Pelvic Fixations

      Total Sacroiliac Fixations

We know today that there are relatively few total fixations of the articular type at the sacroiliacs. By far, most of them seem to be ligamentous. This region is complicated further by the fact that the superior or inferior portions of the sacroiliac ligaments can become tightened quite separately one from the other. The pubic articulation can also appear to be in total fixation, which is also due, it would seem, to shortened ligaments.

      Sacroiliac Muscular Fixations

The primary muscles that Gillet has found to influence the lumbopelvic region are the lower portions of the quadratus lumborum, the fibers extending from the L5 transverses to the crest of the ilia and the two coccygeous muscles coursing from the inferior part of the sacrum and the superior aspect of the coccyx to the corresponding part of the ilium. Two other important muscle groups to consider here are the hamstrings and the lumbar extensors.

The Hamstrings.   Shortened hamstrings are common, and they may be found either bilaterally or unilaterally. Taut hamstrings prevent pelvic rotation at the hip anteriorly by fixing the ischium and destroying normal lumbosacropelvic rhythm; thus, any motion achieved is forced upon the lumbar segments, often with compensatory stretching of the posterior longitudinal ligaments. If movement is sharply forced, avulsion may occur that leads to further degenerative changes. [See Clinical Comment 6.6]

      DR. FAYE'S CLINICAL COMMENT #6.6.

Failure of the hamstrings to elongate normally produces stress on the posterior elements of the lumbar spine because the extensors muscles are at the end of their eccentric contraction and the lumbar spine is hanging on its ligaments. Repeated stress from this scenario causes hypermobility of the zygapophyseal joints and increased intradiscal pressure. Anular tears and the pathogenesis of disc degeneration develop from the faulty biomechanics of the hamstrings. This is just one etiologic factor but an often overloooked point in treatment programs. PNF or spray-and-stretch of the hamstrings, quadriceps, and psoas muscles should be a priority consideration with all patients except those that are in the acute stage and cannot withstand the stretches. Chiropractors should declare war on shortened back and thigh muscles.

The Lumbar Extensors.   Shortening of the lumbar extensors has the opposite effect as that of hamstring shortening. This is a common cause and/or effect of hyperlordosis. If the hamstrings are normal and the perivertebral muscles are tight, it will be found that pelvic motion is free but lumbar flexion is restricted. If movement is forced, overstress is placed on the hips, sacroiliac joints, and posterior soft tissues of the lumbar region. This leads to chronic strain, sprain, avulsion, spurring, and degenerative arthritis.

The effects of shortened iliopsoas or piriformis muscles upon the hip and lumbar spine will de described later in this chapter. In a certain number of purely muscular fixations, the contracted or hypertonic muscle will have a tendency to degenerate and become fibrosed. For all practical purposes, it becomes a "ligament" and, as most muscles are accompanied by a ligament, it is often difficult to determine which structure is responsible for the fixation. Fortunately, the type and direction of a corrective thrust is practically the same, and even the amount of change to be expected from a fibrosed muscle or a shortened ligament is the same. Both of these types of fixations can therefore be considered "ligamentous." From the point of view of correction, this fixation is the most common, although it is not the most irritative.

      Correction of Anterior or Posterior Pelvic Tilt

Forward Tilt.   An anterior tilt of the ilium is primarily the product of

(1) weak abdominals, hamstrings, or both,

(2) hypertonicity of the lumboextensors or hip flexors,

(3) contractures of the rectus femoris, or a combination of these factors.

Some authorities believe that the resulting distortion is "the most common postural fault of muscular origin." Strengthening the inferior pull of the hamstrings posteriorly and the rectus abdominis superiorly offers an in-line force couple to correct anterior pelvic tilt. The erector spinae, quadratus lumborum, and iliopsoas usually need stretching.

Backward Tilt.   Conversely, posterior tilt of the ilium is typically the result of

(1) hypertonic abdominals,

(2) shortened hamstrings, or

(3) weakened lumboflexors or hip extensors, or a combination of these factors.

In either cases of forward or backward pelvic tilt, biomechanical correction should incorporate

(1) mobilization of fixated facets,

(2) strengthening of weak musculature,

(3) stretching of contractures, and

(4) relaxation of hypertonicity.

      The Sacroiliac Ligaments

The Posterior Sacroiliac Ligaments.   White/Panjabi state that the interosseous sacroiliac ligaments supporting the thin joint capsule posteriorly and inferiorly are the strongest of the body. These ligaments, considered the major bond between the sacrum and ilia, are so thick that they fill the roughened space between the sacral and iliac tuberosities behind the sacroiliac joint. There is an upper portion that spans between S1-S2 and the anterior medial iliac crest. Immediately below is the lower part of the ligament that arises from S3 and inserts into the iliac crest. The strength of these ligaments helps prevent displacement of the sacrum even during forceful jumping.

The Anterior Sacroiliac Ligaments.   The primary ligament straps anteriorly are the thinner anterior sacroiliac ligaments at the superolateral aspect of the sacrum and the stronger sacrospinous ligaments that extends from the inferolateral aspect of the sacrum and coccyx to the spine of the ischium. The superolateral ligaments appear to be little more than extensions from the anterior capsule.

      Sacroiliac Ligamentous Fixations

According to Gillet, no other area of the axial skeleton is prone to fixation from ligamentous shortening more than the sacroiliac articulations. In fact, he feels that it is almost impossible to find a state of clinical imbalance that does not reflect this state. This is probably because few occupations require pelvic motion throughout the maximum range of possible motion. However, generalized bilateral ligamentous shortening in itself is not necessarily a cause of clinical concern even if a state of mobility is considered ideal. Gillet believes that the clinical state of the sacroiliac ligaments is determined by the habitual positions the articulations are required to maintain in the patient's lifestyle. See Figure 6.10.

The iliolumbar, sacroiliac, and sacrotuberous ligaments are common sites of ligamentous shortening that affect pelvic dynamics, and they appear to become involved in that order according to Grieve. Gillet, however, reports many cases of iliolumbar and sacrotuberous fixation without involvement of the sacroiliac ligaments.

The Iliolumbar Ligaments.   The iliolumbar ligaments connect the transverse processes of L5 to the crests of the ilia and sacral base. As an iliolumbar ligament becomes shortened, the iliac crest tends to be pulled medially while the ischium is forced outward. In response to the load above, the sacral base is pushed forward and the sacral apex is pulled backward. Thus, the patient's pelvis will exhibit the normal state of the sitting pelvis in the standing position. This same condition may be the result of a fibrotic or reflexly contracted quadratus lumborum.

Aside from the articular facets, the iliolumbar ligaments are often the most important structures limiting axial rotation of L5 on the sacrum and preventing forward gliding of L5 on the sacrum. Because of its deep position below the iliac crests and the strong strapping by the iliolumbar ligaments and spinal extensors, L5 is only as movable as the sacral base will allow. Thus when lipping or spurs at the inferior aspect of the centrum of L5 are seen (signs of overstress), a history of instability can be presumed.

In Gillet's studies of fixation, as mentioned in the previous chapter, he found that the 5th lumbar acts as part of the pelvis and there the most common ligament at fault is the iliolumbar.

The Sacroiliac Ligaments.   When the posterior ligaments shorten, they tend to push the sacral base forward so that the PSISs appear more prominent and closer together. When the anterior ligaments shorten, the sacral base has a tendency to bulge posteriorly, with an unusual mass palpable medial to the PSISs that have flared further apart.

The Sacrotuberous Ligaments.   The sacrotuberous ligaments have a strong tendency to shorten. When tight, the sacrum displaces deeper between the two ilia like a driven wedge. With the patient in the lateral recumbent position, deep gluteal palpation will reveal the taut cords. Grieve reports that ipsilateral calf and heel numbness is often associated, thus suggesting sciatic nerve involvement.

Shortening of the sacrotuberous ligaments can also be palpated through the relaxed gluteal muscles when the patient is prone. They will be felt as short, taut, tough cords. The pull of the ligament is usually not total, reports Gillet. In the knee lifting test, the sacrum is capable of moving downward towards the ischium somewhat but it does not move back into its normal location. Furthermore, this motion takes place in one articulation only, the one opposite the side of the lifted knee instead of moving harmoniously in each articulation. This is another example of the hypermobility that usually accompanies partial fixations (ligamentous or muscular).

Shortening of the Sacroiliac Capsular Ligaments.   Shortening of the capsular ligaments should give us an "articular" fixation, but here again the amount of fixation is not total for there is still a certain amount of torsion possible in the fixed articulation.

This characteristic of capsule ligament shortening is especially found in extraspinal articulations; eg, in the feet where there are many fixations between the calcaneus, the metatarsals, and the tarsals. These same fixations can also be found in the superior articulation of the fibula with the tibia, in the metacarpals, and in the lateral and medial articulations of the clavicle. Remember that these fixations have noxious effects either in themselves or through the reflex fixations they produce in the spine.

Gillet and associates have found few spinal fixations that can be explain- ed by shortening of capsular ligaments. On the other hand, practically all other spinal ligaments seem to be involved in fixations. In fact, ligament shortening should be a characteristic of all articular fixation, for it is a normal function of ligaments to take up the slack and adapt themselves to the amount of motion produced in an articulation.


Sacroiliac Motion Palpation

It has just been explained that covering the sacroiliac articulations are a host of ligaments which, if normal in tension and elasticity, control sacroiliac motion and assure that the articular surfaces remain within normal limits. Unfortunately, most people use a majority of specific and specialized movements rather than maintaining a healthy mobility in all possible ranges of motions. This causes one or several of these ligaments to shorten and tighten, which in turn causes the involved ligament to serve as a new, but abnormal, center of rotation that may restrict mobility in one or several directions. The pubic joint, for example, may tighten and effectively hinder A-P and P-A rotation of the ilia. In the sitting position, however, the sacrum will still be able to move between the ilia; in fact, hypermobility of both sacroiliac joints in the sitting position will occur, and at the same time, a total fixation of the ilia will be found in the standing knee lift test described earlier in this chapter.

Some of Gillet's postulates described previously in this chapter will be summarized in this section for emphasis.

      The Standing Flexed-Knee-Raising Test

The sacroiliac and the lumbosacral joints should be palpated in the standing and/or sitting positions. Several sacroiliac tests are suggested below, and each should be conducted bilaterally. The thumbs are usually used for palpation because deep pressure is necessary to hold firm contact during the tests.

