Aubrey Taow, DO

2016 FOMA Convention

February 19, 2016
 Osteopathic structural exam and osteopathic manipulative treatment are
valuable tools in diagnosing and treating low back pain
 Remember the guiding principles for treating soft tissue injury
 1. Identify and eliminate possible causes of pain (e.g. poor posture, abnormal
biomechanics)
 2. Reduce pain and inflammation
 3. Restore full pain-free range of motion
 4. Achieve optimal flexibility and strength
 5. Maintain fitness
 1. Visual inspection of back and  Quadratus lumborum
posture  Gluteal muscles
 From behind and from the side
 4. Neurologic assessment of L4, L5,
 2. Active movements and S1 nerve roots
 Flexion
 5. Special tests
 Extension
 Unilateral straight leg raise test (Lasegue
 Lateral flexion test)
 Single-leg extension  Crossed straight leg raise test (Well
straight leg raise test)
 3. Palpation of spine and paraspinal
 Slump test
muscles
 Spinous processes
 Femoral nerve stretch test
 Transverse processes
 Sacroiliac joint tests
 Apophyseal joints
 Patrick or FABER test
 Sacroiliac joints
 Gaenslen’s test
 Iliolumbar ligament
 Single leg extension
 Paraspinal muscles
 Centralization test
 Hip Flexion (Iliopsoas)
 L1, L2, L3, L4 (Femoral Nerve)

 Knee Extension (Quadriceps)

 L2, L3, L4 (Femoral N)

 Knee Flexion (Hamstrings)

 (L4), L5, S1, S2, (S3) (Tibial N)

 Ankle Dorsiflexion (Tibialis Anterior)

 L4, L5 (Deep Fibular N)

 Great Toe Extension (Extensor Hallucis Longus)

 L5, S1 (Deep Fibular N)

 Ankle Plantar Flexion (Gastrocnemius)

 S1, S2 (Tibial N)
 Assessment for sciatic nerve compression (80% sensitive)
 How to perform:
 With the patient supine, lift leg up while keeping knee extended
 When the patient experiences pain/tightness, slowly lower the leg until the pain
resolves. Then dorsiflex the ankle and have the patient flex his neck.
 Positive test: pain at 30-60° that radiates down the leg being raised
 Indicates sciatic nerve root irritation
 Pain after 70 ° may be indicative of muscle stretching, sacroiliac pain or
lumbar facet joint pain
 How to perform:
 Same as SLR
 Positive test: pain radiates down the side opposite of the leg being
raised
 Indicates herniated intervertebral disc that is irritating the nerve root (as
opposed to sciatic nerve irritation)
 Assessment for movement
restriction or impingement of
the dura and spinal cord
 How to perform:
 1.Patientseated at the edge of
the table with legs hanging off
the table and hands behind his
back. Instruct patient to
slump forward into thoracic
and lumbar flexion, while
keeping neck and head in
neutral position and sacrum
vertical.

http://lumbar-spine-special-test.blogspot.com/
 How to perform (continued)
 2. If there are no reproduction of
neurologic symptoms, then the
physician adds the folowing
modifications:
 a.) Instruct patient to put chin on
chest and apply overpressure.
 b.) While maintaining overpressure,
patient actively extends the knee.

 Positive test: Reproduction of

pain or neurologic symptoms
 Indicates impingement of dural
lining, spinal cord, or nerve
roots
http://lumbar-spine-special-
test.blogspot.com/
 Tests for nerve root impingement at L2,
L3, L4
 How to perform:
 Patient is lying prone with a pillow under
the abdomen. The examiner stands at the
patient’s side.
 The examiner stabilizes the patient’s far
hip with the heel of his cephalad hand
over the PSIS. He then passively extends
the far hip, while holding the knee flexed
at 90°
 Positive test: Pain in anterior and lateral
thigh
 Assesses for dysfunction of anterior SI ligament
 How to perform:
 Patient lies supine with her forearms under her lower back to support the
lumbar spine and a pillow under her knees.
 With arms crossed and elbows straight, the examiner places the heels of his
hands on the patient’s ASIS and applies a slow steady posterior force by leaning
down toward the patient
 Positive test: Unilateral pain at SI joint or in gluteal/leg region

http://si-bone.com/providers/sacroiliac-joint-diagnosis/si-joint-
 Assesses for dysfunction of sacrospinous ligament
 How to perform:
 Patient lies supine with hip being tested flexed to 90 degrees and knee fully
flexed. Examiner stands on the same side as the flexed leg.
 While stabilizing the opposite ASIS with heel of cephalad hand, the examiner
uses his upper body to apply a steady pressure through the axis of the femur
 Positive test: Pain reproduced posteriorly in the buttock.

