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14.2 • Sacro-iliac articulation nearer side prone

Operator applies gentle pressure along perceived plane of joint with cephalic hand and then performs a circumduction movement with other hand controlling leg. As sense of tension accumulates in sacro-iliac joint, firmer pressure is applied to ilium along joint plane to mobilize joint. The arc of movement within the circumduction where the joint play will be felt varies slightly with different patients.

Tips: Most useful in larger patients where reaching across may be a problem when working on the other side. Least useful if the table is not adjustable, and it is not possible to get the angle of the articulating arm vertical. Not comfortable in acute patients where lying prone is a problem, or in the presence of lumbar disc lesions where extension may be painful. Extra considerations: Use of a pillow under the abdomen will often make the correct joint plane accessible.

14.3 • Sacro-iliac articulation anteriorly side-

lying The patient is put into some rotation of the spine, and the upper leg flexed to a comfortable position. The operator firmly grasps the ilium between his own forearm, abdomen and other hand. A rocking back and forward along the plane of the joint can be applied. Sufficient rotation must be applied to obliterate most of the lumbar movement, as otherwise the rocking action will simply produce flexion and extension of the lumbar area.

Tips: Most useful in patients who cannot lie prone such as pregnant women, and acute lumbar pain syndromes. Least useful in very flexible subject where the lumbar movement tends to absorb the forces. Extra considerations: Harmonic technique can be performed in this position if the upper part of the body is made to oscillate, and if the ilium is held very firmly, an anterior gapping can be applied if the operator flexes his own knees and holds the pelvis in the same plane. This hold can also be used for lumbar sidebending and several other directions of articulation with a little thought.

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14.4 • Sacro-iliac springing prone This is as much a testing hold as it is a treatment technique. The operator is palpating in the sulcus of the sacroiliac joint on the opposite side, and the other hand is applying a force vertically towards the table. If movement is felt in the sacro-iliac it must be hypermobile, as the plane of the joint is far more medial to lateral than vertical. Rotary movement of the lumbar spine is sensed with this pressure also, and if excessive gives a clue as to possible cause of dysfunction states.

Tips: The pressure must be applied carefully over the posterior superior iliac spine as otherwise only soft tissue mobility will be sensed. Least useful in acute subjects where lying prone is a problem. Extra considerations: This hold develops into the next one illustrated as a means of sensing from where movement is being induced.

14.6 • Harmonic technique pelvis supine

Operator cups anterior superior iliac spines in the palms of both hands and initiates an oscillatory movement into rotation of the pelvis. This can be diagnostic as well as therapeutic, as differences in rotary capability of the pelvis on the lumbar spine can be sensed.

Tips: A pillow behind the knee may change the angle of the pelvis and make movement easier. Least useful in cases of sacro-iliac hypermobility as this pressure may induce pain in the joint concerned. This is in itself diagnostic.

14.5 • Sacro-iliac articulation and springing prone This illustration directly follows on from the previous one. The springing hand has gradually changed direction until the plane of the joint has been sensed, and the combined sense of proprio-ceptive awareness with the springing hand and tactile sensing with the other hand allows the optimum direction of movement to be used. If the best direction for joint play cannot be sensed, use less force not more as the applied weight of the hands may have obliterated the free play, and more pressure will only rotate the lumbar spine and not have any more effect on the sacro-iliac joint.

Tips: Gradually moving the shoulder of the springing hand through a circle will allow the optimum direction of force to be assessed. A pillow under the abdomen may help to.reduce the lumbar lordosis, and make the sacro-iliac joint more accessible. Least useful in acute lumbar pain syndromes where lying prone may be a problem.

14.7 • Sacro-iliac articulation supine The fingers of the palpating hand are placed so that the tips are in the sulcus of the joint and while gentle downward pressure is applied toward the table the knee is taken through a circular movement to mobilize the joint.

Tips: Excessive pressure toward the table should be avoided as this will obliterate joint movement. Within the arc of circumduction of the knee, a point of resistance will be felt and this can be emphasized with increased downward pressure at that time to optimize the mobilizing force. Most useful where patient cannot lie prone for any reason. Least useful in the presence of osteoarthrosis in the hip or knee.