Standing General Sacroiliac Motion.   To screen iliac flexion and extension on the sacrum in the standing position, the examiner's thumbs are placed on the patient's PSISs and the patient is asked to raise the right knee up and down, bending the knee as if taking a high step. The right PSIS will be felt to arc posteriorly and inferiorly. After about 20° of leg raise, the patient's left sacroiliac PSIS also drops backward and downward. This is normal sacroiliac motion. Any motion other than this indicates a problem in this joint. Repeat the test by having the patient raise the left flexed knee up and down (Fig. 6.11). If the joint is fixated, the pelvis tends to move as a whole and the ipsilateral thumb will tend to remain level or possibly raise rather than drop. These signs of thumb movement can be seen as well as felt.

Standing Superior Joint Motion.   Place one thumb on the sacral base of the patient and your other thumb on the right PSIS. Ask the patient to raise the right flexed knee as if taking a high step, and note the separation of the thumbs. The sacral base will normally be seen and felt to arc ¼–½ inch anteriorly and inferiorly. Or, conversely, the PSIS will move backward and downward. Repeat the test with the patient raising the left flexed knee. During these tests, the tissues over the sacroiliac joint should relax. If the superior sacroiliac joint or the symphysis pubis is locked, the sacrum and ilium will move as a unit, the thumbs will not separate appreciably, and the sacral tissues (ligaments and spinal muscle attachments) will remain taut. This, states Gillet, is probably the most common pelvic fixation found. Invariably, there is a degree of forward tilting of the pelvis and associated lum- bar hyperlordosis.

Standing Inferior Joint Motion.   Place a thumb on the patient's sacral apex and your other thumb on the ischial protuberance. Ask the patient to raise the knee on the side first being tested. A ¼–½-inch excursion should be felt as the ischium moves anterosuperior and slightly lateral on the sacrum. If the inferior sacroiliac joint is locked, the ischium and sacral apex move as a unit (Fig. 6.12). Fixation of this motion is most often associated with a contralateral sacral base fixation. The direct cause is usually failure of the muscles acting on the sacral apex to stretch. Piriformis contracture is a common cause, but the iliopsoas or deep glutei may be the cause or a contributing factor.

Anterior Sacral Fixation.   In some patients, the anterior sacroiliac ligaments will have shortened but not the posterior ligaments. These anterior ligaments can be divided into superior and inferior straps. If one is short, A-P rotation in the knee lifting test will still take place, but the center of sacroiliac rotation will have changed. Instead of taking place at the head of the femur, it will be found at the offending ligament. A related hypermobility will exist at the pubic articulation. This A-P mobility or immobility can be palpated by placing one thumb on a PSIS and the other thumb on the corresponding part of the sacrum. When the patient lifts the knee, the ipsilateral ilium will normally arc backward and downward. If the contacts are taken on the inferior part of the ilium and sacrum, the former will be felt to move forward and upward. During fixation, both of these movements will be sluggish, quickly reaching their limits and pulling the sacrum into a visible distortion.

Posterior Sacral Fixation.   Fixation at the posterior ligaments is more difficult to palpate because the palpating thumbs are over the actual center of rotation, thus unable to register perceptible movement. However, if the patient is turned around and the ASISs are contacted, the knee lifting test will show abnormal mobility. It appears that these forms of sacroiliac fixations also insult the movement of the sacrum itself between the ilia, as tested in the sitting patient, making the motion sluggish or even nonexistent. Bilateral shortening of these ligaments also alters the in- and out-flaring of the ilia when the patient is either standing or sitting.

      Gillet's Standing Straight-Leg-Raising Test

With the patient standing, it is also helpful to have the patient lift the leg with the knee extended. This will produce a decided change in the movement found in partial fixations, for, as previously explained, the normal movement of the ilium on the side of the flexed knee is a rotation around a point that is about the head of the femur. When the knee is not flexed, the pull of the posterior muscles will change the center of rotation to a point at or near the pubic articulation (contrary to that seen in the supine position). This will make no practical difference if these articulations are completely free, but it may cause a partial sacroiliac fixation to appear as a total fixation. To make this clear, it will be necessary to describe all possible points of fixa- tion in this area.

      Differential Analysis

It seems that the different sacroiliac ligaments can shorten individually. Four of these points can be found on each side, two anterior (one superior and one inferior) and two posterior (one superior and one inferior). Any combination of fixation at these four points on each side can be seen; any two or three points being simultaneously in fixation would be considered a "total" fixation. See Figures 6.13 and 6.14. For this reason, a detailed differentiating form of analysis in this region should be used.

Let us take as an example a sacroiliac fixation at the anterior-inferior portion of the sacroiliac articulation. It is evident that when the patient's knee is raised (patient standing), the ilium rotates around this fixed point rather than around an axis at the head of the femur. There will be motion, but the motion will be around an abnormal axis. Furthermore, the posterior part of the ilium opposite the fixed point will appear to move, although the amount of motion will be smaller than normal. In some cases, especially if the palpator is in a hurry, this half movement may be mistaken for total motion.

There are other ways of revealing such a fixation for confirmation. One will be described later when the patient is in the sitting position. In the standing position, which is our present topic, the following two tests can be made:

1.   When lifting the leg straight, the pubis is blocked physiologically, forcing the facet of the ilium to glide downward on its sacral counterpart. Thus, any fixation in the joint will effectively stop this gliding and the fixation will be more evident.

2.   It is also possible to have the patient lift the opposite knee, while you maintain your palpation contacts on the ilium and the part of the sacrum on the side of the weight-bearing limb.

To fully grasp the purpose of this, it is necessary to review the normal movement of these articulations. When the unfixated subject lifts a knee, the first part of sacroiliac motion occurs in a gliding manner, in the articulation that does not bear body weight. If, however, the knee is forced a little higher, the first articulation to come to the end of its range of motion is the opposite joint, the weight bearing one that is forced to move. That is, the active ilium continues its motion by pulling the sacrum with it, forcing the sacrum to move on the opposite ilium.

This motion can be felt and seen when the palpating thumbs are put in contact with the sacrum and ilium on the weight-bearing side. It is thus necessary, in this test, to have the patient raise the knees one after the other, putting your thumbs alternatively over the right, left, superior, and inferior portions of the articulations. There must be palpable-visible movement at all points when each knee is raised to be sure that these articulations are completeIy free of fixation.

When an articulation is completely free, it must be remembered that the sacrum will remain vertical. If it tips laterally, it is a sign that there is a partial fixation somewhere. If the point of partial fixation is at the posterior aspect of the joint, all rotation occurs around that point. No motion will be felt when either the patient's right or left knee is lifted, or even when the limb is lifted straight. This may give the impression of a total fixation, but it is not; for if contact points far removed from the area of fixation are used (ie, the ischia, the iliac crests, or the ASISs of the ilia), a definite motion will be felt.

Readers of Gillet's early notes may be surprised that he does not mention here the test in which the standing patient flexes laterally. The lateral flexion test can be used, but the amount of mobility in a normal pelvis is relatively small in this movement and it is difficult to evaluate correctly.

Gillet's Standing Straight-Leg-Extension Test.   It is also sometimes helpful to have the patient lift the leg backward. Theoretically, this movement should produce the opposite movement to those described above. In practice, however, this test is not used frequently because, in the standing position, the sacrum comes to rest near one end of its range of motion the ischia are close together, the crests are separated, and the sacral base has moved backward to fill the space between the crests. Posterior movement is therefore normally restricted. This is not true in the sitting position, where the sacrum "floats" at or near the center of its range of motion. This permits the palpator to evaluate motion in the different parts of the pelvis quite easily when the patient is in the sitting position.

Evaluating Horizontal Parallel Sway.   Faye attributes the following test for horizontal parallel sway to Grice: The patient stands with legs parallel and is asked to bend sidewards and run the palm of his or her ipsilateral hand down the lateral aspect of the thigh. During the maneuver, the examiner should feel the patient's PSIS glide parallel to the floor in the opposite direction of the patient's lateral flexion. Hip or sacroiliac fixation, however, will cause the PSIS to raise on one side of the pelvis and rotate around one hip joint. Possible quadratus lumborum or psoas imbalance is given as a primary cause.

      Gillet's Comments on Palpation in the Sitting Position

Several alternative contacts taken from Gillet's writings will be described in this section. The important thing is to understand what you are palpating and why, then you may select the contacts of your preference.

According to the principle of palpating the major fixations first, it is helpful to use the back of your hand to generally perceive sacroiliac fixation. As during a spinal screen, your fingers are placed vertically to cover the whole surface of the sacrum. Your forearm may be reinforced by your thigh, which can be used to push your palpating hand forward against the patient's sacrum. This is especially helpful with the patient whose spine has not been corrected to any great degree because its resistance may fatigue your palpating arm.

The sensation of sacroiliac fixation is evident after it has been felt on several patients. It can be described as the difference in sensation that is felt when the hand is pushed against the knee cap (fixation) or the muscles of the thigh (no fixation, or at least, no total fixation). A total fixation will be perceived as a resistance to movement at all points of the articulation. Partial, though important, fixations can be felt if the contact is moved to the superior or inferior parts of the sacrum, or also to the right and left articulations. It has been noticed that some students neglect to palpate the inferior parts of this joint.

Sacral Lateral Flexion During Sitting.   Many palpators prefer changing the contact from the back of the hand to the thumb to find the principal area of fixation. In fact, it is even possible to perceive lateral flexion and rotation of the sacrum between the ilia by placing the thumb in the sacroiliac groove at the four points of contact. To judge medial and lateral glide of the upper sacroiliac joint, Gillet palpates just medial to the PSIS and asks the patient to open and close the legs. The ilium should glide medially and laterally over the lateral border of the sacrum.

Lateral flexion and rotation can be felt in still another way, by placing the lateral aspect of the forefinger vertically against the tips of the sacral spinouses. The patient is flexed to one side and then to the other with your free hand on the patient's shoulders. The sacral spinouses should be felt to glide towards the convexity of the lumbar curve. This movement is normally a wide and free one. In fact, an abnormal amount of motion may be felt in some cases. This occurs when there is a total fixation of the pubis.

For palpators who have difficulty in palpating the movement of the whole sacrum in this way, it is possible to feel the mobility of the superior part of the joint by contacting the first sacral tubercle with the thumb and then the mobility of the inferior part of the joint by palpating the end of the coccyx with the tip of your second finger. The back of the hand is anchored on the palpating stool, with the tips of the fingers pressed up against the tip of the coccyx (through the patient's underclothes). On lateral flexion of the patient, the coccyx will be felt to glide right and left over your finger. Care must be taken to concentrate the lateral flexion of the patient's lower back by pushing down and centrally against the patient's shoulder on the side of lateral flexion.

In lateral bending of the spine, there is also a tilting of the ilia toward the convexity. This distorts the pelvis into a sort of leaning capital M in which the two upright lines represent the ilia and the two others (forming the internal V) represent the sacrum. In this movement, the pubis is forced into lateral gliding. If there is any fixation in this articulation, the sacral motion will occur, but the ilia will not tip. This movement (or the lack of it) can easily be felt by placing the palpating thumb on the iliac crest on the side opposite to the lumbar flexion. Upon forced flexion, this crest flares laterally.