http://si-bone.com/providers/sacroiliac-joint-diagnosis/si-joint-
provocative-tests/
 Assesses for dysfunction of sacroiliac joint pathology, with possible
involvement of posterior SI ligament
 How to perform:
 Patient lies in lateral recumbent position with a pillow between the knees.
 The examiner stands behind the patient and places one hand on top of the other
directly over the patient’s iliac crest, exerting a steady downward pressure.
 Positive test: Pain reproduced

http://si-bone.com/providers/sacroiliac-joint-diagnosis/si-joint-
 Assesses for pathology of hip
joint, iliopsoas spasm, or
sacroiliac joint dysfunction
 How to perform:
 The patient lies supine. While
stabilizing the contralateral ASIS
with the cephalad hand, the
examiner moves the leg being
tested into hip and knee flexion,
hip abduction, and hip external
rotation.
 Positive test: The patient’s pain is
reproduced and/or the tested leg
does not abduct below the level http://lumbar-spine-special-test.blogspot.com/
of the straight leg.
 Helps distinguish between lumbar
spine and SI joint dysfunction.
 How to perform: Pt is supine with the
leg being tested hanging off the edge of
the table. The patient actively flexes
the other leg at the hip and knee.
While helping stabilize the opposite
pelvis to keep the patient on the table,
the examiner applies overpressure to
the leg being tested to put it into
further extension and adduction.
*Note- Always test the unaffected side
first
 Positive test: Reproduction of pain
 Indicates SI joint problem, pubic
synthesis instability and/or L4 nerve
root lesion.
Source: http://lumbar-spine-special-test.blogspot.com/
 Determines which movements (flexion or
extension) increase or decrease reported
symptoms and whether centralization is
occurring
 How to perform:
 First note the patient’s baseline symptom locations
in the standing position, with emphasis on the
most distal symptoms.
 Instruct the patient to bend forward as far as
possible and return to starting position. Record any
effect the movement has on the symptoms.
 Repeat 10 – 12 times, then have the patient report
any lasting change in location or intensity of
symptoms.
 Repeat the assessment with standing extension,
recumbent flexion, and prone extension
 Test extension in both prone and
standing positions

www.braceability.com
www.osteoinfo.com.au

 Test flexion in both supine and

www.drtimspeciale.com standing positions
 Positive test: Referred pain moves from a
distal to a more proximal location
(centralization)
 Indicates that pain is being caused by internal
disk disruption
 When centralization does occur, it is normally
related to a single direction of movement
(flexion vs extension). This indicates that
symptoms will likely improve with continued
flexion- or extension-based exercises as part of
the patient’s rehabilitation program.
 Seated Flexion Test +

Sacral base is deep, ILA is Sacral base is deep, ILA is

posterior/inferior on same side posterior/inferior on opposite side

Sacral Shear Sacral Torsion

(SI joint problem) (L5/S1 and/or muscle problem)

Seated Flexion Test + Seated Flexion Test +

left right left right
sacral sulcus is deep: sacral sulcus is deep:
left right left right left right left right
LSF LSE RSE RSF R/R Sacral L/R Sacral R/L Sacral L/L Sacral
Torsion Torsion Torsion Torsion
 If the seated flexion test is negative, the ILA equal

