www.amtamassage.org/mtj 85 body mechanics body

by Joseph E. Muscolino E. Joseph by

motion palpation assessment of assessment palpation motion the sacroiliac is challenging to assess and treat because its motion is subtle. For this reason, a clear understanding of SIJ structure motion is subtle. to assess and treat because its is challenging for competent assessment and and function, and experience working with clients with SIJ conditions, are necessary treatment to be performed. The (SIJ), one ofThe sacroiliac in the human body, the most controversial BEFORE PRACTICING ANY NEW MODALITIES OR TECHNIQUES, CHECK WITH YOUR STATE’S MASSAGE THERAPY REGULATORY AUTHORITY TO ENSURE TO AUTHORITY THERAPY REGULATORY MASSAGE STATE’S YOUR WITH CHECK TECHNIQUES, ANY NEW MODALITIES OR BEFORE PRACTICING THERAPY. FOR MASSAGE DEFINED SCOPE OF PRACTICE STATE’S THE WITHIN ARE THEY 86 mtj/massage therapy journal winter 2011 body mechanics Right pelvic A SIJ isdescribedasaligamentousjoint.Aconsequence the majorityofitsstabilityisprovidedbyligaments, o providestability, theSIJisheavilyinvestedwith fibrous fascialligamentoustissue(Figure3).Because the SIJ. As a result, there is little muscular stability provided to but thesefibersdonotrunfromthesacrumtoilium. attachments thatspanoverthesacrumandiliaccrest, as theerectorspinaeandlatissimusdorsihavefibrous hip joint. Other muscles from the lumbar region such continues ontoattachthefemur, alsocrossingthe only the SIJ. The piriformis does cross the joint, but it crossing andprovidingstability(aswellasmotion)to that attachdirectlyfromthesacrumtoilium, the SIJfrombelow(Figure2). travel upthroughthelowerextremityandpass and everytimeourfootstrikestheground,shockwaves bearing compressionforcesenterthejointfromabove; body below. Wheneverwearestandingorsitting,weight axial bodyabovewiththelowerextremityappendicular because theSIJistransitionaljointthatbridges stresses comefrombothdirections,aboveandbelow, it changes to become a . These physical ages, becauseofthephysicalstressesplaceduponit, joint inthatearlylife,itissynovial,butasaperson each sideofthebody(Figure1).TheSIJisanunusual the and the iliac portionof the pelvic bone on The SIJsarepairedleftandright,locatedbetween THE SACROILIAC JOINT(SIJ) B, Posterior view. ofthepelvic bones.A,FIGURE 1Thesacroiliacjointsarelocated betweenandiliacportion Anteriorview. thesacrum T The SIJisalsounusualinthattherearenomuscles bone Sacrum coccyx and Left pelvic bone superiorly; relatively, thepelvicbonetiltsanteriorly. (superior end)ofthesacrummovesposteriorlyand bone tiltsposteriorly. Withcounternutation,thebase moves anteriorlyandinferiorly;relatively, thepelvic 4). Withnutation,thebase(superiorend)ofsacrum and describedasnutationcounternutation(Figure that occur at the SIJ are primarily sagittal plane motions within thepelvisisalsopossible.Thetypesofmotion joint located between the bones of the , motion given thattherearetwoSIJsandapubicsymphysis the thighsinferiorlyorspinesuperiorly. However, looked at as moving as a fixed unit relative to either it ishelpfultoexamineSIJmotion.Thepelvisoften Before discussingthetechniqueofSIJmotionpalpation, SIJ MOTION motion palpationassessment. accomplished viatheassessmenttechniqueknownas keys toSIJassessmentisassessitsmotion*.This mobility and create a hypomobility. One of the major over timewithinthejoint,whichtendstodecrease countered bythetendencytoaccumulatefibroustissue This tendencytowardinjuryandhypermobilitycanbe in nature,oftencreatinganunstablehypermobileSIJ. do nothealwellandthereforetendtobecomechronic have agoodbloodsupply;thereforesprainsgenerally has implicationsforhealingbecauseligamentsdonot in whichtheligamentsareoverstretchedortorn.This injury isoftenasprain(comparedtomuscularstrain) of thisstructureisthatwhentheSIJinjured, B www.amtamassage.org/mtj 87 “The sacroiliac “The sacroiliac joint is probably one of the most controversial joints in the and human body, one of the most challenging joints to assess and treat.” Greater sciatic foramen Sacrospinous Lesser sciatic foramen FIGURE 2 (Left) enters stress the Physical above sacroiliac joints from and below. FIGURE 3 (Below) are The sacroiliac joints A, ligamentous. heavily Anterior B, view. Posterior view. IIiac crest Anterior sacroiliac ligament Sacroiliac interosseus ligament L5 Sacrotuberous ligament Anterior longitudinal ligament L5 Ischial tuberosity pubis joint Anterior ligament Posterior Sacrospinous Intertransverse ligament B sacroiliac ligament Iliolumbar ligament A sacroiliac 88 mtj/massage therapy journal winter 2011 extremity isallowedagreater rangeofmotionwhiletheupperbodyandleft independently fromtherest of thepelvis.Inthismanner, therightlower this isolatedmotionsothatthe rightpelvicbonecanmove(posteriorlytilt) posture oftheleftpelvicbone andleftlowerextremity. TherightSIJallows this wouldaffecttheposture ofthesacrumandupperbody, aswellthe the