Contact may also be taken on the ischium of the same side. The palpating hand is placed as in palpation of the coccyx, with the back of the hand on the palpation stool and two fingers on either side of the ischium. Upon forced lateral flexion of the patient, the patient's ischium should normally be felt to glide laterally.

Sacral Rotation During Sitting.   Normal rotation (or its absence) can be felt: (1) on the sacrum by evaluating the lateral movement of the upper sacral tubercles, (2) in the ilium, by contact on the iliac crest and feeling its forward rotation. The ASIS can also be palpated (from the back or the front) and felt to move downwards. Torsion-rotation of the different parts of the pelvis in the sitting position normally takes place around one ischium. The sacrum flexes to the anterior side of rotation, the anterior ilium rotates forward, and the posterior ilium rotates backward but to a lesser degree almost as if all the movement takes place around it.

General Effects of Partial Fixations.   Apart from fixations resulting from shortening of the various sacroiliac ligaments, there also exists a certain number of partial fixations in this area that are due to hypertonicity of the sacroiliac muscles mentioned elsewhere in this chapter (especially the coccygeous and the lower portion of the quadratus lumborum). The coccygeous muscles will pull the ischia together, and their hypertonicity will block these two bones in the position that they normally have when the subject is standing. The patient will then prefer to stand rather than sit and will not feel comfortable when sitting for any length of time.

Both coccygeous muscles are not necessarily hypertonic at the same time. When only one is "spastic," the related ilium is functionally as it is in the standing position. When the patient stands, the pelvis seems to be normal because the other ilium takes the same position naturally. When the patient sits, however, one ilium, the mobile one, changes to the sitting position (crest in, ischium out), while the other remains as in the standing position. In this case, the patient's lumbar region will be scoliotic in the sitting position but be straight when standing.

The opposite is true when the lower part of the quadratus lumborum is taut and fails to relax. This pulls the crests of the ilia together and, naturally, pushes the ischia outward. As with the case described above, but in the opposite direction, the patient will feel more comfortable in the sitting posture. In fact, while standing, the patient will rapidly tire and feel pain. Here the lumbar scoliosis will appear in the standing position, and the lumbars will straighten when the patient sits. This point should be quite important to those who radiograph the patient in the standing posture only.

L5 Motion During Sitting.   Fixations due to any part of the quadratus muscle or iliolumbar ligament will have also a partial effect on the A-P and P-A rotation of the ilia on the sacrum as seen with the knee lifting test. The knee-raising test will show a characteristic sign of the ilium rotating posteriorly, pulling L5 into rotation with it. With the patient sitting, it is also possible to feel the normal movement between L5 and the ilium on either side by placing the palpating thumb in the space between these two structures and rotating the patient's thorax with your free hand. Normally, the thumb can be pushed relatively easily into this area. The tissues should feel fairly relaxed. If this ligament is shortened, the tissues in the area will feel hard and taut and this will not change when rotating the patient's thorax.

At the other end of the sacrum, we have previously described how the ischia will separate upon lateral flexion and how the coccyx-iliac space will open on one side and close on the other.

Sacral Apex Motion During Sitting.   To test forward flexion freedom of the sacral apex with the patient sitting, place a thumb on one PSIS and the other thumb on the sacral apex. Keep in mind that the PSISs are normally about ¼ inch closer together in the sitting position than the standing position due to ischial spread. Note the separation of the thumbs as the patient flexes forward enough to flatten the lumbar curve. This separation will normally be about a half inch if the dynamics are normal. The tissues over the sacrum will be felt to tighten. If either the spinal extensors (multifidi, sacrospinalis) or pelvic extensors (hamstrings, gluteus maximus) fail to elongate during flexion, the sacroiliac joint will be inhibited from above or below, or both, and the lumbars will remain somewhat lordotic. Thus, this type of fixation can be secondary to failure of the lower thoracic and lumbar muscles to stretch. Gluteal lengthening can be further evaluated by flexing the thigh of the supine patient diagonally towards the opposite shoulder. To test motion during spinal extension, take the same contacts described above and have the patient arch the back. The distance between your thumbs should reduce and the tissues overlying the sacrum should relax.

Sacroiliac End-Play Motion During Sitting.   The degree of translatory motion (end play) at the end of voluntary motion reflects ligamentous elastcity: The test, originally suggested by Mennell, is made at the end of extension by firm thumb pressure on the sacral apex while the other thumb is on the PSIS. This palpation should elicit further tissue relaxation.

      Summary Review of Highlights

Lateral Flexion of the Pelvis During Sitting.   Place both thumbs on the patient's PSISs so that your fingers firmly grip the crests of the ilia bilaterally. As the patient curves his trunk laterally, the lumbar spine should arc smoothly. The sacrum will normally tilt towards the side of the concavity,\but the PSISs should remain almost level even though there is some bilaterally reciprocal iliac rotation. The tissues overlying the sacrum on the side of lateral flexion should relax while those on the side of the convexity should tighten. At the end of voluntary motion, added thumb pressure on the sacrum in the direction of its movement should reveal further tissue relaxation. This will not occur if the ligaments have stiffened. If one PSIS raises during lateral flexion, it suggests elongation failure of the lumbar extensors (multifidi, erector spinae) or lateral stabilizers (iliopsoas, quadratus lumborum). If there is bilateral sacroiliac fixation, there will usually be associated lumbar fixations.

In the standing position, lateral sacral flexion is difficult to differentiate from pelvic lateral rotation about the weight-bearing head of the femur.

Position-Change Iliac Alterations.   Place your thumbs on the PSISs of a sitting patient. Note the distance between the contacts, and then have the patient stand. Observe the distance between your thumbs. On standing, the PSISs normally open laterally (like a book) so that the inter-PSIS distance increases. If a firm contact can be held on the ischial spines, a reverse reaction will be revealed; ie, the ischia tend to close medially when arising to the standing position. If fixation is present, these iliac and ischial motions will not be felt.

Sitting Iliac Horizontal Rotation.   With the patient sitting, place your thumbs on the patient's PSISs and ask the patient to fan his knees open and close several times. As the knees are abducted laterally, the PSISs normally move medially so that they are closer together. Frequently, one PSIS will be felt to move less than the other, indicating a fixation at the inhibited base of the sacrum.

Sitting and Standing Pelvic Changes.   Keep in mind the various pelvic changes that occur between the sitting and standing postures that vary with different occupations. These changes are essentially controlled by the sacroiliac-ligament complex. If the superior ligaments are tightened, the crests will be pulled together and actually fix the pelvis in the shape characteristic for the sitting position. Such a patient will feel more comfortable when seated, and spinographs taken in the sitting posture appear quite normal. On standing, however, the crests of such a pelvis would be incapable of separating and the ischia will not approximate. The opposite may also occur; ie, the inferior sacroiliac ligaments may shorten and pull the ischia toward each other, locking the pelvis in the standing position and making sitting uncomfortable if not painful. There are many such states of fixation; eg, one ilium may be blocked or one fixed in a position of flexion on one side and one in a position of extension on the other. Careful analysis is necessary in dif- ferentiation.

It is interesting to see that in Gillet's explanation of his findings in sacroiliac fixation many concepts of sacroiliac dynamics taught by Hugh Logan and his son from the 1920s through the 1950s in Basic Technique (and generally ignored by the profession as a whole) are confirmed. Gillet received his ini- tial training at Palmer.

      Static Palpation

Theoretically, if your thumbs are placed on the patient's PSISs and one thumb is more posterior and inferior or anterior and superior than the other when the patient is either standing or sitting, it would indicate a fixed unilateral pelvic rotation. Likewise, if the thumbs are placed on the patient's PSISs and one thumb is more superior and anterior or inferior and posterior than the other when the patient is prone, it would indicate unilateral pelvic rotation. However, because osseous asymmetry is so common, these static signs are frequently misleading. Dynamic tests, such as those described in motion palpation, correlated with other signs and the patient's symptoms are much more reliable during analysis.

      Palpating the Lumbosacral Junction

Gillet frequently adds words of caution about palpating the lumbosacral area. He states that the posterior articulations of L5 are probably those in which errors of palpation can most easily arise. This is because of the wide range of motion of the sacrum. For instance, if there is movement in the lumbosacral articulation during lateral flexion toward the left, the sacral apex tilts to the right and the spinous process of L5 glides a little less laterally to the right than the process of the first sacral segment. However, if L5 is fixed to S1 and the sacrum is freely movable, L5 and the sacrum must move as a whole.

The 5th lumbar vertebra has a great range of movement under the skin but no appreciable movement relative to the sacrum. Special care must be taken to feel the scissor-like movement between the spinous process of L5 and the 1st sacral process and not be misled by the general movement of the sacrum and L5 felt under the skin.

There are other combinations of fixations of the 5th lumbar and the sacrum. As soon as you are capable of palpating the dynamics in this area, you will be able to appreciate the different combinations of fixations of this highly important articular complex.

In the palpation technique described above, Gillet takes into consideration the local movement between two contiguous bones. Palpation of the general movements of the spine also shows resistance to movement, sometimes of several spinal segments. In addition, as described in a previous chapter, palpation of the perivertebral region will usually indicate fixations in the lower thoracic costovertebral and costocostal complex.

At this point in his teaching, Gillet reviews two points of caution in the hope of preventing his students from committing serious errors in palpating the lumbosacral area. The first error is the gliding of the skin over the spinous process, which may give the impression of movement between the spinous process of L5 and the 1st sacral tubercle even if there is a complete fixation. Therefore, you must concentrate sufficiently to avoid this error. Secondly, in rotation and lateral flexion, lateral bending of the whole spine may give the impression of local movement. Constantly keep in mind that the local movement between two spinous processes is a scissor-like movement. This mistake, states Gillet, is commonly made in the following areas of the spine: from C7 to T2, T10 to T12, and L5 to S1.


Differentiating Sacroiliac from Lumbar Fixations

To differentiate sacroiliac from lumbar fixations, Faye offers the following comments for consideration.

With the patient sitting and their hands placed behind their head, rotate the patient's trunk first to the right and then to the left. Special care should be taken not to lift the patient's pelvis. Motion restriction of the patient's left lumbar facets or left sacroiliac joint will reduce rotation to the left (positive theta Y). Motion restriction of the patient's right lumbar facets or right sacroiliac joint will inhibit rotation of the patient's trunk to the right (negative theta Y).