14.8 • Sacro-iliac thrust into anterior direction supine The optimum direction of the joint is found and then a downward pressure is applied with some internal rotation of the hip to put the hip capsule on some tension. The knee will be approximately over the midline of the body in most cases. Small adjustments of flexion and extension of the hip will be necessary to find the optimum, and then a short sharp downward force is applied to direct the ilium into an anterior rotation direction. At first this may seem to be doing the opposite of what is intended, but it should be remembered that the sacro-iliac joint is superior to the hip, and therefore when a pressure is applied towards the table, the ilium will be rotated forward, not backward. If, however, the hip is taken further into flexion, the ilium will be rotated backward.

Tips: Very accurate joint plane sense is required for this technique, and it may be necessary to feel this with fingers in the sulcus of the joint first, and then remove the hand and apply it to the knee. Most useful in simple uncomplicated sacro-iliac dysfunction in fairly stiff subjects where the force will not be dissipated into the lumbar spine. Least useful in cases where there is osteo-arthrosis of the hip and this pressure will be uncomfortable or impossible. Extra considerations: May be repeated several times as a springing rather than a specific thrust if correct barrier sense cannot be found.

14.9 • Sacro-iliac thrust and articulation anteriorly prone The plane of the joint has been found with the caudal hand and while maintaining this direction of force, the operator applies the other hand to the sacrum near to the other sacro-iliac joint. The sacral hand becomes a fixing hand, and the sacro-iliac can be mobilized with springing into an anterior direction. If a crisp barrier is sensed, a thrust can be applied, but, owing to the small range of movement of the joint, this will be a very short amplitude.

Tips: The sacral hand can be placed in such a way to tip the sacrum into flexion, rotation or sidebending to optimize the tension at the sacroiliac joint. Different phases of breathing can be used as felt appropriate. If the thrust is applied when the patient is holding a full breath in, the pelvis will become firmer, and the thrust may be easier. In a very tight subject, exhalation may be more useful. Most useful in uncomplicated subacute or chronic cases. Least useful in acute cases or where the patient may find lying prone a problem.

14.10 • Thrust sacro-iliac anteriorly prone The medial aspect of the elbow is applied over the posterior superior iliac spine and along the crest of the ilium. The other hand levers against the table and the other thigh, to produce an anterior rotation movement of the ilium. Adjustments will be necessary of the adduction and extension of the thigh to produce the optimum tension in the joint. At the point of accumulation of forces, the thrust is applied along the crest of the ilium.

Tips: Most useful in small patients, and where there is no problem lying prone. Least useful in acute cases where the prone position may be a problem. Extra considerations: Care must be taken not to hyperextend the lumbar spine and thus cause pain. In this respect keeping the anterior of the pelvis on the table is a help. If the correct tension sense does not accumulate, reduce tension rather than increase it, as it is very easy to over-lock. Different phases of respiration may help to produce the best barrier.

14.11 • Thrust sacro-iliac anteriorly prone Pressure is applied to the posterior superior iliac spine of the opposite ilium in the direction of the joint. The other hand lifts the thigh into extension and some adduction of the hip until tension accumulates at the sacro-iliac. Varied rotation of the hip will aid the build-up of tension. The thrust is applied with the hand on the ilium, not the lifting hand.

Tips: Most useful in chronic cases where fixation is liable to be more crisp and, therefore, more easy to release. Least useful in acute cases where lying prone may be a problem or where the patient is very heavy, making lifting of the leg a problem. Extra considerations: Keep the pelvis firmly applied to the table as otherwise hyperextension of the lumbar spine can occur. A pillow under the abdomen may assist patient comfort. Different phases of breathing will often assist in accumulation of optimum tension.

14.12 • Thrust sacro-iliac anteriorly prone The thrusting hand is applied behind the posterior superior iliac spine, and the fingers of the other hand interlock with the thrusting hand so that the leg can be lifted until tension is felt to accumulate. Adduction of the leg will help the build-up of tension.