entirepelvistoposteriortiltalongwithrightpelvic bonebecause the rightfoottorisehigherinair(Figure5).However, wedonotwant joint. To augment this, we posteriorly tilt the right pelvic bone, which allows there is a limit to how far the foot can raise by flexing the thigh at the hip This isaccomplishedbyflexingtherightthighathip joint.However, example offemoropelvicrhythmisliftingourrightfootin front ofourbody. motion ofthefemurathipjointandpelvicbone attheSIJ.An femoropelvic rhythm describes the coupled-action interplay between bone, tomoverelativethesacrumandothersideof body. Theterm functioning becauseitallowsthelowerextremity, includingthepelvic and thesacrum.Thismotionisextremelyimportantto lowerextremity that sideofthebody, itallowsmotiontooccurbetweenthatpelvicbone atthesacroiliacoccurs joint.” is helpfultoexaminethemotionthat sacroiliac jointmotionpalpation,it “Before discussingthetechniqueof body mechanics Because eachSIJislocatedbetweenthesacrumandpelvicboneon A roiretsoP Sacrum Superior Inferior Pelvic bone roiretnA B roiretsoP palpation technique. technique andPSIS-sacraltubercle presented: bilateralPSISpalpation SIJ motionpalpationtechniques are challenge theSIJstomove. Two SIJ utilizesfemoropelvicrhythmto Motion palpationassessmentofthe palpation ofthejoint’s posture). as itmoves(incomparisontostatic motion isbeingassesseddynamically motion palpation because the joint’s of theSIJ.Thistechniqueiscalled rhythm canbeusedtoassessmotion An understandingoffemoropelvic SIJ MOTIONPALPATION TECHNIQUE a stableposture. lower extremityareabletomaintain posteriorly tiltsattherightSIJ. posteriorly the rightpelvicbone right thighflexes atthehipjointand Example offemoropelvic rhythm. The FIGURE 5(OppositePage) Counternutation. Motion attheSIJ.A, Nutation.B, FIGURE 4(Below) Superior Inferior roiretnA www.amtamassage.org/mtj 89 FIGURE CREDITS: from FIGURES 1-5 JE: MUSCOLINO, THE KINESIOLOGY: SYSTEM SKELETAL AND MUSCLE FUNCTION. ST. 2011. LOUIS, ELSEVIER. (FIGURE 8-1 PHOTOGRAPHY BY ALL ELIOT. DAVID ILLUSTRATIONS BY JEANNIE ROBERTSON; FIGURE 8-2 MODELED FROM IA: KAPANDJI PHYSIOLOGY OF THE JOINTS: THE TRUNK AND VERTEBRAL ED COLUMN, EDINBURGH, 2, CHURCHILL 1974, LIVINGSTONE.) B B This palpation protocol should then be carried If the right PSIS drops and the left PSIS does not, then If the right PSIS drops and the left PSIS raise the side by asking the client to out on the other This technique can be left thigh in a similar manner. performed in a smooth, flowing manner by asking the at a time, side one each thigh, raise to alternately client in a repeated fashion, at a pace that gives the therapist of the both or the one at have occurred must motion SIJs between them. Usually this motion occurs at the SIJ on the side where the thigh flexed, in this case the right SIJ. But if the right SIJ is locked (hypomobile), the sacrum will posteriorly tilt with the right pelvic bone, resulting in motion occurring between the sacrum and the left pelvic bone at the left SIJ. Therefore, palpating both PSISs as the right thigh lifts could result in motion right PSIS flexes, if the As the right thigh at either SIJ. does not drop at all relative to the left PSIS, it indicates that both SIJs are hypomobile. A bilateral PSIS palpation technique technique, perform bilateral PSIS SIJ motion palpation To is there so enough far wall, a facing stand client the have sufficient room to lift the thigh in front, but close enough so the client can place her fingertips against the wall for balance. It is important that the client does not lean into the wall; she should just use her fingertips to prevent wobbling as she lifts her thigh (Figure 6). The therapist places his palpating thumb pads at the inferior margins of the posterior superior iliac spines (PSISs). Now ask the client to raise her thigh until it is parallel with the floor; it is important that the client lifts the thigh to no lower (Figure 7). Via exactly 90 degrees, no higher, femoropelvic rhythm, flexion of the thigh couples with posterior tilt of that pelvic bone, which should result in the PSIS on that side dropping (moving inferiorly). The assessment of the motion at the SIJ occurs by feeling for this inferior motion of the PSIS on that side (Figure 8). “Motion palpation of joint is a valuable the sacroiliac should be added to the physical assessment tool that examination of every / presents with low client who pelvis pain or dysfunction.” A 90 mtj/massage therapy journal winter 2011 the right pelvic bone (Figure 9). If relative motion is not sacrum nutate(dropanteriorandinferiorly)relativeto therapist should feel with the left palpating thumb the the motionisoccurring at theright sacroiliac joint,the can bepalpatedwiththerightthumb.However, now, if which shoulddroptherightPSISasitdidbefore;this to raisetherightthighuntilitisparallelwithfloor, vertebral spinousprocesses).Theclientisagainasked posterior surfaceofthesacrumandareanalogousto