following are possible: Bilateral positive

seated flexion test

 1. No sacroiliac dysfunction (i.e., the patient is

normal)
Sulci deep Sulci shallow
 2. Bilateral flexion or extension Good spring test
BILATERAL SACRAL
Poor spring test
BILATERAL SACRAL
FLEXION EXTENSION
 3. The test could be a false negative caused by
iliosacral compensation.
 1. Patient lies on side with axis side down (left
side if L/L torsion) with torso rotated so that
he is face down (modified Sims position).
 2. Flex patient’s hips until motion is felt at the
lumbosacral junction
 3. Physician is seated behind the patient and
drapes the patient’s legs off the side of the
table over the physician’s cephalad leg (as
shown in picture) so as to induce sidebending
and engage the sacral axis (left sacral oblique
axis if L/L torsion).
 4.Cephalad hand monitors at the superior pole
while the caudad hand guides sidebending
until the sacral base starts to rotate in the
opposite direction (rotate to the right for L/L
torsion)
 4. While continuing to monitor with the
cephalad hand at the superior pole, ask the
patient to lift his legs toward the ceiling
against your equal counterforce for 3-5
seconds.
 5. Repeat 3-5 times, each time re-engaging a
new restrictive barrier. Then retest for Source: Jones 2009
 1. Patient lies on side with axis side down
(left side if R/L torsion) with torso rotated
so that he is face up.
 2. Grasp patient’s inferior arm and pull
through to further rotate his torso. Flex
patient’s hips until motion is felt at the
lumbosacral junction
 3. Drop the patient’s superior leg off the
table to induce sidebending and engage the
axis (left sacral oblique axis if R/L torsion).
 4. While monitoring superior pole with
cephalad hand, ask the patient to lift his
superior leg toward the ceiling against your
equal counterforce for 3-5 seconds.
www.hal.bim.msu.edu
 5. Repeat 3-5 times, each time re-engaging a
new restrictive barrier. Then retest for
symmetry.
  Monitor sacrum at the middle transverse axis, abduct
left leg to about 15 degrees to disengage the
sacroiliac joint.
 Internally rotate the hip to further gap the posterior
sacroiliac joint.
 Heel of hand is on the left ILA, pressing anteriorly.

 Encourage inhalation, resist exhalation.

 Repeat for a total of 3-5 cycles.

 Retest.

Source: Jones 2009

Inhalation:
Curves flatten,
sacrum
counternutates

Exhalation:
Curves
accentuated,
sacrum nutates
  Monitor sacrum at the middle transverse
axis, abduct to about 15 degrees to
disengage the sacroiliac joint.
 Externally rotate the hip to further gap the
anterior sacroiliac joint.
 Heel of hand is at the left side of sacral
base, pressing anteriorly (other hand may
monitor on the PSIS)
 Encourage exhalation, resist inhalation.

 Repeat for a total of 3-5 cycles.

 Retest.

Source: Jones 2009

 Abduct both legs to about 15 degrees to
disengage the sacroiliac joint.
 Internally rotate both hips to further gap
the posterior sacroiliac joint.
 Heel of hand is on the central portion of
the apex of the sacrum, pressing
anteriorly.
 Encourage inhalation to bring the sacral
base posterior and superior
(counternutation), resist exhalation.
 Repeat for a total of 3-5 cycles.

 Retest.

Source: Jones 2009

 Abduct both legs to about 15 degrees to
disengage the sacroiliac joint.
 Externally rotate both hips to further gap
the anterior sacroiliac joint.
 Heel of hand is on the central portion of
the base of the sacrum, pressing
anteriorly.
 Encourage exhalation to bring the sacral
base anterior and inferior (nutation), resist
inhalation.
 Repeat for a total of 3-5 cycles.

 Retest.

Source: Jones 2009

 Positive
standing The side with the positive standing flexion test determines the
landmarks used to diagnose the iliosacral dysfunction.
flexion Therefore, if the standing flexion test is positive on the right, the
test right ASIS, PSIS, sacral sulcus, and leg are used to determine
the diagnosis.