Tips: Most useful in patients who are fairly tight as tension will accumulate more easily. Least useful where there is any hip dysfunction or where extension of the lumbar spine is going to be a problem. Extra considerations: If the operator is small, the position may be difficult, as the leg-lifting hand is drawing the operator toward the feet of the patient, and thus reducing the force available at the sacro-iliac. Use of a pillow under the abdomen can be useful to avoid hyperextension of the lumbar spine.

14.13 < Thrust/articulation sacro-iliac anteriorly supine The patient has firmly clasped the other thigh into flexion to lock the lumbar spine. The operator has fixed the patient's leg between his thighs and is assisting the patient in holding the other leg in flexion. He applies a downward force to the knee so that the sacro-iliac is torsioned forward on the sacrum. If tension is sufficient, a thrust can be applied toward the table.

Tips: Most useful in young and fairly fit patients as the position can be rather extreme. The position of extreme flexion of the other hip puts the lumbar spine in a flexed position which can help to obliterate movement which may be useful. Least useful if there is any hip disorder. Extra considerations: A useful fulcrum can be made if the patient is capable of lying with the sacrum on the edge of the table. This position is also a differential test of lumbar and sacro-iliac dysfunction. If pain is reproduced in this position, as the lumbar spine is not involved in the movement, it can be reasonably assumed that the sacro-iliac is the source of the symptoms. If pain gets much worse as the patient releases the other knee, there is a good chance that it is movement of the lumbar spine which is implicated in the pain syndrome.

14.14 • Thrust/articulation sacro-iliac anteriorly sidelying This position is fundamentally the same as photograph 14.13 except that the leg has been flexed at the knee. The movement is now much stronger as the quadriceps is put on tension earlier.

Tips: Varying the flexion of the knee can focus the tension more efficiently. Extra considerations: The same implications of the testing nature of this position apply as for photograph 13.15.

14.15 • Thrust using leg tug sacro-iliac anteriorly supine The hand hold is shown before being applied to the foot. Note that one hand is supinated and the other pronated. The thumb of the pronated hand is interposed between the third and fourth fingers of the other hand. This has the advantage that as the operator leans back, without actively gripping, the hold becomes tighter automatically.

Tips: Experimentation will reveal which is the most comfortable way to interlock the hands.

14.16 • Thrust anteriorly sacro-iliac using leg tug supine The hold shown in photograph 14.15 is applied and the lower extremity is taken into some flexion to clear the other leg as adduction is applied. Apply adduction and internal rotation of the hip until the fascia lata and hip capsule, respectively, are on tension. A preliminary traction force is used until tension is felt to accumulate in the sacro-iliac and then without releasing the tension a sharp longitudinal tug completes the thrust.

Tips: Least useful where there is any knee or hip dysfunction or in very lax subjects where the force will be dissipated. Extra considerations: Greater efficiency is sometimes achieved if the patient is asked to hold their breath or to cough coincident with the thrust. Try bracing the patient's other leg on the table against the operator's thigh.

14.17 • Harmonic technique for sacro-iliac This technique shows longitudinal harmonic technique to the pelvis and particularly the sacro-iliac. Tips: Refer to earlier section relating to harmonic technique.

14.18 • Thrust sacro-iliac anteriorly prone Operator focuses forces applied to posterior superior iliac spine along the plane of the joint and fixes pelvis to the table. Patient performs a one-handed push up and as tension accumulates at the joint, operator applies a very short amplitude thrust.

Tips: Most useful in very mobile subjects where the use of active muscle contraction in the patient helps reduce spinal mobility. Extra considerations: Try adjusting initial sidebending to find the optimum tension.

14.19 • Thrust to sacro-iliac anteriorly sidelying

This is a modified lumbar roll position. The cephalic hand of the operator is pushing towards himself on the posterior superior iliac spine of the ilium on the table. The other hand is applying a rotary force on the pelvis so that the lower sacro-iliac is gapped. Firm compression with both hands is necessary to focus the forces at the target joint. Excessive rotation of the spine must be avoided.