To discern between a lumbosacral or sacroiliac lesion, the patient is allowed to relax against the doctor (patient's hands are still behind their head). In this position, the lumbosacral joint is relatively stress free. Next, twist the patient's trunk into posterior rotation on the right until the patient's left ischial tuberosity lifts slightly (buttocks remaining on palpation stool). In this position, there is a marked posterior torsion strain on the right sacroiliac joint. If pain arises in the right sacroiliac that can be relieved by pushing the left ilium posteriorly, then the pain can be assumed to arise from the right sacroiliac joint. Reverse the doctor-patient positions to differentiate fixations on the left. This is Mennell's modified Kemp's test for the lumbosacral area.

Here are some helpful clues: The patient suffering from sacroiliac dysfunction gets up in the morning with stiffness that improves with activity. The patient suffering with facet inflammation and/or an IVD lesion arises improved, but the condition worsens as the day goes on. Fixation produces a sharp pain on certain movements that is relieved when the site is not stressed. Other points characteristic of a sacroiliac lesion are:

1. There is usually unilateral pain in the sacroiliac joint.

2. The patient may describe an onset involving a lifting or twisting maneuver upon which a "catch" in the back is felt.

3. The patient has difficulty rising from bed, and the disability is worse in the morning, improving with activity.

4. The patient has difficulty getting into or rising from a chair because the joints fail to accommodate the normal pelvic changes that occur from changing from a sitting to standing posture.

5. The associated pain may refer to the
          (a) ipsilateral buttock,
          (b) ipsilateral posterior thigh (usually no further than the knee),
          (c) ipsilateral groin, and/or
          (d) ipsilateral anterior thigh (rare). See Figure 6.15.

6. The pain is usually an "achy" type, but it may be sharp on certain movements.

7. There is usually no severe pain on coughing or sneezing.

8. There is usually no abnormal neurologic signs, but there may be some current or recent history of paresthesia in the ipsilateral buttock and thigh.

9. The most common sites of pelvic fixation are found within the sacroiliac joints themselves or the hip joints.

10. A corrective adjustment frequently results in dramatic relief immediately.

Pubic Fixations

Pubic fixation offers a clinical dilemma that awaits resolution. The pubic articulation is not a gliding type as seen in the spine, thus, states Gillet, one would think it would be prone to only a ligamentous type of fixation. If this were true, a degree of torsion would be possible in spite of fixation. However, motion palpation demonstrates that:

(1) normal A-P and P-A iliac rotation does not take place when the pubis is fixated, and

(2) a fixation-mobilizing adjustment results in a rapid improvement in mobility. Neither of these characteristics are typical of ligamentous fixation.

See Figure 6.16.


Myofascial Pain Syndromes

Muscles can undergo changes that of themselves are primary components of a subluxation complex. If this abnormal state is not treated specifically, it can severely hinder recovery.

Apart from obvious trauma, states Faye, the examiner must discern if there are any areas of myodysneuria that serve as a trigger point and/or if there is a shortening of the overall length of a group of muscles. The iliopsoas, hamstrings, quadriceps, and tensor fascia lata muscles often have areas of myofascitis.

Proprioceptive neuromuscular facilitation (PNF) and postisometric relaxation (PR) are two effective stretching techniques. It has been Faye's experience that shortened muscles respond best to PNF, PR, or Travell's "spray-and-stretch" technique. A trigger point refers pain outside its neuromere and should respond to two or three treatments utilizing pressure, ultrasound, electrotherapy, etc. PNF is contraindicated for active trigger points.


Significant Neurologic and Orthopedic Tests

Any patient subjected to pelvic pain should be given a thorough physical, orthopedic, and neurologic examination, plus any other tests directed by clinical judgment. Evaluating the possibility of hernia; pelvic, genital, and rectal lesions; and testing light touch and pain perception should be routine. Anal, adductor, cremasteric, obliquus, patellar, and Achilles reflexes should be checked, as well as gross and segmental motions of the lumbar spine, pelvis, and hips. Following are several additional clinical tests that are applicable for syndromes involving the pelvis. Only a few will be necessary to apply in any particular case, depending on early clinical suspicions.

Goldthwait's Test.   The patient is placed supine. Place one hand under the patient's lumbar spine, with each fingerpad pressed firmly against the interspinous spaces. Your other hand is used to slowly conduct an SLR test. If pain occurs or is aggravated before the lumbar processes open (0° 30°), a sacroiliac lesion should be suspected. In general, Goldthwait believed that if pain occurred while the processes were opening at 30°–60°, a lumbosacral lesion was suggested; at 60°–90°, an L1–L4 disc lesion. If pain is brought on before the lumbar spine begins to move, a lesion, either arthritic or a sprain involving the sacroiliac joint, is probably present. If pain does not come on until after the lumbar spine begins to move, the disorder is more likely to have its site in the lumbosacral area or less commonly in the sacroiliac areas. The test should be repeated with the unaffected limb. A positive sign of a lumbosacral lesion is elicited if pain occurs at about the same height as it did with the first limb. If the unaffected limb can be raised higher than the affected limb, it is thought to be significant of sacroiliac involvement of the affected side. These specific points in differentiation, however, are difficult to explain biomechanically.

In reference to Goldthwait's test, Faye mentions that "The examiner, of course, would have already conducted the SLR test and once pain was experienced would have lowered the leg 5° and then dorsiflexed the foot to see if root stress caused the pain. The examiner must also remember that facet, radicular, and trigger-point syndromes can also be present."

Smith-Peterson Test.   If it is possible during Goldthwait's test to raise the limb on the unaffected side to a greater level without pain than the involved side, a positive Smith-Peterson's sign is found, which helps to confirm a sacroiliac lesion; ie, pain usually occurs at the same level for either leg when a lumbosacral lesion is present.

Nachlas' Test.   The patient is placed in the prone position. Flex the patient's knee to a right angle, then, with pressure against the anterior surface of the ankle, the patient's heel is slowly directed straight toward the patient's ipsilateral buttock. Stabilize the patient's contralateral ilium with your other hand. If a sharp pain is elicited in the patient's ipsilateral buttock or sacral area, a sacroiliac disorder should be suspected. If pain occurs in the patient's lower back or is sciatic-like in nature, a lower lumbar disorder (especially L3 or L4) is suggested. If pain occurs in the patient's upper lumbar area, groin, or anterior thigh, quadriceps shortening (spasticity or contracture) or a femoral nerve lesion should be suspected.

Erichsen's Test.   With the patient supine, place your hands on the patient's iliac crests, and localize your thumbs on the lateral aspect of the patient's ASISs (Fig. 6.17). Forcibly compress the pelvis toward the midline. This tends to separate the sacroiliac joints posteriorly. If conducted very carefully, this test can be quite specific. Pain experienced in the sacroiliac joint suggests a joint lesion (postural, traumatic, or infectious).

Iliac Compression Test.   The patient is placed on the side with the affected side up. Place yours forearm over the patient's iliac crest and apply pressure downward for about 30 seconds. This tends to compress the sacroiliac and pubic joints. A positive sign of joint inflammation or sprain is seen with an increase in pain; however, absence of pain does not necessarily rule out sacroiliac involvement. This test is usually contraindicated in geriatrics and pediatrics or with any sign of a hip lesion or osseous pelvic pathology.

Hibb's Test.   The patient is placed in the prone position. Stand next to the patient on the side of involvement. Stabilize the patient's contralateral uninvolved hip, flex the patient's knee on the involved side toward the buttock, and then slowly adduct the leg, which internally rotates the femur. Pain initiated in the hip joint indicates a hip lesion; pain rising in the sacroiliac joint but not the hip points to a sacroiliac lesion.

Sacroiliac-Lumbosacral Differentiation Test.   To differentiate these two common disorders, the patient is placed supine on a firm flat table. A folded towel is placed transversely under the small of the patient's back. The doctor stabilizes the patient's pelvis by cupping the hands over the ASISs and exerting moderate pressure. The patient is instructed to raise both extremities simultaneously with the legs held straight. If the patient senses discomfort or an increase of discomfort in the low back or over the sacrum and gluteal area at about 25°–50° leg raise and before the small of the back wedges against the towel, sacroiliac involvement is suspected. If, on the other hand, discomfort is experienced or augmented only after the legs have been raised beyond 50° and the small of the back wedges firmly against the towel, lumbosacral involvement should be the first suspicion.

Mennell's Tests.   The patient is placed prone, and one hand of the examiner is used to stabilize the contralateral pelvis. With your palpating hand, place a thumb over the patient's PSIS and exert pressure, then slide your thumb outward and then inward. The sign is positive if tenderness is increased. When sliding outward, trigger deposits in structures on the gluteal aspect of the PSIS may be noted. If when sliding inward tenderness is increased, it suggests sprain of the superior sacroiliac ligaments. Confirmation is positive when tenderness is increased when you pull the patient's ASIS posterior when standing behind the patient or when you pull the patient's PSIS forward when standing in front of the supine patient. These tests are helpful in determining that sacroiliac tenderness is due to overstressed superior sacroiliac ligaments.

Sacroiliac Stretch Test.   The patient is placed supine. Stand facing the patient, cross the patient's arms, place one of your hands on the patient's contralateral ASIS, and place your other hand on the patient's ipsilateral ASIS. Apply oblique (posterolateral) pressure to spread the anterior aspects of the patient's ilia laterally. A positive sign of sacroiliac sprain is a deep-seated pelvic pain that may radiate into the buttock or groin. While the iliac compression test is designed to stretch the posterior sacroiliac ligaments, this test stretches the ligaments on the anterior aspect of the joints.

Gillis' Test.   With the patient prone, stand on the side of involvement. Reach over and stabilize the uninvolved sacroiliac joint while the patient's thigh on the involved side is extended at the hip. Pain initiated by this maneuver in the sacroiliac area of the involved side is a positive sign of an acute sacroiliac sprain/subluxation or sacroiliac disease.

Belt Test.   The standing male patient, with feet about 12–15 inches apart, flexes forward while you hold the patient's belt at the back. If bending over without support is more painful than with support, it suggests a sacroiliac lesion. Conversely, if bending over with support is more painful than without support, it suggests a lumbosacral or lumbar involvement. A variation of this test is to stand behind the patient and place your hands so that they firmly support the patient's innominates. Some examiners brace a hip against the patient's sacrum while the patient flexes forward to stabilize the pelvis.

Yeoman's Test.   The patient is placed prone. With one hand, apply firm pressure over the patient's suspected sacroiliac joint, fixing the patient's anterior pelvis to the table. With your other hand, flex the patient's leg on the affected side to the limit. The patient's thigh is hyperextended by your lifting the patient's knee off the examining table. If pain is increased in the sacroiliac area, it is significant of a ventral sacroiliac or hip lesion because of the stress on the anterior sacroiliac ligaments. Normally, no pain should be felt on this maneuver.

