysfunctional?

What are the findings indicative of? e/g/ spring test (what direction are you springing in - AP/PA/CC?)

Limitation into direction determines treatment - of what? and how?

De-rotation of L/S segments - which direction? which side? e.g. L L/S facet joint prominence with R hip IR?

Some more information would be nice?

Is there anything in particular that you would like to discuss?

Thanks!

[mulberry]

Thanks for the feed back sorry i didn't explain the process very well i will try again

you start with the patient in prone throughout the test; first perform unilateral knee flexion (pheasants test) stabilising the sacrum over S2/3, to determine tight hip flexors which causes a hip flexion if tight.

start on the tight side first then perform a spring test (PA) while in prone over the ischial tuberosity; this should cause posterior rotation of the hemipelvis which will indicate either the restriction of the hip flexors or restriction of the deep hip rotators attached to the ischial tuberosity; obturators and gemelli and indicates limited outflare and posterior rotation of the hemipelvis.

the next step is to apply sustained pressure over the ischial tuberosity take up the slack with knee flexion until you feel the ischial tuberosity dig into your palm. hold this position and apply hip external / internal rotation. the osteokinematics of the ischial tuberosity should derotate;meaning move away from the palm of the hand down into the surface which feels as though the bone is moving away from you and your palm should feel as though it is sinking into the body down intothe ground, with Hip ER. this demonstrates the ability and of the hemipelvis to outflare and posterior rotate. limitation will indicate limitation into this direction.

Hip ER in prone position should cause the sacrum to counter nutate (posterior rotation) because of the open kinetic chain the hemipelvis and the ipsilateral sacral base and ILA will follow the posterior rotation which is usually opposite in nature with a closed chain movement.

then sustained pressure is applied over the ipsilateral ILA adjacent to the sacral hiatus and hip ER /IR is performed . The osteokinematics of the sacral ILA should derotate with hip ER. limitation will indicate a fixation of the ILA which considered with the sacral base will lead to diagnosis of a sacral shear or torsion.

the sacral base is assessed with sustained pressure over the ipsilateral region of the sacral base while hip ER / IR is performed. the osteokinematics of the ipsilateral sacral base should increase in prominence; move towards your hand giving you the feeling of the bone pushing into your palm with hip ER and derotate with hip IR. limitation will help diagnose a flexion or an extension fixation of the ipsilateral SIJ.

Finally the lumbar segments are assessed with sustained pressure over the ipsilateral facets of each level while performing hip ER /IR. the ipsilateral lumbar facets should derotate away from the thumb; the thumb should sink deep into the body toward the ground with hip ER. limitation will demostrate the fixated lumbar segments.

the fixations are released once demonstrated and reassessed.

thanks for the feedback much appreciated hope the editing has helped try it out and tell me what you think.

[alophysio]

Hi Mulberry.

If i have followed correctly, i think you have an interesting concept but it may have gaps in the theory - potentially causing things to be missed...

... I will put my thoughts in with your quotes if you don't mind...also, it seemed to me to be a random kind of post...there isn't any question or discussion point...almost like a statement of belief...are you trying to clarify your thinking?

Please take my comments as a fellow colleague, not as someone who is better than you or judging you (which i AM NOT doing!!)

Thanks for the feed back sorry i didn't explain the process very well i will try again

No problem - happy to help

you start with the patient in prone throughout the test; first perform unilateral knee flexion (pheasants test) stabilising the sacrum over S2/3, to determine tight hip flexors which causes a hip flexion if tight.

Had to look this one up It seemed to be a L/S test...it might also be overactive hip flexors (which is a neural, not myofascial problem) or it might be a physical shortened nerve or a chemically sensitised nerve...all of which can cause premature hip F...

start on the tight side first then perform a spring test (PA) while in prone over the ischial tuberosity; this should cause posterior rotation of the hemipelvis which will indicate either the restriction of the hip flexors or restriction of the deep hip rotators attached to the ischial tuberosity; obturators and gemelli and indicates limited outflare and posterior rotation of the hemipelvis.

ok...are you stabilising the sacrum? Otherwise you might just be causing F at L5/S1 and higher. Also, what about the effects of mm bulk affecting the ability to cause a true PA on the ish tub? Overactivity of the superficial sacral and lumbar multifidus can affect your test as can the obturator nerve to some extent... just some thoughts...also, how far do you PA - what joint are you looking to assess? the SIJ? how do you know when you have taken up the joint ROM to R1 and R2?

the next step is to apply sustained pressure over the ischial tuberosity take up the slack with knee flexion until you feel the ischial tuberosity dig into your palm. hold this position and apply hip external / internal rotation.

hmmm, sounds like obturator nerve involved here and femoral nerve in addition to your hip flexors...just adding other possible structures/reasons for the positive result of this test...

the osteokinematics of the ischial tuberosity should derotate;meaning move away from the palm of the hand down into the surface which feels as though the bone is moving away from you and your palm should feel as though it is sinking into the body down intothe ground, with Hip ER. this demonstrates the ability and of the hemipelvis to outflare and posterior rotate. limitation will indicate limitation into this direction.

yes, i agree with these these statements except for the outflare bit...but that is language - i think the outflare you see in posterior rotation is just the normal movement that occurs because of the angle of the SIJ which is neither purely in the coronal, saggital or transverse plane...but you are assuming the tight hip flexors are causing the problem (and/or overactive hip F, nerves, etc). But what about if they have a truly articular problem like a calcified hip, labral tear, etc or a motor control problem such that they can't control the centering of the femoral head? Or what if their L/S has increased relative flexibility such that it will extend under the myofascial tension BEFORE the hip stops extending and thus causes the innominate to posteriorly rotate?