ASIS ASIS ASIS ASIS Pubic

superior inferior medial lateral Rami

PSIS PSIS PSIS PSIS

Rami
inferior superior inferior superior PSIS PSIS Ramus Ramus
equal
lateral medial superior inferior
& tender
Sulcus deep Sulcus equal Sulcus equal Sulcus shallow
Sulcus wide Sulcus narrow
Leg length Leg length Leg length Leg length
shorter shorter longer longer
COMPRESSED
POSTERIOR SUPERIOR INFERIOR ANTERIOR INFLARE OUTFLARE SUPERIOR INFERIOR
PUBIC
INNOMINATE INNOMINATE INNOMINATE INNOMINATE INNOMINATE INNOMINATE PUBIC SHEAR PUBIC SHEAR
SYMPHYSIS
ROTATION SHEAR SHEAR ROTATION

Iliosacral Muscle Energy, Paul R. Rennie, D.O., F.A.A.O., 050906

1. Patient is supine with the feet off the end of the table.
2. Physician places their thigh up to the contralateral foot
(non-dysfunctional side) to stabilize the pelvis and then
holds the patient’s leg (dysfunctional side) just above
the ankle.
3. The leg is abducted to about 10-15° to loose-pack the
SIJ.
4. The hip is then internally rotated to close-pack the hip
joint.
5. The physician pulls on the leg while the patient
performs a series of about three to four inhalation and
exhalation efforts.
6. During the last exhalation effort the patient is asked to
cough while simultaneously the leg is pulled in a caudal
direction.
7. Assess that proper release is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906
1. Patient is prone with the physician standing on the
same side as the dysfunction.
2. The patient’s foot is placed between the physician’s
knees and then the patient’s knee is stabilized with
one hand while the other hand is placed on the
patient’s ipsilateral ishial tuberosity.
3. The leg is abducted to about 10-15° to loose-pack
the SIJ.
4. A cephalad force is placed on the ipsilateral ishial
tuberosity while the patient performs a series of
deep inhalation and exhalation efforts.
5. Additionally, the patient attempts to straighten the
ipsilateral arm (that is holding on the table leg)
which results in a caudal force through the trunk.
6. Assess that proper release is obtained.

Iliosacral Muscle Energy, Paul R. Rennie, D.O., F.A.A.O., 050906

1. Patient is supine with the physician standing on the side
of the dysfunction.
2. The pelvis is shifted to the edge of the table being sure
to maintain stability.
3. Physician’s legs are utilized to hold the freely hanging
leg.
4. Physician places one hand on the opposite innominate
to stabilize the pelvis while placing the other hand over
the distal femur on the dysfunctional side.
5. Mild hip extension stretch to the barrier is applied.
6. The patient performs hip flexion muscle effort for three
to five seconds.
7. The physician takes-up the “slack” in the myofascial
movement and repeats this process until proper release
is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906
1. Patient is supine with the physician standing on the
opposite side of the dysfunction.
2. The patient has the dysfunctional hip and knee flexed
while the physician slightly internally rotates the hip
rolling the pelvis to the opposite side.
3. Physician places the middle and ring fingers around the
PSIS and the heel of the hand to the ishial tuberosity.
4. The pelvis is placed back on the table and a superior
and medial force is applied against the ishial
tuberosity.
5. Physician resists three to five efforts of three to five
second muscle effort for the patient to straighten the
leg in a caudal direction.
6. The physician takes-up the “slack” in the myofascial
movement and repeats this process until proper release
is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906
1. Patient is supine with the hips and knees
flexed and feet flat on the table and together.
2. Physician stands at the side of the table
holding the patient’s knees together.
3. Physician resists the patient’s attempt to
abduct both knees for a three to five second
period of time.
4. Physician now places the forearm between
the patient’s knees.
5. The patient adducts against the physician’s
counterforce two to three times for up to
three to five seconds until release is felt at
the pubic symphysis.