Piedallu's Sign.   When a sacral base is locked unilaterally anteroinferior and lateral so that the adjacent ilium is found to be more posteroinferior and medial than normal, the ipsilateral PSIS on the side of inferiority will be low in the standing and sitting positions. If this PSIS becomes higher than the contralateral PSIS during forward flexion, the phenomenon is called a positive Piedallu's sign. Such a sign signifies either ipsilateral sacroiliac locking where the sacrum and ilium move as a whole or muscular contraction that prevents motion of the sacrum on the ilium. Regardless, it shows that sacral dysfunction is probably present.

Laguerre's Test.   With the patient supine, the thigh and knee are flexed and the thigh is abducted and rotated outward. This forces the head of the femur against the anterior portion of the coxa capsule. Increased groin pain and spasm are usually positive signs of a lesion of the hip joint, iliopsoas muscle spasm, or a sacroiliac lesion. This test can help to differentiate a hip or sacroiliac disorder from a lumbar disorder.

Gaenslen's Test.   In this test, the patient is placed supine with knees and hips acutely flexed by the patient who clasps his knees with both hands and pulls them toward the abdomen. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. Standing at right angles to the patient, bring the patient well to the side of the table and slowly hyperextend the patient's opposite thigh by gradually increasing force by pressure of one hand on top of the patient's knee while your other hand is on the patient's flexed knee for support in fixing the lumbar spine and pelvis. Some examiners allow the hyperextended limb to fall from the table edge (Fig. 6.18). The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis. The pull is made on the ilium through the Y ligament and the muscles attached to the AIISs. The test is positive if the thigh is hyperextended and pain is felt in the sacroiliac area or referred down the thigh, providing that the opposite sacroiliac joint is normal and the sacrum moves as a unit with the side of the pelvis opposite to that being tested. This test should be conducted bilaterally. A positive sign may be elicited in a sacroiliac, hip, or lower lumbar nerve root lesion. If the L4 nerve is involved, pain is usually referred anteriorly to the groin or upper thigh. If this sign is negative, a lumbosacral lesion should be the first suspicion. This test is usually contraindicated in the elderly.

Lewin-Gaenslen Test.   The patient is placed in the sidelying position with the underneath lower limb flexed acutely at the hip and knee. Stabilize the uppermost aspect of the patient's hip with one hand. With your other hand, grasp the patient's leg near the knee and extend the patient's thigh on the hip. Initiated or aggravated pain suggests a sacroiliac lesion.

Lewin's Standing Test.   With the patient standing with the back toward you, cautiously forces first the right and then the left knee of the patient into complete extension. Then both knees are straightened at the same time. In lumbosacral, lower lumbar, sacroiliac, and gluteal disturbances, these movements will be accompanied by increased pain and the knee will snap back into flexion.

Mazion's Step-Flex Test.   A standing patient with low back pain is asked to take a large step forward, hold this position by keeping the toes in place, and then flex the trunk forward. According to Mazion, the initiation or aggravation of the patient's complaint on the contralateral limb (the one behind) exhibits a positive sign of a unilateral subluxated ilium in relation to the sacrum (ie, sacral base anteroinferior).

Neri's Bowing Sign.   This sign is positive when a standing patient can flex the trunk further without low-back discomfort when the ipsilateral leg is flexed than when both knees are held in extension. A positive sign suggests hamstring spasm, contractures of the posterior thigh and/or leg muscles, sciatic neuritis, a lumbar IVD lesion, or a sacroiliac subluxation syndrome.

Minor's Sign.   Sciatic radiculitis is suggested by the manner in which the patient with this condition rises from a sitting position. Body weight is supported on the uninvolved side by holding on to the chair for firm support in arising or the patient places the hands on the knees or thighs while working into the upright position, balances on the healthy leg, places one hand on the back, and flexes the leg and extends the thigh of the affected limb. The sign is often positive in sacroiliac lesions, lumbosacral strains and sprains, lumbar fractures and disc syndromes, dystrophies, and myotonias.

Muscular Fixations

Muscle spasms in the pelvis generally reflect themselves in the trunk, thigh, or both. Shortening of most major muscles acting on the pelvis has a restrictive influence upon the mobility of the femur and an effect upon an individual's stance. When evaluating relative muscle function, note that mild unilateral hypertonicity is difficult to differentiate from contralateral hypotonicity. In differentiation, static palpation may reveal more than kinetic tests.

      Piriformis Hypertonicity

If a patient has deep gluteal pain, sciatic neuralgia, and walks with the foot noticeably everted on the side of involvement, involvement of the piriformis should be suspected. Abnormal piriformis tone tends to pull the sacrum anteriorly and to externally rotate the thigh.

The sciatic nerve should pass under the piriformis and follow the "wisdom" of the textbooks. In many cases, however, the nerve takes a different course and is found on surgery to be stretched over or even pass through the muscle in 15% –20% of the population (ie, about one of every 5–7 patients). This common "anomaly" and its consequences are often overlooked.

Piriformis Spasm Test.   The patient is placed supine on a firm flat table. The patient's heels are grasped and firmly inverted and abducted, and the feet are externally rotated. If one foot resists this effort and the act is attended by pain in the gluteal area, piriformis spasm should be suspected. Differentiation of piriformis spasm from other causes can often be elicited by reproducing the pain on internal rotation of the femur when it is at a lower level than the original point of pain.

Thomas' Test.   This is another test to determine excessive iliopsoas tension. The supine patient holds one flexed knee against the abdomen with the hands while the other limb is allowed to fully extend (Fig. 6.19). The patient's lumbar spine should normally flatten. If the extended limb does not extend fully (ie, the knee flexes from the table) or if the patient rocks the chest forward or arches the spine, a fixed flexion contracture of the hip is indicated, as from a shortened iliopsoas muscle. Michelle uses the degree of pain elicited on forceful extension of the flexed knee as his criteria of iliopsoas tension. This test should always be conducted bilaterally.

Piriformis Myofascitis Test.   The patient is seated on a table with the hips and knees flexed. Apply resistance as the patient attempts to separate the knees. In piriformis myofascitis, pain and weakness will be noted on resisted abduction and external rotation of the thigh. Inflammation will be confirmed by rectal examination exhibiting acute tenderness over the lateral pelvic wall proximal to the ischial spine.

      Iliopsoas Hypertonicity

In the normal erect posture, only about 12% of the weight of the abdominal organs is borne by the suspensory ligaments. The majority of weight is supported by the inclined iliopsoas and held there by the abdominal wall.

Increased tone of the psoas major muscle tends to pull the lumbar spine into anterior and inferior flexion, and externally rotate and flex the thigh. The psoas minor, which spans between T12 and L1 to the arcuate line of the hip bone, assists the psoas major.

In psoas spasm, the thigh is flexed to some degree on the trunk, but this is usually concealed by forward bending of the trunk. Hypertonicity can be confirmed by tension and pain during deep palpation of the abdomen below the umbilicus, lateral to the linea alba, medial to and slightly inferior to the ASIS. The psoas will feel as a taut longitudinal bundle. It is also palpable in the upper sulcus of the pubic arch.

Bilateral psoas shortening results in lumbar rigidity, anterior pelvic tilt, and hip flexion. When associated with acute back pain, the patient tends to flex the knees and hips to help decrease the degree of pelvic tilt and lordosis. When the hip flexors are short, the lumbar region does not flatten in the supine position unless the knees and hips are flexed. In psoatic sciatica, states Faye, the patient walks on their toes on the ipsilateral side of involvement.

Electromyographic studies conducted by Nachemson showed that the iliopsoas is just as important a lumbar stabilizer against gravitational forces in standing as it is a hip flexor during gait. Some authorities feel that the psoas is the key to postural correction.

Michelle, who asserts that 30% of the population has an iliopsoas imbalance, boldly charges that any and all defects of the spine and hip structures should be evaluated in terms of iliopsoas dysfunction. His studies present some evidence that practically all conditions working against the "straight child" are attributable to the failure of the iliopsoas to elongate during bipedal maturation. He claims: "When the abnormal force of the nonelongated iliopsoatic musculature is presented bilaterally, the directional force is symmetrical, with the formation of an exaggerated dorsal kyphosis."

Ely's Test.   To support iliopsoas spasm suspicions, the patient is placed prone with the toes hanging over the edge of the table, legs relaxed. Either heel is approximated to the opposite buttock. After flexion of the knee, pain in the hip will make it impossible to carry out the test if there is any irritation of the psoas muscle or its sheath. The buttock will tend to rise on the involved side. However, a positive Ely's test can also be an indication of rectus femoris contraction, a lumbar lesion, a contracture of the tensor fascia lata, or an osseous hip lesion. Few singular orthopedic maneuvers will isolate a specific lesion.

      Psoas Abscess

If the urogenital complex, colon, appendix, pancreas, or lumbar lymph nodes or nerves are diseased, the sheath of the psoas is likely to be secondarily inflamed and painful. As the psoas muscle also crosses the sacroiliac joint, inflammation is likely to lead to a protective reflex to fix the joint from irritating motion.

Buttock Sign.   To conduct this test, a lower extremity of a supine patient is passively flexed at the hip with the knee extended as in an SLR test. If the flexion of the limb on the trunk is restricted by local or radiating buttock pain (rather than pain in the hip or lower back), it is significant of an inflammatory pelvic lesion such as ischiorectal abscess, osteomyelitis of or near the hip joint, coxa bursitis, sacroiliac septic arthritis, or an advanced pelvic neoplasm.

Baron's Sign in Appendicitis.   The patient is placed supine, relaxed, and instructed to breath deeply. The examiner's 2nd, 3rd, and 4th fingers are placed on the patient's Poupart's ligament and pressure is made in the direction of the psoas muscle. The patient is then told to elevate the leg of the same side with the knee extended, forming about a 45° angle at the hip. In this position, the palpating fingers can readily palpate the now tensed psoas muscle. Similar palpation should be made bilaterally for comparison. In suspected cases of chronic appendicitis, Baron found that the right psoas muscle was frequently hypersensitive to pressure. Even in the healthy individual, a tensed psoas may be tender, but when the appendix is involved, the tenderness is more marked on the right side. It is also important to realize that because the psoas is covered by peritoneum it can be painful in the presence of sacrospinal and gluteal myalgias; in lumbar, lumbosacral, and iliosacral arthrosis; and sometimes in sciatica.

      General Hip Hypertonicity

Two forms of spasm are common in the hip joint:

(1) that which is due to irritation of the psoas alone, and

(2) that in which all the muscles moving the joint are more or less contracted. The normal range of hip flexion is 120°. In isolated psoas spasm, motions of the hip (rotation, adduction, abduction, and flexion) are not impeded.