tubercle (sacraltuberclesarelocatedmidlineonthe PSIS andplacestheotherpalpating thumb onasacral the therapist places one palpating thumb on the right example. Theclientispositionedsimilarly, butnow and thesacrum.Again,let’s usetherightsideasour done: this time by palpating the PSIS of the pelvic bone other, anotherSIJmotionpalpationprotocolmustbe To determinethemotionatoneSIJcomparedto PSIS-sacral tuberclepalpationtechnique which SIJismoving. two PSISs,butdoesnotallowthetherapisttodetermine PSISs allows the therapist to assess motion between the palpation oftheSIJsbypalpatingsimultaneouslyboth time to feel the PSIS motion on each side. Thus, motion body mechanics all ofyourclientswithlowbackconditions.Afteryou For thisreason,beginpracticingtechniqueon making thesedeterminationsrequiresexperience. or easilyvisualizedandquantifiedindegrees.Rather, not somethingthatcanbemeasuredwithagoniometer difficulty lies inthe fact that measuring SIJ motion is joints hypomobile or are both joints hypermobile? The amount representahealthynormalamount,orareboth Or, if both SIJs move the same amount, does that the right SIJ is hypomobile and the left SIJ is healthy? is hypermobileandtherightSIJhealthy, orisitthat is movingmorethantherightSIJ,itthatleftSIJ or not.Forexample,ifitisdeterminedthattheleftSIJ determine ifthatdegreeofmotionisfelthealthy of motion is accurately assessed, it can be challenging to practice tobecomeproficient.Further, evenifthedegree these jointmotionsaresmallandsubtle,itcantake motion canbeaccuratelyassessed.However, because of themotionatthatspecificSIJ. this motion palpation techniqueallowsforassessment fingers on the bones on either side of one specific SIJ, that SIJ is hypomobile. Thus by placing the palpating felt betweentherightpelvicboneandsacrum,then client toraisethethighuntilit isparallelwiththefloor. Motion palpationassessment is doneby askingthe FIGURE 7(Above) right SIJ. positionfor motionpalpationassessmentofthe Starting FIGURE 6(Left) Using thesetwomotionpalpationtechniques,SIJ

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FIGURES 6-9: PHOTOGRAPHY BY YANIK CHAUVIN YANIK BY PHOTOGRAPHY 6-9: FIGURES CREDITS: FIGURE Joseph E. Muscolino, DC, has been a massage therapy educator for 25 years and currently teaches anatomy and physiology at Purchase College. He is the owner of The Art and Science of Kinesiology in Stamford, Connecticut, and the author of The Muscle and Bone Palpation Manual, The Muscular System Manual and The Skeletal System Kinesiology, and Muscle Function textbooks 2009, 2010 and 2011). (Elsevier, website at www. Joseph’s Visit Joe learnmuscles.com. Follow Dr. on his facebook page: The Art and Science of Kinesiology

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Motion palpation of the SIJ is a valuable assessment tool that should Another technique of SIJ motion palpation is done by palpating the PSIS on one side and a sacral tubercle, is done by FIGURE 9 Another technique of SIJ motion palpation anteriorly and the sacral tubercle to move (nutation) toward inferiorly and inferiorly to move the PSIS for and feeling starting The right PSIS has thigh on that side. A, position. B, the when the client flexes the pelvic bone on that side, anteriorly and the sacral tubercle has moved and inferiorly. inferiorly moved One technique of SIJ motion palpation is done by palpating both PSISs and feeling for a PSIS to move to move a PSIS for and feeling palpating both PSISs motion palpation is done by FIGURE 8 One technique of SIJ inferiorly. moved The right PSIS has starting B, thigh on that side. A, position. the when the client flexes inferiorly activity self-care advice. be added to the physical examination of every client who presents with successfully are SIJs client’s a Once dysfunction. or pain back/pelvis low assessed, you can apply the appropriate treatment techniques. These include soft tissue manipulation to loosen associated muscles and break up fascial adhesions, stretching and joint mobilization to loosen a hypomobile joint**, and self-care recommendation to the client to strengthen adjacent postural and as other well as joint, hypermobile a stabilize to musculature have practiced these techniques a number of times, you will have a feel have practiced these techniques a number you Then SIJ. the for healthy is considered that motion degree of the for assessing SIJ range of motion, and will be comfortable and competent at hypomobile, or are healthy, SIJs the client’s determine whether you can hypermobile. ** A treatment method of mobilization of the sacroiliac joint was presented ** A treatment method of mobilization of the sacroiliac joint was in the winter 2009 MTJ body mechanics column article, joint mobilization of back. the low * Other orthopedic presented assessment tests for the sacroiliac joint were orthopedic assessment of the in the fall 2010 MTJ body mechanics column, sacroiliac joint.