Hip ER in prone position should cause the sacrum to counter nutate (posterior rotation) because of the open kinetic chain the hemipelvis and the ipsilateral sacral base and ILA will follow the posterior rotation which is usually opposite in nature with a closed chain movement.

This, however, i have issues with...In the presence of increasing load (myofascial/ligamentous tension), the SIJ will accept the load by close-packing the joint a bit more (in normals). Therefore, the intrapelvic torsion that you induce (e.g. R posteriorly rotated innominate causes a relatively R rotated sacrum and relatively anteriorly rotated inominate) will cause that R SIJ to close pack - that is the sacrum will nutate RELATIVELY to the R innominate AND to the L innominate in normal function. However there will be torsion within the pelvis itself - torsion is a normal physiological function.

Now if you mean that the sacrum will appear to come further posteriorly than the L innominate, then i agree. I suppose i am talking arthrokinematics rather than osteokinematics but this confuses people.

Arthrokinematically, in normal function, increasing load increases relative nutation at the SIJ relative to that innominate to accept increasing load transfer. Now that should occur in no matter what position the pelvis is in, even in supine where the SIJs are in the loose packed position.

Whether closed chain or open chain, accepting increasing load should close pack the joint - and i do think the load is different in open vs closed chain function but the principle of increased load = inc close pack position of the SIJ still applies...

then sustained pressure is applied over the ipsilateral ILA adjacent to the sacral hiatus and hip ER /IR is performed . The osteokinematics of the sacral ILA should derotate with hip ER. limitation will indicate a fixation of the ILA which considered with the sacral base will lead to diagnosis of a sacral shear or torsion.

Now i am assuming that we are still progressing from the positions above...Ok, problems with the language here again...a PA here SHOULD produce a counternutating motion of the SIJ with a torsion/rotation of the sacrum since you are ipsilaterally doing this. Is this what you mean by de-rotate?

When you say “detrotate” i think of counternutation of the sacrum arthrokinematically. Again during ER in normal function, i think it will still maintain it’s efficient load transfer position.

Now about what it should and shouldn’t do...what if there is ligamentous disruption of the SIJ – then it will definitely move too much but you don’t mention that. You assume that the problem is a fixation of the joint...which it might be with a history of trauma but what if the joint is myofascially compressed and held so tight it doesn’t move in the way you want? Or if the joint motion (which has been shown to be variable across individuals) is taken up with the other tests already? This is where a lot of what i would consider some logical errors might occur...

the sacral base is assessed with sustained pressure over the ipsilateral region of the sacral base while hip ER / IR is performed. the osteokinematics of the ipsilateral sacral base should increase in prominence; move towards your hand giving you the feeling of the bone pushing into your palm with hip ER and derotate with hip IR. limitation will help diagnose a flexion or an extension fixation of the ipsilateral SIJ.

Again, language. De-rotate, rotate, etc – we need to define these more carefully. Standard osteokinematic terms for the sacrum are I believe nutation, counternutation, rotation and side bending...i will need to check these again.

Again, by applying your pressure over the sacral base and feeling for osteokinematic movement, it doesn’t tell you about the joint function which i think is much more important. If the joint does what you (as in mulberry) expect it to as described above, then all that tells me is that the articular structures seem to be intact. It doesn’t tell me about the myofascial structures, the neural structures or motor control nor about their normal function. A positive result in your test doesn’t distinguish between these problems in my honest opinion.

Finally the lumbar segments are assessed with sustained pressure over the ipsilateral facets of each level while performing hip ER /IR. the ipsilateral lumbar facets should derotate away from the thumb; the thumb should sink deep into the body toward the ground with hip ER. limitation will demostrate the fixated lumbar segments.

So just like problems in the SIJ can cascade into the L/S, problems in assumptions and logic can cause problems further down the track!! Again, this is just my opinion and a great discussion if i may say so myself!

Again, i would prefer to see the joints themselves assessed. With a thumb only on one bone, it will only tell you have one bone moves. I do like the thought that the kinetic chain is being assessed and i don’t disagree (so long as we agree on the language) as to what the bones should be doing in normal function but language is very confusing.

Other starting position issues include...
1. Is the patient symmetrical already?
2. Are the L/S joints in Flexion (and so increased movement available) or extension and so decreased movement available?
3. Do they have a hip problem, SIJ problem or L/S problem?
4. What is the driving factor...for example, the L/S driving the problem can cause rotation from the top down – that is, A right rotating L5 on S1 will appear rotated further R than the sacral base and ILA...however a R rotated sacrum driving rotation will have a R rotated sacrum but the L5 will appear relatively rotated to the L when compared to the sacral base EVEN THOUGH it is rotated R compared to it’s initial starting position. I hope that made sense!

the fixations are released once demonstrated and reassessed.

Again, you assume these are joint problems and treat them as fixations...or at least that is what i think of when you say fixation. And i believe you truly get results because joint treatments have neurophysiological effects which improve overactive muscles and can “reset” motor control even if only for a short time which can give you a window to retrain their system.

So please don’t think i am judging or saying you aren’t any good. I am in fact glad to be contact with you and discussing this because at least you are thinking about things which is more than most physios in my honest opinion! If i didn’t think it was worthwhile, i wouldn’t spend the time talking about it 

Also, i don’t proclaim to be the world’s foremost authority on this nor do i claim to be better than you...i am just discussing my beliefs of the lumbopelvic hip with you, a fellow colleague so please take my comments as such.

thanks for the feedback much appreciated hope the editing has helped try it out and tell me what you think.

No problems. I have tried similar things before...it is the language that is confusing!

Have you read the new edition of Diane Lee’s book – “The Pelvic Girdle”? It is awesome and contains good information on all of this and practical assessment and treatment techniques with videos included!

Sorry for the long post but i love this topic!