General spasm of the hip muscles is tested with the patient supine and the limb flexed at a right angle, both at the knee and at the hip. A child may be tested on its parent's lap. Using the asymptomatic limb as a standard for comparison, draw the patient's knee away from the midline (abduction), toward and past the midline (adduction), and toward the patient's chest (flexion). Rotation is tested by holding the knee still and moving the patient's foot away from and toward the median line of the patient.

      Physical Tests for Hip Pathology

Patrick's F-AB-ER-E Test   This test helps to confirm a suspicion of hip joint pathology. With the patient supine, grasp the patient's ankle and flex knee. The patient's thigh is flexed (F), abducted (AB), externally rotated (ER), and extended (E). Pain arising in the hip during the maneuvers, particularly on abduction and external rotation, was attributed by Patrick to be a sign of hip pathology. [See Clinical Comment 6.7]

      DR. FAYE'S CLINICAL COMMENT #6.7

While doing this test, I find it clinically significant to differentiate capsular restriction from muscular fixation. At the end range of the F-AB-ER-E maneuver, I spring the joint by pressing on the knee. A springy end feel warrants a stretching technique. The loss of springiness demands a hip joint manipulation that produces an audible movement and muscle stretching.

Hip Abduction Stress Test.   The patient is placed in the lateral recumbent position with the underneath lower limb flexed acutely at the hip and knee. With the upper limb held straight and extended at the knee, the patient is instructed to attempt to abduct the upper limb while you apply resistance. Pain initiated in the area of the uppermost sacroiliac joint or the hip joint suggests an inflammatory process of the respective joint.

Trendelenburg's Hip Test.   If the hip and its muscles are normal, the iliac crest and sacral dimple will be slightly low on the weight-bearing side and high on the leg-elevated side when one leg is lifted. To test this, have the patient with a suspected hip involvement stand on one foot (on the side of involvement), and raise the other foot and leg in hip and knee flexion. If there is hip joint involvement and muscle weakness, the iliac crest and sacral dimple will be markedly high on the standing side and low on the side the leg is elevated. A positive sign suggests that the gluteus medius and minimus muscles on the supported side are weak. The gait will exhibit a characteristic lurch to counteract the imbalance caused by the descended hip. The sign is is not specific, however, It is also commonly positive in a developing Legg-Calve-Perthes disease, poliomyelitis, muscular dystrophy, coxa vara, Otto's pelvis, epiphyseal separation, pathology of the superior gluteal nerve, coxa ankylosis, hip dislocation, fracture, or chronic subluxation of L4, L5, or the sacrum.

Ligamentous Fixations

Gillet reports that there are three common ligamentous fixations that occur in the pelvis:

(1) sacrotuberous ligament fixation,

(2) posterior sacroiliac ligament fixation, and

(3) anterior sacroiliac ligament fixations. These fixations are extremely common and tend to recur unless proper exercises are conducted frequently.

It should be remembered that, contrary to what is found in muscular hyper- tonicity, ligaments can he "pulled" into shape; ie, a slow forcing of the articulation in fixation can often be sufficient to stretch the shortened ligament. A dynamic thrust is not always indicated.

      Sacrotuberous Ligament Fixation

To elongate a shortened sacrotuberous ligament, Gillet recommends a strong thrust on the apex of the sacrum that is directed cephalad. He states that this type of maneuver is usually effective, rarely needs to be made more than once, and that the postadjustive change should exhibit at least a 50% improvement. In contrast, Faye has found that knee-chest stretching exercises are the most effective.

      Posterior Sacroiliac Ligament Fixation

Shortening of the ligaments binding the posterior surface of the sacrum to the iliac crest is found far more often than sacrotuberous shortening. Tight posterior sacroiliac ligaments tend to pull the iliac crests posteromedially, closing the distance between the PSISs (which would indicate movement of the sacral base anteriorly). Thus, the adjustive thrust should be directed to separate the joint to allow the sacrum to move posteriorly. A short, stiff adjustment is recommended by Gillet on the fixated aspect of the sacrum (base or apex) or on the superior or inferior aspect of the ilium, depending on where the major fixation is found. The points of contact will vary according to the particular planes of motion determined to be restricted. Preadjustive thrusts will help determine whether the major site of fixation is on either the superior or inferior aspect of the sacroiliac complex.

      Anterior Sacroiliac Ligament Fixation

Shortening of the anterior sacroiliac ligaments tends to pull the iliac crests anterolaterally, increasing the distance between the PSISs, and push the sacral base posteriorly. The adjustment should be designed to move the sacral base forward, relative to the ilia, allowing the two ilia to glide backward. This type of fixation can often be felt by the resistance of the inferior or superior aspect of the sacrum during preadjustive thrusts.

      Supportive and Rehabilitative Exercise

To assist in the elongation process of shortened soft tissues, instruct the patient to:

(1) Lie supine on a firm surface, flex the right knee toward the chest, grasp it with both hands, pull the thigh firmly against the abdomen, hold this position for 30 seconds, and then slowly return the limb to the extended position. During this maneuver, the other limb should remain in contact with the surface on which the patient is recumbent. The same exercise is then conducted with the contralateral limb.

(2) After this, both knees are flexed toward the chest in a similar manner.

(3) Each knee is then pulled diagonally toward the opposite shoulder and held there for 30 seconds.

(4) Last but not least, the sitting patient places the lateral side of the ipsilateral ankle on the opposite knee in a figure 4 manner and pushes down on the medial side of the knee to the point of firm resistance and holds the knee there for 30 seconds. This exercise should be conducted once each morning and evening to assure that corrected fixations will not return. If the patient can effectively conduct this exercise initially, states Gillet, it is likely that a diagnosis of pelvic ligamentous fixation is in error.

This exercise will, unfortunately, not have any important effect on total sacroiliac fixations. It is also evident that the effect of this exercise will only be momentary in cases where the pelvic fixations are due to fixations elsewhere, principally those of the feet.

Faye teaches the same technique with the patient in the sitting position. Little modification is required, and the stretching exercise conducted in either position will be equally effective. [See Clinical Comment 6.8]

      DR. FAYE'S CLINICAL COMMENT #6.8

In acute low-back pain cases, marked relief can often be achieved by the doctor, seated behind the sitting patient, reaching around the patient and pulling the patient's ipsilateral hip into flexion by using a knee as a fulcrum. This pull should be held for 30 seconds. The relief obtained is often enough to get a house-confined patient into the office for roentgenography and further care.

In bilateral articular fixation of the sacrum or total fixation of the pubis, all contact points will show no movement, whether the right or left knee is raised. In unilateral total articular fixation, all points will show a diminished amount of motion, because only one articulation is functioning. It will then be necessary to change contacts to the sacrum and each ilium separately to determine the articulation responsible.

Total vs Partial Sacroiliac Fixations

      Total Sacroiliac Fixations

It is well to repeat here that in total articular fixation of both sacroiliac articulations, all the tests devised by Gillet will be positive. Even if the pubis is free, it is evident that a total lack of movement in the sacroiliac articulations will not permit motion in the pubic joint. The contrary is also true. In pubic fixation, the normal sitting-standing changes in the pelvis will not be found, the knee-lift test will show no motion, but the sacrum will still be able to rotate between the ilia (in fact, to a degree of hypermobility.

      Partial Sacroiliac Fixations

Partial fixations of a sacroiliac joint show up differently. The pubic test will show movement, and the knee raising test will show movement if the palpatory contact is taken on both ilia but will indicate fixation if the contacts are taken individually; ie, one thumb on the sacrum and the other on the ilium. Obviously, if the two contacts are made on the articulation in fixation, no movement of the ilium will be felt.

The technique of pelvic palpation is mandated by the great number of potential partial fixations. This makes it necessary to use multiple contacts to correctly analyze the type of fixations being palpated (Figs. 6.20 and 6.21). In the first knee-lifting palpation, it is often necessary to use some eight different points, two on the superior posterior iliac spines, two on the crests, two near the inferior end of the sacroiliac articulations, and two underneath on the ischia. These last contact points are somewhat difficult to maintain and especially to follow if movement is normal.

      Considerations in the Lateral-Recumbent "Roll" Adjustment

The most popular adjustment in this region is the side-position "lumbar roll." It is known that this adjustment, as it is usually given, does not restrict its force to one articulation, much less to one part of an articulation. It is also evident that the same adjustment position can often be used for many different types of pelvic fixations. Fortunately also, and contrary to the observations made in other regions of the spine, a poorly delivered adjustment in this area will have far less adverse effect, either locally or in the remainder of the spine, not forgetting the highly sensitive upper-cervical region. This should, however, not be interpreted that no harm can be produced by a traumatizing "cracking" adjustment on the pelvis. We always desire to use the minimal amount of force necessary to correct the fixation, no more.

Gillet asks us to remember that an adjustment in any region may be used to do one of three things:

(1) break up adhesions in the articulation by opening it,

(2) force it to glide in the plane lines of its articular surfaces (in any direction that is restricted) but with a preference for the direction that will "replace" the "subluxated" bone, and/or

(3) move the two bones in fixation in such a way that separates the two ends of the muscle to "break down" the hypertonicity or apply a force at right angles to the shortened muscle or ligament to elongate it. In fact, these adjustive effects may explain the dif- ferent types of adjustments that have been invented by chiropractors since the turn of the century.

Summary of Sacroiliac Pathodynamics from an Adjuster's Viewpoint

Because of the boot or bean-shaped design of the sacroiliac joint and the architecture of its major ligaments, there are two potential sites of fixation on each side: one at the superior aspect of the joint at the S1 level, and one at the inferior aspect of the joint near the superior aspect of S3. The sacral facets of each of these articulations faces anterolaterally. Between these two articulation, at the S2 level, is a rounded protuberance on the sacrum that serves as a pivot for the joints above or below if either of these joints are fixated. The surface of the facets on the ilium are reciprocally congruent with those of the sacrum. See Figure 6.22.

With this understanding of the sacroiliac articulations, we see that there are four functional articulations to consider in sacroiliac analysis: the right superior and inferior joints, and the left superior and inferior joints. Inasmuch as each articulation participates in anterior and posterior rotation of the ilium on the sacrum, there can be eight motions that may be restricted, any one of which can greatly disturb pelvic dynamics and that of the spine above the pelvic foundation. See Table 6.1.

  Articulation        Motion                          
  Left superior       Iliac rotation posteroinferiorly
  Left superior       Iliac rotation anterosuperiorly
  Left inferior       Iliac rotation posteroinferiorly
  Left inferior       Ischial rotation anteroinferiorly

  Right superior      Iliac rotation posteroinferiorly  
  Right superior      Iliac rotation anterosuperiorly
  Right inferior      Iliac rotation posteroinferiorly
  Right inferior      Iliac rotation anteroinferiorly

Some points in communication should be kept in mind when sacroiliac motion is described:

1. Normal iliac and sacral actions are reciprocally opposite. That is, one might say that the PSIS of the ilium normally rotates backward and downward relative to the sacrum during the knee-raising test. One might also say, and be just as correct, that the sacral base unilaterally rotates forward and downward relative to the ilium. Conversely, if a free ilium rotates upward and forward on the sacrum, the sacrum can be said to have rotated backward and downward on the ilium. Always keep in mind that these terms of rotatory motion are relative. You need no longer be confused when the points of reference (ilium or sacrum) are interchanged.