Tips: Most useful where there is a disc syndrome making rotation to the other side difficult. Least useful in very large subjects where it may not be possible to achieve sufficient compressive force. Extra considerations: With compression maintained, roll the pelvis forward and backward to find the optimum barrier sense.

14.21 • Thrust to sacro-iliac anteriorly sitting

The operator's knee pushes firmly forwards against the posterior superior iliac spine. The patient is flexed slightly and rotated down until tension accumulates at the operator's knee. The thrust is a combination of a slight increase of rotation of the patient's body and a forward movement of the knee against the ilium.

Tips: This is a very long lever technique and rarely used; however, there may be some cases where it can be a method of choice, particularly those where it is desired to have the spine vertical, thereby slightly driving the sacrum down between the ilia.

14.20 • Thrust to sacro-iliac anteriorly sidelying shown on skeleton This photograph may clarify the hand position of photograph 14.19.

14.22 • Thrust to sacro-iliac anteriorly part standing Patient lies across the table keeping the other foot on the floor. The operator applies the heel of his thrusting hand to the posterior superior iliac spine and his knee in the popliteal space of the f'exed knee. He pushes down with his knee while pulling up with the hand holding the ankle until tension accumulates at the sacro-iliac. The thrust is mostly a force with his hand but the knee and other hand assist slightly.

Tips: This will be a rarely used manoeuvre but was taught by Andrew Taylor Still. Most useful where lumbar torsion is to be avoided. Least useful where there is any knee dysfunction. Extra considerations: The barrier sense will accumulate more easily, in most cases, if the patient holds the breath for the thrust.

Techniques for the sacro-iliac area 103

14.23 • Thrust sacro-iliac anteriorly part standing The patient lies across the table which has been lifted to the height of the patient's pelvis. She flexes her knees slightly so that the anterior superior iliac spines support her weight. Pressure is applied along the plane of the joint with one hand and the other stabilizes the sacrum. The thrust is applied forwards on the posterior superior iliac spine to break fixation of the sacro-iliac furthest from the operator.

Tips: Most useful where it is necessary to avoid torsion of the lumbar spine. Least useful where the patient is elderly and the position may be difficult to attain. Extra considerations: The sacrum-stabilizing hand can hold the bone in a variety of directions. It will be necessary to experiment to find the optimum direction which focuses the forces at the sacro-iliac. It will usually be easier to accumulate tension if the patient holds the breath for the thrust.

14.24 • Thrust sacro-iliac posteriorly supine

This photograph shows the hand hold and patient positioning for this technique. The palm of the cephalic hand will be applied with the anterior superior iliac spine. The other hand will be placed under the ischial tuberosity and the flexed knee and hip are positioned across the operator's abdomen.

14.25 • (see facing page, top right) Thrust/ articulation sacro-iliac posteriorly supine The hold shown in the previous photograph is applied and the operator is pushing the thigh into abduction with his elbow. The thrust is performed as a combination of pushing back with one hand, pulling up with the other and a bending of the knees to further abduct and flex the hip. This will drive the ilium back on the sacrum.

Tips: Most useful in patients with a fairly rigid lumbar spine where the force will focus more easily in the sacro-iliac. Least useful in the presence of any hip dysfunction. Extra considerations: Barrier sense may accumulate more easily if the patient holds the breath at the time of the thrust.

14.26 (see facing page) Thrust position sacroiliac posteriorly supine The patient is positioned into sufficient initial sidebending so that when the operator applies the other components, the side-bending may reduce, but will not be completely lost.

14.27 < (see facing page) Thrust sacro-iliac posteriorly supine The so-called 'Chicago' technique has been applied with the operator's cephalic hand maintaining sidebending and producing a rotation of the patient's torso towards him. His other hand holds the ilium against the table, and as tension accumulates in the sacro-iliac a short amplitude thrust is applied to the anterior superior iliac spine.