Iliosacral Muscle Energy, Paul R. Rennie, D.O., F.A.A.O., 050906

1. Patient is supine with the physician standing on
the opposite side of the dysfunction with the hip
and knee flexed.
2. Physician places the heel of the hand on the
ishial tuberosity with the fingers monitoring
motion at the SIJ.
3. The dysfunctional innominate is taken to the
barrier in flexion, external rotation, and
abduction (engagement of the barrier and loose-
packing the SIJ).
4. Physician exerts a cephalward and lateral force
on the ishial tuberosity while the physician
resists three to five efforts of three to five
second muscle effort for the patient to extend
the leg against resistance.
5. The physician takes-up the “slack” in the
myofascial movement and repeats this process
until proper release is obtained.
6. This is similar to the treatment for inferior pubic
Iliosacral Muscle Energy, Paul R. Rennie,
shear excepting the loose-packing of the SIJ and D.O., F.A.A.O., 050906
cephalward and lateral force on the innominate.
1. Patient is supine with the physician standing on the
same side as the dysfunction.
2. The patient’s sacrum is brought to the edge of the
table.
3. The patient’s leg is placed between the physician’s
knees while the pelvis is supported with a hand placed
over the contralateral innominate.
4. Physician’s other hand is placed over the distal femur
above the patella to push the hip toward anterior
rotation.
5. Physician resists patient’s effort to flex the hip through
a series of contractions of three to five seconds.
6. This treatment is similar to the superior pubic shear
except that here the sacrum is the fixed point on the
edge of the table versus the innominate.
7. Assess that proper release is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906
1. Patient is supine with the physician standing on the
same side as the dysfunction.
2. Physician flexes the hip and knee rolling the pelvis to
the opposite side.
3. Physician monitors the medial side of the PSIS and then
the pelvis is brought back to the table to rest on the
physician’s monitoring hand.
4. Physician’s other hand adducts the femur to the
internal rotation barrier while maintaining lateral
traction on the PSIS.
5. Patient attempts to abduct and externally rotate the
hip with three to five muscle contractions for three to
five seconds with the slack in the tissues taken up
between the contraction intervals.
6. Assess that proper release is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906
1. Patient is supine with the physician standing on the
same side as the dysfunction.
2. The patient’s hip and knee is flexed with the ipsilateral
foot placed on the contralateral knee (below patella).
3. Physician places one hand over the contralateral
innominate to stabilize the pelvis and places the other
hand over the medial side of the knee on the
dysfunctional side, externally rotating the hip until a
barrier is engaged.
4. The physician resists three to five efforts of three to five
second muscle contractions for the patient to
internally rotate the leg against resistance, taking up
the slack in the tissues between the contraction
intervals.
5. Assess that proper release is obtained.

Iliosacral Muscle Energy, Paul R. Rennie,

D.O., F.A.A.O., 050906
 T10-L5 may be treated with HVLA using the
“lumbar roll” technique.
 Flexion, extension, or neutral lesions can all
be treated in the same lateral recumbent
position
 The technique can be performed with the
posterior transverse process down (i.e., the
patient is laying on the same side as the
posterior transverse process) or posterior
transverse up (i.e., the patient is laying on
the opposite side as the posterior transverse
process)
 The only modification is which direction the
patient’s inferior arm is pulled
 1. Patient should be in the lateral recumbent
position with the physician standing in front of the
patient.
 2. Flex the patient’s legs until you palpate motion at
the level of somatic dysfunction.
 3. Straighten the patient’s inferior leg and add
slight hip extension.
 5. Hook the patient’s superior foot in the popliteal
fossa of the inferior leg.
 6. Position patient’s arm according to the type of
dysfunction and which transverse process is up (see
chart below).
 7. Place cephalad forearm anterior to the patient’s
shoulder and caudad forearm on the patient’s iliac
crest, with cephalad hand monitoring at the level of
dysfunction. http://4.bp.blogspot.com/-NRV-
VkpXE2s/URPL2nCs7kI/AAAAAAAAAlI/
 8. Use caudad forearm to rotate the patient’s hip pV2F021Sya0/s1600/1DLumbarLateralRecumbentThrust.jpg
forward until you feel lockout at the level of
dysfunction.
 9. Instruct the patient to take a deep breath in and
exhale.
 10. At end exhalation, apply HVLA thrust by
 Jones J. Muscle energy treatments: Sacral shears, sacral torsions.
Presented at Touro University Nevada College of Osteopathic Medicine
2009. Henderson, NV.
 Rennie P. Iliosacral (innominate) muscle energy pre-lab. Presented at
Touro University Nevada College of Osteopathic Medicine 2009 by Claire
Galin, DO. Henderson, NV.
 Savarese R. OMT Review. 3rd edition. March 2003.