2. Inasmuch as iliac and sacral action are reciprocally opposite, it rarely matters whether the adjustive contact is taken on the ilium or the sacrum. For example, a thrust delivered anterosuperiorly on an ilium's PSIS will have the same biomechanical effect as a thrust delivered anteroinferiorly on the sacral apex of that side or anterosuperiorly against the contralateral ischium. Thus, you frequently have the option of taking an iliac, sacral, or ischial contact, depending on how the joint motion is restricted. One exception to this is the obvious fact that it is difficult to move the sacral base backward; much easier to move the ilium forward.

3. Iliac and ischial actions are reciprocally opposite because they are just different aspect of the same bone, the innominate. When the ilium moves backward and downward on the sacrum, the ischium on the same side must move forward and upward, and vice versa. It has been explained previously that as the iliac crests rotate backward, as in sitting, the sacral base nods forward and the ischia flare laterally. Conversely, when the iliac crests rotate forward, as in standing, the sacral base slides backward and the interischial space decreases.

4. The options in chiropractic technic are usually not based on mechanical principles, but on their ease of administration. For example, rotating the iliac crest forward has the same mechanical effect as moving the sacral base backward. However, the former is much easier to apply than the latter. Conversely, moving a sacral base or ischium forward has the same mechanical effect as moving the iliac crest backward, but the former is much easier to apply that the latter.

5. The superior and inferior articulations of the sacroiliac joint on each side resemble a toggle switch. That is, as the sacral base nods forward the sacral apex juts backward. Conversely, as the sacral base slides backward, the sacral apex arcs forward. This toggle effect between the sacral base and sacral apex can be utilized in a large number of sacral technics. It is much easier to move the sacral base posteriorly by a thrust directed anteroinferiorly against the sacral apex than attempt to directly move the sacral base posteriorly. The pressure required anteriorly would undoubtedly injure the pelvic organs and be highly painful to the patient because of the intervening plexus. This toggle effect between the superior and inferior sacral articulations is afforded by the interarticular proturberance on the sacrum that serves as a fulcrum. It is not applicable, however, if the both the superior and inferior aspects of the joint are fixated.

Once these basic principles are understood, chiropractic sacroiliac technics will no longer be a confusing subject. You will immediately see that they are either logical for the situation at hand or in error.


Adjusting Pelvic Articular Fixations

It is Gillet's opinion that total sacroiliac fixations are second in importance only to total occipitoatlantal fixations. The lesion may be bilateral or unilateral. If unilateral, the contralateral joint will usually be hypermobile in compensation and be the site of pain and tenderness.

      Patient Laterally Recumbent

Gillet recommends the standard side-posture "roll" for releasing sacroiliac fixations, but special care must be made to deliver the thrust in the proper plane against the site of fixation. The adjustment may be made with the patient in the lateral recumbent position by placing the patient so that the fixated side is upward and taking contact on the the involved iliac crest or ischium, depending upon what intra-articular motion is to be achieved. This is the common application. An alternative method is applied by placing the patient so that the fixated side is downward and taking contact on the contralateral aspect of the sacrum; base or apex, depending upon what intraarticular motion is desired.

In either position, there is no need in most cases to produce heavy pressure on the patient's flexed knee just enough to stabilize the patient during the adjustment. It will sometimes be found, however, that a firm pressure on the flexed knee will be beneficial in opening the superior aspect of the joint. Each adjustment must be adapted to the needs of the situation and patient at hand.

The following technics are described by Faye:

1. Fixation at the Upper Aspect of the Sacroiliac Joint: Involved Side Upward.   Place the patient in the lateral recumbent position with the involved ilium facing upward. The patient's uppermost knee is flexed to the maximum. Assure that the patient's lumbars and shoulders are in the neutral position, and apply the contact of the active hand on the PSIS of the involved joint. Support the patient's uppermost shoulder with your stabilizing hand (Fig. 6.23). Open the posterior aspect of the sacroiliac joints by applying downward pressure against the patient's flexed knee with your knee, and with your active hand, deliver an impulse with a body drop directed to mobilize the area of fixation.

2. Fixation at the Upper Aspect of the Sacroiliac Joint: Involved Side Downward.   Place the patient in the lateral recumbent position with the involved ilium against the adjusting table. Assure that the patient's lumbars and shoulders remain in the neutral position. Flex and depress the patient's uppermost knee to stretch the posterior aspect of the sacroiliac joints. Support the patient's uppermost shoulder with your stabilizing hand (Fig. 6.24). Apply contact on the upper quadrant of the sacrum just medial to the PSIS that is closest to the table, and deliver an impulse with body drop directed against the fixation.

3. Fixation at the Lower Aspect of the Sacroiliac Joint: Involved Side Upward.   Place the patient in the lateral recumbent position with the involved ilium facing upward. The patient's uppermost knee is flexed to the maximum (Fig. 6.25). Support the patient's uppermost shoulder with your stabilizing hand. Assuring that the patient's lumbars and shoulders are in the neutral position, apply an ischial contact, depress the patient's knee to open the sacroiliacs posteriorly, and deliver an impulse with body drop to rotate the involved ilium.

4. Fixation at the Lower Aspect of the Sacroiliac Joint: Involved Side Downward.   Place the patient in the lateral recumbent position with the involved ilium against the adjusting table. Assure that the patient's lumbars and shoulders remain in the neutral position. Flex and depress the patient's uppermost knee to stretch the posterior aspect of the sacroiliac joints. Support the patient's uppermost shoulder with your stabilizing hand. Apply contact on the lower quadrant of the sacrum (on the side closest to the table), and deliver an impulse with body drop directed against the fixation (Fig. 6.26).

      Patient Prone

If posterior intra-articular adhesions are suspected, the joint may be opened by "springing" the joint open in either the side position or with the patient prone. In adjusting a unilateral fixation, the contacts made on the ilium or ischium are bilateral; ie, one serving as the contact hand and the other as the stabilizing hand. The thrust should be firm, rapid, and short, with the abdominal piece of the adjusting table relieved of firm tension.

Lateral flexion mobility of a sacroiliac joint may still be restricted after A-P and P-A mobility has been restored.

      Using Muscle Tension as an Aid During an Adjustment

Schafer advocates using muscle tension as an aid to sacroiliac adjustments whenever possible. For example, when rotating an iliac crest anteriorly on the sacral base with the patient in the side position, he does not flex the patient's uppermost knee. Rather, he flexes the patient's underneath knee and moves the extended upper limb backward to produce tension on the quadriceps and hamstring relaxation, which passively helps to rotate the iliac crest anteriorly. He only flexes the patient's uppermost limb when an ischial contact is taken so that tension on the hamstrings will assist in rotating the innominate posteriorly. This, states Schafer, is the approach frequently used in pioneer chiropractic. The more commonly applied flexed uppermost limb positioning taught today is of osteopathic heritage.

The same principles of using muscle tension as a passive aid can be used when the adjustment is applied with the patient prone. For example, when a contact is taken on an iliac crest, the patient's extended lower limb can be raised at the knee with the stabilizing hand to produce tension on the quadriceps and relax the hamstrings. Unfortunately, the advantage of a contralateral stabilizing hand will be lost. To prevent the contralateral side of pelvis from raising during the adjustment, a 2-inch-wide leather strap across the patient's pelvis just below your contact can be used. An alternative is to have a clinical assistant apply the stabilizing counterpressure.

      Patient Supine

The following techniques are taught by Faye:

1. To perform general posterior rotation of an ilium on the sacrum with the patient supine, flex the patient's knee and hip on the side of involvement. The patient's foot should rest flat and comfortably against the tabletop. Stand on the side of involvement, apply a palm contact over the near ASIS, support the patient's contralateral hip with your stabilizing hand, lean against the patient's flexed knee to bring it toward the medial line and open the sacroiliac joint posteriorly, and then deliver a stiff-arm body drop upon the ASIS. This will rotate the ilium posteriorly (extend) on the sacrum. In stubborn fixations, it may be helpful to place your stabilizing hand under the patient's ischium and lift upward as your active hand applies the thrust against the iliac crest.

2. To perform general anterior rotation of an ilium on the sacrum with the patient supine, stand on the side of involvement, and shift the patient's body near to the edge of the table where you are standing. Flex the patient's knee and hip on the side of involvement, raise the patient's leg, extending the knee, bring the limb laterally past the side of the tabletop, and allow the limb to lower by its own weight below the level of the tabletop. This will place a stretching force on the anterior muscles of the thigh attached to the ilium that will tend to rotate the ilium anteriorly.

The above technique, not advised for the elderly patient or a patient afflicted with osteoporosis or coxa pathology, should be applied as a slow stretching maneuver. If the limb is allowed to drop suddenly in other than a supple youth, it is easy to produce a groin strain or an anterior dislocation of the head of the femur. It is also contraindicated in the supple child whose acetabulae are shallow.


Gillet's Method of Correcting Lumbosacral Kyphosis or Hyperlordosis

This leaves us with two remaining lumbosacral distortions: kyphosis and hyperlordosis. The patient who enters bent forward and cannot straighten up is frequently seen in clinical practice. Such a patient represents a problem to the chiropractor who wants to give the usual "adjustment to replace a subluxated vertebra." In this type of case, the lumbar muscles will usually react so strongly to a rapid thrust that not only will nothing "move," but the patient's pain will be greatly exacerbated immediately. Specific correction of lumbar kyphosis and hyperlordosis will be described in a following section of this chapter. See Figure 6.27.

      Lumbosacral Kyphosis

The patient is placed prone on the adjusting table, as comfortable as possible (ie, the abdominal support is raised and/or cushions are inserted anteriorly to fit the forward flexion of the spine. Pressure is then applied to the apex of the curve to a degree that produces discomfort but not enough to set up a defensive reaction on the part of the patient's lumbar muscles. This pressure is applied in a series of short "kneading" thrusts, always to the degree that the patient can stand without producing a "splinting" reaction in the patient's lumbar and abdominal muscles. Little by little, the thrusts will become less painful, and the patient's lumbar muscles will be felt to relax under your hands. After 4 or 5 minutes of this, it will be possible to lower the abdominal piece or remove one cushion after another until the lumbars, instead of being kyphotic, will actually be in normal lordosis. At this time, a vigorous recoil thrust can be given at the point where the apex of the kyphosis was previously. Upon arising slowly, the patient will be able to walk out far straighter than when he came in.