Tips: Initial positioning of the patient is critical with this technique. The sidebending must not be lost or the force will dissipate higher in the spine. The direction of force applied to the ilium will govern whether the technique focuses at the sacroiliac or the lumbo-sacral. If the thrust is applied with the cephalic hand, it will tend to focus forces on the thoraco-lumbar junction. It may be necessary to experiment to find the optimum. Most operators find that tension accumulates best if the patient's leg on the operator's side is crossed over the other one, but sometimes the opposite is true.

Tips: Least useful for small operators working on large patients where it may be impossible to reach sufficiently well to accumulate the correct tension.

14.28 A Thrust sacro-iliac posteriorly sitting The patient has folded her arms and the operator has rotated her whole torso down to the sacrum. He holds back on the ilium with index finger and thumb. He applies a rotary force away from the ilium with the other hand and as tension accumulates he thrusts backwards on the ilium. Side-bending toward the thrust side is maintained at all times to help focus the forces as otherwise they will dissipate through the lumbar spine.

Tips: Most useful in tight subjects who have no major spinal dysfunction. Least useful in very tall subjects where it will be difficult to control the levers. Extra considerations: It may sometimes aid the technique if the patient sits astride the table.

14.29 • Thrust/articulation sacro-iliac posteriorly prone The operator has abducted and flexed the patient's hip and knee and the tibia is resting on his own flexed thighs. He fixes the whole lower extremity between his forearm and abdomen and cups the anterior superior iliac spine in the palm of his thrusting hand. The wrist of his other hand has applied pressure behind the ischial tuberosity and the two hands together pull the ilium backwards. The thrust is applied with a combination of operator's hands and body.

Tips: Least useful where the patient may find prone lying a problem. Extra considerations: It is important to hold the ilium and pelvis against the table as abduction is applied to the hip, as otherwise rotation occurs into the lumbar spine and the force will not accumulate at the sacro-iliac.

14.30 • Thrust sacro-iliac posteriorly sidelying

This is a modified lumbar roll position. The operator has applied only a small amount of rotation to the thorax and lumbar spine but has substituted compression toward the table, through the shoulder. The thrusting forearm is placed behind the ilium and the elbow pushes the ischial tuberosity towards himself to rotate the ilium backwards. The thrust is applied with a compression force from the operator's body at the same time as an adduction and external rotation of his arm applied to the ilium.

Tips: Excessive rotation of the lumbar spine will dissipate the force up to the thoraco-lumbar junction; hence the use of compression. A gentle oscillatory rolling of the whole patient will enhance the ability to find the optimum thrust plane. Least useful in very flexible subjects where the thrust will merely produce lumbar flexion.

14.31 • Thrust to sacrum prone This shows a recoil technique where the operator has applied a slight compressive force to the sacrum toward the table and then squeezes the sacrum between both hands to slightly buckle it. The technique is performed with the release of tension allowing the natural recoil of the bone to act as the mobilizing force. This may need to be repeated two or three times.

Tips: Most useful where despite ilio-sacral gapping, some dysfunction remains which may be due to intra-sacral distortion. Extra considerations: It may be found that compressing the sacrum more on one side than the other will produce a more specific result.

14.32 • Thrust to sacrum sidelying This is a modified lumbar roll position. The operator has applied compression to the pelvis and the thorax to reduce the range of rotation necessary to reach the sacrum. The thrust is a combination of an increased compressive force on the ilium with the operator's chest at the same time as the heel of his hand drives the sacrum forwards.

Tips: Most useful where torsion of the sacrum rather than the ilium is the prime element in the dysfunction. Least useful in very flexible or very large subjects. Extra considerations: The direction of the sacral thrust can vary according to the optimum sense of barrier accumulation.

14.33 • Thrust to symphysis pubis supine This is a combined technique where the operator holds the patient's knees apart as she attempts to draw them together. The patient does not use full power but allows him to gradually work the knees further apart until tension accumulates at the joint. He applies a short amplitude thrust into abduction of the thighs while the patient maintains muscle tone.

Tips: Vary the range of hip flexion and knee flexion to find the optimum. Ensure the amplitude of the thrust is very short. Least useful when the patient is very strong and the operator is small.

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