In a few cases, the above technique will not be applicable; ie, no amount of easy thrusts on the lumbars will produce relaxation. On the contrary, the more "kneading" done, the more the lumbar muscles will contract. It will then be necessary to leave this region alone and to correct all the major and secondary fixations in the remainder of the spine. Remember that fixations as a whole summate the amounts of irritation that they produce. This causes a general tightening of all the spinal muscles. Therefore, every time a fixation anywhere in the spine is corrected, the amount of residual tone of all the spinal muscles is lessened. Little by little, day by day, the lumbar muscles will slowly relax without early local treatment, the kyphosis will reduce, and the associated pain will disappear.

      Lumbosacral Hyperlordosis

In contrast to lumbosacral kyphosis is the chronic low-back fixation that exhibits as a local hyperlordosis. This usually occurs in the lower lumbars and is clearly seen by moving the sitting patient into full forward flexion. In this position, the whole spine should form a smooth curve posteriorly. The lordotic fixation, however, will exhibit as two or three vertebrae that do not follow the general curve. They will remain flat or lordotic. A dimple may be seen in the skin, indicating some degree of spondylolisthesis.

It is possible to "motion palpate" this fixation by placing the palpating finger or thumb in the interspinous space. This space will be unusually small, and it will not open when the spine is flexed forward or close during exten- sion.

Gillet reports that this fixation is due in most cases to hypertonus of the interspinous muscles or shortened ligaments. In many cases, the muscular hypertonicity is such that the spinouses of the two consecutive vertebrae are pulled against one another. In many cases, the pre- and post-zygapophyses will be in an abnormal position relative to each other, leaving a triangular space with the inferior articulation jutting into the IVF. This condition often gives the typical picture of a facet syndrome or radiculitis.

In the beginning, states Gillet, it is always the muscle that pulls the spinouses together. It is only later that the ligament shortens and the muscle degenerates and atrophies. A recoil adjustment with a contact on the inferior spinous, or in between the spinouses (abdominal piece free) according to the principle of thrusting at right angles to the muscle, will usually release the muscle hypertonicity.

There is no way to determine whether it is the muscle or the ligament that is pulling the vertebrae together. If the recoil does not succeed, then the patient must be placed on the back, the knees pulled up toward the chest, and then forced a little farther. If the knees flex easily to the chest, you can place the palm of your free hand under the patient's buttocks and force that part of the spine inferior to the fixation backward. In chronic fixations of this type, it is necessary to ask the patient to continue this lumbar-curling exercise at home.

Schafer notes that this exercise may also be done in the sitting position, and that the typical patient is more apt to apply it several times a day while watching television than attaining the supine position. Forward flexion of the trunk on the pelvis while sitting has the same biomechanical effects on the lumbar spine as hip and knee flexion in the supine position. Instruct the patient to slowly curl forward, stretching the arms downward between abducted knees. When the maximum range of passive motion is reached, tightness and a soft motion block will be perceived in the lower back. When this point is reached, the patient is instructed to bob up and down in a small arc (about 6 inches) several times rhythmically to slowly stretch the posterior spinal tissues and increase the range of motion. The patient then slowly returns to the neutral position and repeats the stretching exercise two or three times. This exercise bout should be repeated at least three times daily during rehabilitation; every 2 hours during the acute stage. [See Clinical Comment 6.9]

Measuring the Amount of Correction Obtained.   An effective way to measure the amount of correction obtained, states Gillet, is to place a ruler (about 10 inches long) under the back of the supine patient while he is in full forward flexion. The mid point of the ruler should be centered as nearly as possible over the mid point of the patient's lordosis. A mark is then made on the patient's skin over the two ends of the ruler. After the adjustment, the patient is again put into full forward flexion (sitting), and the distance between the two points described above is remeasured. If the involved spinouses now separate more than before the adjustment, the two points on the skin will be farther apart. In muscle fixations, the change may be as large as a centimeter. In ligament fixations, however, it will rarely exceed 8 millimeters because the involved ligament(s) cannot "relax" like a muscle. It is normal, therefore, to expect a slower change in a ligamentous fixation than in a muscle-induced hyperlordosis.

      DR. FAYE'S CLINICAL COMMENT #6.9

In countries where people frequently squat on their heels flat footed, much less degenerated disc disease exists. This squatting posture produces interspinous separation of the lumbar spine. Patients with lumbosacral hyperlordosis should be asked to practice this posture until they can remain comfortable for at least 3 minutes. If they cannot achieve this posture easily, instruct them to hold on to the edge of a desk or a sink until balance is easily achieved. The worse they are at this exercise initially, the more they need it.

Correcting Pubic Fixations

Pubic fixations are of the ligamentous type. The supine exercise previously described for sacroiliac fixations is usually quite effective in correcting and maintaining pubic fixations. If the pubic fixation is strongly fixed, the following adjustment should be considered: Place the patient supine and select the ASIS that has rotated the most anteroinferiorly. Flex the patient's hip and bring the corresponding knee toward the patient's chest, adding some body weight of your own if necessary. Stabilizing the patient's contralateral ilium with your nonactive hand. This is a slow stretching maneuver. A heavy sharp thrust should never be applied.


Gillet's Comments on Cases of Low-Back Pain

In this concluding section, we will describe the routine of palpation and correction used by Gillet in all cases of low-back pain of neuromusculoskeletal origin.

In Gillet's practice, for all cases, he searches for total fixations of the first two cervical vertebrae and corrects them first. In a large number of cases, nothing else is required if the results are complete and rapid. This does not mean that the patient's "lumbago" or "sciatica" was simulated or that it was some type of psychologic "revenge." The upper-cervical fixation did exist, and it was probably brought on by an emotionally induced contraction of the muscles at the base of the skull. Any lower lumbar fixation found would therefore be a localizing factor and the cervical fixation would be the precipitating focus of the patient's pain.

True, these cases would probably get well eventually if these fixations were corrected in inverse order, or even if they were adjusted during the same visit. It has been Gillet's experience, however, proved time and again, that the best, the most rapid, and the most lasting results are attained when the fixations are corrected in the order suggested (upper cervical, pelvis, and lower lumbars), with at least several hours between the two corrections to give time to the body to adapt itself to the corrections made.

Gillet employs the following two palpations:

(1) palpation for total occipitoatlantal fixation (A-P and P-A movement with the palpation contact placed just below the rim of the occiput, on the two sides of the posterior arch;

(2) palpation for total pelvic fixation (A-P and P-A movement, using the back of the hand). Once fixations within these two structure have been corrected, the lumbar vertebra are examined, first for total fixations and then especially for partial fixations.

A question has often been asked about the difficulty of producing the necessary movements of the spine in palpating for fixations in patients that are in considerable pain. This is not an insurmountable difficulty. It is easy to produce small movements that are revealing: motion that is not enough to exacerbate the patient's pain but enough to reveal any fixations present.

In the lumbar region, three different types of fixation are often found. In fact, as muscular hypertonicity can be severe in this region, it is not difficult to see the type of fixation likely present just by recognizing the characteristic shape of the spinal distortion.

Low-Back Pain on the Convex Side of Lumbar Scoliosis.   The most common "distortion" is one of lateral flexion-rotation. This constitutes the basis for the typical "antalgic" posture, which is caused principally by a contraction of the quadratus lumborum that pulls the lumbar vertebrae towards the iliac crest and rotates them posteriorly on the same side. In this type of distortion, the patient's local pain or sciatica will be on the side of lumbar laterality and posteriority. The mechanism of subluxation, states Gillet, will be due to a rotation of L5 on the sacrum, or L4 on L5, in which the pre- and post-zygopophyses have separated, leaving a space between the articular surfaces and forcing the lower facet into the IVF to produce a classic "pressure on nerve." In this type of fixation, it is the lumbar rotation toward the concave side that should take priority consideration because the articulation on that side is still able to function partially. On rotation to the convex side, the movement will immediately be stopped by the hypertonic muscle.

The most efficient adjustment, if the patient can relax enough to permit it, is a "roll" with the patient lying on the concave side. The contact is applied on the iliac crest to exert a rapid traction on the quadratus lumborum. If this is not possible, the muscle may be relaxed by applying a rapid thrust directly on it when the patient is prone and the abdominal piece is free.

Low-Back Pain on the Concave Side of Lumbar Scoliosis.   Another type of "sciatica" described by Gillet is one in which the pain is on the concave side of the lumbar scoliosis. Here the mechanism is different. Instead of being separated by muscle hypertonicity, the articulations are pulled together. The offending muscle is invariably the intertransverse. It pulls the vertebrae into lateral flexion and flattens the disc on one side. The patient's pain is on the concave side of the curve, and there is little or no vertebral rotation. Inducing movement (lateral flexion) towards the concave side will be easier in spite of the fact that it is the side of pain. On the contralateral side, however, there will be restriction because of the taut intertransverse muscle (this is typical of all muscle fixations). In this type of fixation, as it is difficult to invent an adjustment that will pull the two ends of the muscle apart, the best thrust is one at right angles to the point of fixation when the patient is prone.

IVD Lesions.   The reader may have noticed that little emphasis has been placed on IVD lesions. Gillet's believes that the role of this factor, or its very existence in many cases, has been vastly overplayed. There are probably two types of discal hernias seen clinically:

(1) the true rupture, which can be described as an anular "tumor" invading into the spinal canal;

(2) and the false one, which is a posterolateral "bulging" of the disc as the result of abnormal pressure exerted on it by severe muscle contraction. With the second type, anything that will lessen the chronic muscular contraction will relieve the "hernia."

Thus, reflex techniques, modalities, or even the anesthesia administered before an operation will have the necessary relaxing effect of the muscles responsible for a "false" hernia.

A great amount of information has been described in this chapter. It is suggested that you review it frequently. We are sure that with each reading you will discover a new idea, a new viewpoint, that will contribute to your clinical proficiency. [See Clinical Comment 6.10]

      DR. FAYE'S CLINICAL COMMENT #6.10

As stated in the chapter concerning the thoracic spine for all low-back pain cases determined amenable to manipulation, be sure to include restoring motion to the hip joints and the thoracolumbar junction if these areas are fixated. Both of these sites of fixation can produce hypermobile L4-L5 or L5-S1 function that can readily lead to lower lumbar disc bulging. Upper lumbar and lower thoracic fixations can also produce tension on the spinal cord that results in less angulation of the L5 or S1 nerve roots as they exit from the spine. This more obtuse angulation allows the roots to press against an otherwise tolerable disc protrusion. Such cases will be much more sensitive to Lindner's test, the Soto-Hall test, or a Valsalva maneuver. Thoracolumbar adjustments relieve the root tension, and antalgic postures improve quickly.

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